Rule and Procedure Table of Contents
A. INTRODUCTION TO ILLINOIS MEDICAL ASSISTANCE | B. OTHER AGENCY RESOURCES | C. THIRD PARTY LIABILITY | D. MEDICAL SERVICES AND INFORMATION FOR | E. MEDICAID INELIGIBLE SERVICES | 1. General Services Not Covered by | 2. Specific Services Not Covered by | F. PRIOR APPROVAL PROCESS | Approved Requests | Denied Requests | Emergency Prior Approvals | G. PAYMENT PROCEDURES - MEDICAID ELIGIBLE | H. PAYMENT PROCEDURES - MEDICAID INELIGIBLE
A. INTRODUCTION TO ILLINOIS MEDICAL ASSISTANCE PROGRAM |
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The Illinois Medical Assistance Program is the federal-state public assistance program which implements Title XIX of the Social Security Act (Medicaid). It is administered by the Department of Public Aid (DPA) under the Illinois Public Aid Code. The Department of Public Aid has statutory responsibility for the formulation of policy in conformance with federal and state requirements.
The objective of the Medical Assistance Program is to enable eligible persons to obtain essential medical care and services necessary to preserve health, prevent or alleviate sickness, and correct handicapping conditions. Essential care and services are those which are generally recognized as standard medical services required because of disability, disease, infirmity or impairment.
A variety of medical services are available to children for whom the Department of Children and Family Services has legal responsibility (wards). Most of these services can be obtained through DPA's Medical Assistance Program via the Medicaid card for DCFS wards with the exception of children in the home of parent (HMP), those in the Refugee Assistance Program and Armed Services Duty (ASD). Additionally, coverage has been extended to youth who have been adopted with an ongoing monthly adoption subsidy payment. (Refer to P351, Appendix A)
When any of these DCFS wards (hereafter referred to as DCFS category 98 youth) are determined Medicaid ineligible they can still receive the same medical services as eligible youth. However, payment for such services will be paid from DCFS funds in accordance with Title XIX Medicaid established rates through the Department of Public Aid.
The cost of Medicaid ineligible services for a DCFS category 98 youth is covered when the:
1) service provider is an out-of-state non-Medicaid enrolled provider or an Illinois non-Medicaid enrolled dental or optical provider and the child needs the service, and
2) provider is licensed/certified according to applicable laws of the state in which he/she practices, or
3) child is Medicaid ineligible, and
4) service has been authorized/prior approved by DCFS, and
5)
service provider's bill is submitted to DPA on the appropriate form(s) within
six (6) months of service delivery.
B. OTHER AGENCY RESOURCES |
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State agencies other than DPA and DCFS have responsibility for coordinating the provision of selected medical services under specific conditions. When a DCFS ward is eligible for the services of other agencies, such resources must be used first. Such agencies include but are not limited to those whose programs are described below.
1. University of Illinois Division of Services for Crippled Children:
Refer to P 302, Subpart C, Appendix C, for services and referral procedures.
2. Illinois Department of Rehabilitation Services:
The Department of Rehabilitation Services has responsibility for providing services to individuals with physical or mental disabling conditions which constitute a substantial handicap to employment. Persons who are in need of medical services or prosthetic devices to improve their employability are to be referred through the local DPA or DCFS office to the Department of Rehabilitation Services.
C. THIRD PARTY LIABILITY |
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The state must be assured that all other resources for payment of medical services are utilized before accepting financial responsibility for payment of medical bills. The Department of Children and Family Services will not make payment to a provider for any service for which any other third party is legally obligated to make payment. A third party is defined as an individual, institution, corporation, or public or private agency that is liable to pay all or part of the medical cost of injury, disease, or disability of a person receiving medical assistance. The Department of Children and Family Services is the payer of last resort.
It is the responsibility of the provider to ascertain from each individual whether there are other resources that are available for payment for the services rendered.
At intake or case opening, DCFS staff must obtain and record any information regarding medical insurance or other third party who is financially liable for the child's medical expenses.
D. MEDICAL SERVICES AND INFORMATION FOR MEDICAID ELIGIBLE SERVICES/PROVIDERS |
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1. Physician Services: Covered services include these reasonably necessary and remedial services which are recognized as standard medical care required because of illness, disability, infirmity or impairment, and which are necessary for immediate health and well-being.
Qualified providers include Medicaid enrolled or licensed/certified doctors of medicine (M.D.) or osteopathy (D.O.), specialized surgeons, anesthesiologists, radiologists and M.D.s who are registered psychiatrists.
See Section E, 2c for excluded services.
Prior approval form: DPA 1409
See Section F, 2 for items requiring prior approval.
