Section 140.43  Post Approval for Items or Services When Prior Approval Cannot Be Obtained

a)         Post approval may be requested for items or services provided during Department nonworking hours, or nonworking hours of its agents, whichever is applicable, or when a life threatening condition exists and there is no time to call for approval.

b)         To be eligible for approval consideration, the requirements for prior approval must be met and post approval requests must be received by the Department or its agents, whichever is applicable, no later than 90 days after the date services or goods are provided.  Exceptions to this requirement will be permitted only in the following circumstances:

1)         The Department or the Department of Human Services has received the patient's Medical Assistance application, but approval of the application has not been issued, as of the date of service.  In such a case, the post approval request must be received no later than 90 days after the date of the Department's Notice of Decision, approving the patient's application.

2)         The patient did not inform the provider of his/her eligibility for Medical Assistance.  In such a case, the post approval request must be received no later than six months after the date of service, but will be considered for payment only if there is attached to the request a copy of the provider's dated, private pay bill or collection correspondence, which was addressed and mailed to the patient each month following the date of service.

3)         A request for payment was submitted to a third party billing within six months following the date of service.  In such a case, a post approval request must be received by the Department no later than 90 days after the date of final adjudication by the third party.

(Source:  Amended at 28 Ill. Reg. 4958, effective March 3, 2004)