Section 140.23  Payment Of Claims

a)         The Department shall pay only for those services and supplies that:

1)         Meet the U.S. Department of Health, Education and Welfare's definition of medical service (42 U.S.C. 1396d);

2)         Can be paid by vendor payment; and

3)         Are specified in the individual rules governing particular types of medical services provided.

b)         Except as provided in subsection (d), the Department shall make payment only after services have been rendered.

c)         Payment shall be made only to a provider who:

1)         Participates in the Medical Assistance Program; and

2)         Except as provided in subsections (d) and (e), is the actual provider of service.

d)         The Department may contract with qualified practitioners, hospitals and all other dispensers of medical services for the provision and reimbursement as specified in the contract of any and all medical care or services on a prepaid capitation, volume purchase, ambulatory visit or per discharge basis.  Such contracts shall be based either on formally solicited competitive bid proposals or individually negotiated rates with providers willing to enter into special contractual arrangements with the State.  Payments shall be made in advance of services under prepaid capitation arrangements.  The Department shall not pay a provider for services provided to recipient enrolled in a HMO or other plan as specified above when the service is one which the HMO or plan has contracted to provide.

e)         The Department will make payment to a provider for services provided by a substitute physician when the substitute physician is performing the duties of a qualified attending physician, and all of the following conditions are met:

1)         The attending physician is ill, on vacation, or otherwise unavailable because of an emergency situation;

2)         The substitute physician is a Doctor of Medicine (M.D.) or Osteopathy (D.O.) who holds a license to practice medicine in all its branches;

3)         The substitute physician is not terminated, suspended, barred or otherwise excluded from participation or has not voluntarily withdrawn from the Medical Assistance Program as part of a settlement agreement; and

4)         The substitution does not exceed 14 days for a single incident and up to a maximum of 90 days per year for the attending physician. If the substitute period extends beyond the 14 days per single incident, the substitute physician must enroll with the Department.

(Source:  Amended at 47 Ill. Reg. 16385, effective November 3, 2023)