Illinois Providers - Don't Forget Prior Approval of Medicaid Non-Emergency Ambulance Services Required as of October 1, 2013

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If you arrange for non-emergency ambulance services for Medicaid patients in Illinois, prior approval by the State is required as of October 1, 2013. Effective October 1, 2013, the prior approval for non-emergency ambulance services requirement will be in Phase 2 and fully implemented. The approval of the Illinois Department of Healthcare and Family Services (“HFS”) is obtained by submitting a Medical Certification for Non-Emergency Ambulance form (“MCA Form”) to First Transit (HFS contractor for the program) before the service is provided.

During Phase 1, the state allowed post-transit approval of requests. However, beginning with dates of services on and after October 1, 2013, First Transit will not approve requests received post-transit. Ambulance providers have been instructed to contact the HFS Office of Inspector General if a provider does not provide the MCA Form. Also, HFS can recover overpayments not only from the ambulance provider, but also from the discharging physician or health care facility, for improper or false certifications on the MCA Form.

MCA Form Requirements:

• The form requires certification that the patient’s medical condition warrants an ambulance-level transport.

• The form must be filled out by an authorized provider or its designee.

• The form must be faxed or emailed to First Transit prior to transport and a copy must be provided to the ambulance crew at the time of transport. The form is PDF fillable and can be emailed by clicking “Submit by Email” directly on the form itself.

• The form does not have to be completed if the patient has Medicare Part B coverage and Medicaid is secondary.

• HFS recommends completing the form for Medicaid-pending patients. However, for these patients, the form is not submitted to First Transit prior to the transportation. Instead, the form is completed (with the "Medicaid Pending" box checked) and given to the ambulance provider at the time of transport. The ambulance provider will submit the form as part of the post-Medicaid approval process when the patient becomes Medicaid eligible.

HFS has provided some helpful tips for filling out the form. This guidance can be found here.

More information can be found on the HFS website by clicking here.

Topics:  Healthcare, Medicaid, Pre-approval

Published In: Health Updates, Insurance Updates

DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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