Provider billing form: DPA 2360
2. Chiropractic Services: The only chiropractic service for which payment may be made is manual manipulation of the spine to correct a subluxation of the spine which has resulted in a neuromusculoskeletal condition for which such manipulation is an appropriate treatment.
See Section E, 1 and E, 2, e for excluded services.
Prior approval form: DPA 1409
See Section F, 2 for services requiring prior approval.
Provider billing form: DPA 1443
3. Dental Services: Payment is made for those services essential to prevent dental disease and to restore and maintain adequate dental function to assure good bodily health of the patient.
See Section E, 1 and E, 2, d for excluded services.
Prior approval form: DPA 2242
See Section F, 2 for services requiring prior approval.
Provider billing form: DPA 134
4. Audiological Services: Audiological services are those services consisting of basic and advanced hearing tests, hearing aid evaluations, counseling, hearing aid fitting and retesting of amplification upon the completion of the 30 day trial with a hearing aid and those services offered by a hearing aid dispenser, including the dispensing, fitting, repair, replacement of parts, and the provision of hearing aid accessories.
See Section E, 1 for excluded services.
Prior approval form: DPA 2240
See Section F, 2 for services requiring prior approval.
Provider billing form: DPA 1443
5. Podiatry Services: Services covered are limited and include only diagnostic, laboratory and surgical services for which medical necessity is clearly established.
See Section E, 1 and E, 2, g for excluded services.
Prior approval form: DPA 1409
See Section F, 2 for services requiring approval.
Provider billing form: DPA 1443
6. Optician and Optometrist Services: Covered services include the provision of glasses and other materials which are required to restore and conserve vision. Only one pair of glasses will be provided in a 12 month period. (Replacement glasses within a twelve (12) month period may be authorized for a DCFS category 98 child through the DCFS prior approval process.)
See Section E, 1 and E, 2, h for excluded services.
Prior approval form: DPA 1409
See Section F, 2 for prior approval process.
Provider billing form: DPA 1443
7. Therapy Services: Providers include physical therapists, occupational therapists, and speech therapists/pathologists.
See Section E, 1 and E, 2, i for excluded services.
Prior approval form: DPA 1409
See Section F, 2 for services requiring prior approval.
Provider billing form: DPA 1443
8. Independent Laboratory Services: Payment for services will be made only when the following conditions are met: a) the test for which charges are made is within the specialties or subspecialties the laboratory is certified by Medicare to provide and b) the individual's referring practitioner has provided the laboratory with a written signed order which includes the diagnosis or condition.
See Section E, 1 and E, 2, b for excluded services.
There is no prior approval form for services.
Provider billing form: DPA 2211
9. Medical Equipment/Supplies: A written recommendation of patient care plan authorized by the individual's physician is required in the provision of medical supplies and equipment. Medical items/ services covered are: a) non-durable medical supplies, b) durable medical equipment, c) prosthesis and orthoses, d) respiratory equipment/supplies and e) repair, alteration, and maintenance of necessary durable medical equipment, prothesis and orthoses.
See Section E, 1 and E, 2, a for excluded services/items.
Prior approval form: DPA 2240
See Section F, 2 for services/items requiring prior approval.
Provider billing form: DPA 2210
10. Medical Transportation Services: Transportation to or from a source of medical care is a covered service if the transportation is not available without charge. Oxygen usage is a covered service when required during transport by ambulance. Use of an attendant during transport by Medicar is a covered service when medically indicated. Eligible providers include:
a) Ambulances inspected by Department of Public Health (DPH)
b) Medicars certified by the Illinois Commerce Commission (ICC)
c) Taxicabs certified by the Secretary of State and where appropriate, by local regulatory agencies.
d) Service cars (vehicles in business for hire)
e) Private auto
f) Other modes of transportation (bus, train, airplane, etc.). Providers must be enrolled and approved by DPA for participation in the Medical Assistance Program. Foster parents can become transportation providers when necessary to ensure adequate medical care for the child.
Prior approval for medical transportation of a DCFS category 98 child will be authorized by DCFS Regional staff.
See Section E, 1 and E, 2, f for excluded services.
Prior approval form: DPA 2239
See Section F, 2 for services requiring prior approval.
Provider billing form: DPA 2209
11. Pharmacies - Drugs/Prescriptions: Included are drugs in DPA's Handbook for Pharmacies or drugs/medications not in the Handbook for which the prescribing physician or pharmacist has obtained prior approval via DPA's Pharmacy and Drug Prior Approval Unit. (When any other required drugs/medications are needed for a DCFS category 98 child, authorization will be in accordance with Section F, 3, of these procedures.)
See Section E, 1 and E, 2, j for excluded services.
No prior approval form required.
See Section F, 2 for prior approval process.
Provider billing form: DPA 215
12. Inpatient Hospital: Providers include general hospitals, psychiatric hospitals, and physical rehabilitation hospitals. General inpatient hospital services include medical, surgical, pediatric orthopedic, maternity and intensive care services. Inpatient psychiatric services may be provided by a general hospital or by a psychiatric hospital enrolled with DPA for this category of service. Inpatient psychiatric services provided by psychiatric hospitals are covered services for recipients under age 21. Regardless of where inpatient psychiatric services are provided, Medicaid coverage is limited to a maximum of twenty (20) days per admission and forty-five (45) days in any calendar year. When a short-term extension (up to 5 days) is required subsequent to either a twenty (20) or forty-five (45) day stay, the attending physician must request the extension directly from DPA.
See Section E, l for excluded services.
Provider billing form: DPA ll7
13. Physical Rehabilitation Services: Provided by a general hospital or a rehabilitation hospital enrolled with DPA for this category of service. The recipient must have a major physical disability which may be substantially altered by a program of intensive physical rehabilitation.
See Section E, 1 for excluded services.
See Section F, 2 for services requiring prior approval.
Provider billing form: DPA 117
14. Outpatient Hospital: General outpatient hospital services include referred services (physician referral) for lab tests, X-rays, etc., and emergency services.
See Section E, 1 for excluded services.
No prior approval form required.
Provider billing form: DPA 1438
15. Clinic Services: Included are general clinic services, psychiatric clinic services and physical rehabilitation clinic services. General clinic services are diagnostic, therapeutic and palliative services provided under the direction of a physician. Psychiatric clinic services Type A include diagnostic evaluation, individual therapy, control of medication, electric shock treatment, counseling, group therapy and family therapy. Psychiatric clinic services Type B is an active treatment program in which the individual recipient is participating in social, recreational and task-oriented activities. This treatment program is limited to six months in any twelve (12) month period. Physical rehabilitation clinic services should be utilized when the recipient's condition does not necessitate inpatient care.
See Section E, 1 for excluded services.
No prior approval required.
Provider billing form: DPA 1438
16. Psychological Tests: Must be administered by a registered practicing psychologist. It is a DPA-covered service when the tests are for the purpose of determining the child's functioning related to the continuing suitability of a current living arrangement, or need to secure a new living arrangement or other permanency related placement. The provider must list the tests completed and report the time involved for each test.
See Section E, 1 for excluded services.
No prior approval form required.
Provider billing form: DPA 2734
See Section F, 4 for other psychological services.
17. Nursing Services: Covered services include those services provided by registered nurses and nursing services provided through home health agencies by physician referral.
Prior approval form: DPA 1409
Provider billing form: DPA 1443
18. Psychiatric Services: These services can only be provided by qualified providers who are licensed by the state to provide psychiatric services.
See physicians, inpatient hospital, outpatient hospital and clinic services listed in this section.
Prior approval form: DPA l409
Provider billing form: DPA 2360
19. Other Medical Services: For information on any medical service not explained in this section, refer to Sections E and F of these procedures or contact the appropriate DCFS Regional Medical Liaison.
20. Healthy Kids Program (formerly Medichek)
a) Purpose
The Healthy Kids Program is intended to offer Early Periodic Screening, Diagnosis and Treatment Services (EPSDT) to children on welfare and to ensure diagnosis and treatment of suspected problems discovered through such examinations. EPSDT is expected to evaluate children by means of clinical observations and specific screening procedures to separate the "well child" from the child who appears to need a more definitive evaluation. This EPSDT process allows all Healthy Kids Program eligible children access to a continuing health care program on a periodic basis. Included in this health care program are all required immunizations. When a well child enters the first substitute care placement he/she is to be given a Healthy Kids Program examination regardless of age. The Healthy Kids Program provider must note "Healthy Kids Program service per DCFS request" on the billing form. (Refer to P302(67) for the Healthy Kids Program age schedule.)
b) How to Secure Healthy Kids Program Services for a DCFS Ward
There are two methods available to secure services:
The first method is as follows:
When a Medicaid case is opened on DPA's system for a DCFS category 98 child, DPA will send the foster parents/caregiver of the child a Form DPA 2280 which is a postcard that requests the foster parents/caregiver to fill out the card if help is needed in 1) making an appointment for a Healthy Kids Program exam, 2) making an appointment for a dental exam, or 3) transportation to and from a Healthy Kids Program or dental exam. Failure to return this card does not affect Title XIX medical benefits or any financial aid that is being received. Healthy Kids Program services may still be requested any time.
If the foster parent completes the card and mails it back to DPA, a form DPA 2285 (Healthy Kids Program Outreach Request Follow-Through) will be sent to the assigned DCFS caseworker to help the foster parent/caregiver set up an appointment or arrange for transportation. After the child receives his/her initial Healthy Kids Program screening, he/she is enrolled in the Healthy Kids Program.
The second method is as follows:
The foster parent/caregiver or responsible party can make an appointment with a Healthy Kids Program enrolled provider for a screening. After the child receives his/her initial screening, he/she is enrolled in the Healthy Kids Program.
c) Services Offered by Healthy Kids Program
i. Required School Health Examinations:
Healthy Kids Program screenings (health exams) are available for entry into Head Start and kindergarten, or grades 1, 5, and 9. A Healthy Kids Program screening is to be requested and the provider must make the notation that it is a school health exam.
ii. Immunizations:
All required immunizations.
iii. Day Care Pre-Admission Physical Exam:
A Healthy Kids Program screening can be used for this purpose for a DCFS category 98 child.
iv. Camp Physical:
The Healthy Kids Program will pay for a physical examination for a DCFS category 98 child who is authorized to attend a camp and a physical examination is required for admittance to camp.
v. Employment Physical:
The Healthy Kids Program will pay for an employment physical for a DCFS category 98 child.
vi. School Sports Physical:
The Healthy Kids Program will pay for a school sports physical for a DCFS category 98 child.
vii. Foster Care Placement Physical Exam:
The Healthy Kids Program will pay for a physical exam for a DCFS category 98 child entering foster care placement.
d) Provider Billing Form
The provider who performs the Healthy Kids Program
screening completes form PH0600. When the service is for a DCFS category 98
child, the provider must enter "per DCFS request" on the PH0600. The
PH0600 is a dual purpose 4-page form; the first two copies are the billing form
for the provider to be paid for his services. The provider keeps the second
copy for his records and mails the remaining 3 copies to DPA. DPA will enter
the information into its payment system and after payment is authorized, the
last two copies will be forwarded to the assigned DCFS caseworker for a
follow-up on the client, if a referral for other medical services was made by
the Healthy Kids Program provider. It is the responsibility of the DCFS
caseworker to ensure that the client is aware of the referral and to be aware
of the course of action the client intends to take regarding the referral.
a) Direct Vendor Payment,
DCFS shall submit to the Illinois Department of Human Services (DHS) a request for payment of burial and
funeral expenses for a child for whom the Department is legally responsible at the time of his or her death.
DHS reviews the submitted documentation and, after approval of the request, DHS submits a request to the Illinois Department of Public Aid (DPA) for payment, not to exceed DPA limits. The vendor (funeral home or cemetery) prepares the appropriate DPA form(s), attaches necessary receipts and forward the documentation to the DCFS regional office for approval signature. After signature, the DCFS office shall send the completed DPA form(s) and attached receipts to the DHS, Resource and Recoveries Unit at 100 South Grand Avenue East, Springfield, Illinois 62762.
b) Reimbursement:
Reimbursement may be made to any person, other than a financially responsible relative, up to the DPA limits when the person pays the expenses of the funeral/burial for the child. The individual is to complete the appropriate DPA form(s) and forwards the documentation to the DCFS regional office for approval signature. After signature, the regional office must send the DPA form(s) and receipts to the DPA Resources and Recoveries Unit at the above address.
Note: For reporting procedures due to the death of a ward, or for additional services available to families served by the Department, please refer to Procedures 302.387, Crisis Response Protocol.
The Illinois Department of Public Aid will not pay for abortions performed under any of the medical programs it administers, except when an Illinois licensed doctor has determined, in his/her professional judgment, that the life of the mother would be endangered if the fetus were carried to term. Doctors and hospitals will not be able to accept medical eligibility cards for abortions except as specified above.
E. MEDICAID INELIGIBLE SERVICES |
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1. General Services Not Covered by Medicaid |
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Services and supplies for which payment cannot be paid as Medicaid eligible include, but are not limited to, the following (see Section E, 2 below for other exclusions which are related to specific categories of service):
a. Services available without charge
b. Services prohibited by state or federal law
c. Experimental procedures
d. Research oriented procedures
e. Medical examinations required for entrance into educational or vocational programs
f. Autopsy examinations
g. Preventive services, except those provided through the Healthy Kids Program for children through age 20, and required school examinations
h. Routine examinations
i. Artificial insemination
j. Abortion, except in accordance with DPA Rule 4.03 (see Section D, 22, page 109)
k. Medical or surgical procedures performed for cosmetic purposes
l. Medical or surgical transsexual treatment services
m. Diagnostic and/or therapeutic procedures related to primary infertility/sterility
n. Acupuncture
o. Subsequent treatment for venereal disease, when such services are available through state and/or local health agencies
p. Medical care provided by mail or telephone
q. Unkept appointments
r. Medically unnecessary items and services provided for the convenience of individuals and/or their families
s. Preparation of routine records, forms and reports
t. Visits with persons other than a recipient, such as family members or group care facility staff.
u. Desi ineffective drugs
2. Specific Services Not Covered by Medicaid |
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1. Items/services for which medical necessity is not clearly established
2. Items/services inappropriate for the individual's medical condition
3. Prostheses inserted or implanted which do not increase physical capacity, overcome a handicap, restore a physiological function, or eliminate a functional disability
4. Items/services where DPA prior approval has not been obtained when required
5. Stock orthopedic shoes made on special order and attached to a brace
6. Medical equipment and supplies for persons who are residents of long-term care facilities, except when the item is necessary for the continuous care and exclusive use of the individual to meet an unusual medical need.
7. Major bracing and prosthesis except when recommended by a licensed/certified amputee clinic or rehabilitation center
1. Laboratory services when not specifically required by the condition for which the recipient is being treated
2. Laboratory services provided to persons eligible for Medicare Part B benefits when the Medicare intermediary determines that the services are not medically necessary
3. Laboratory tests which are available without charge from the Illinois Department of Public Health or other private and governmental agencies (e.g. cities and counties)
4. Tests and study of specimens referred as a result of an autopsy examination
5. Tests which have not been performed on the laboratory's premises, by the laboratory's staff, using the laboratory's equipment and supplies
6. The collection and handling of specimens obtained for referral to another laboratory
7. Sensitivity studies when a culture shows no growth or when a growth is identified as beta hemolytic streptococcus
8. Tests ordered for Healthy Kids Program screening purposes
1. Examinations required for the determination of disability or incapacity
2. Services provided in federal or state institutions
3. Procedures performed to attempt to restore fertility subsequent to sterilization
4. Those prostheses inserted or implanted which do not increase capacity, overcome a handicap, restore a physiological function or eliminate a functional disability
1. General screening when there is no presenting complaint and request for care
2. Routine or periodic examinations other than:
o Initial examination
o Periodic examinations, when a minimum of 12 months has elapsed since the initial or previous periodic examination
o Required school examination
3. Acrylic crowns
4. Provider transportation costs to provide services at a location other than the dentist's office
5. Full mouth X-rays taken more than once every 3 years
6. Root canal treatment and apicoectomies for other than front teeth
7. Complete dentures except for AABD recipients and only for adult AFDC recipients
1. Diagnostic office visits (screening)
2. X-rays and laboratory tests provided in office
1. Non-emergency transportation where prior approval has not been given
2. Services inappropriate for the individual's condition (e.g., a non-emergency ambulance trip when a service car trip is warranted)
3. Services of a paramedic, emergency medical technician, or nurse
4. Transportation of a person having no medical need
5. "No Show" trips
6. Charges for mileage other than loaded miles--miles incurred while actually transporting the patient
7. Transportation of a deceased child
8. Charges for waiting time
9. Charges for meals, lodging, parking, tolls
10. Transportation by a non-adoptive legally responsible relative
11. Transportation provided by vehicle other than those owned or leased and operated by the provider
1. Visits and services provided to individuals eligible for Medicare benefits, if the services are determined not medically necessary by Medicare
2. Preventive or reconstructive services
3. Screening for foot problems
4. Visits by more than one family member on the same day when definitive pathology is not present
5. Provider transportation cost
6. X-rays, laboratory work or similar services when not specifically required by the primary condition for which the recipient is being treated
7. X-rays and laboratory procedures performed at a location other than the podiatrist's own office
8. Routine post-operative visits
9. Surgical assistants and/or co-surgeons
10. Services available from other sources including, but not limited to, private and governmental agencies
11. Treatment of flat feet, non-involved sprains or strains and minor skin condition, including services directed toward the care or correction of these conditions
12. Any services billed in association with non-covered services, such as X-ray, laboratory, routine visits
13. Services performed in the absence of localized illness, symptoms or injury involving the foot or digit
14. Repeat surgery performed because original surgery was not successful
15. Podiatric consultations
1. Non-standard frames which are not considered as standard
2. Frames replaced due to the recipient's preference for a change in style, color, etc.
3. Second pair of eyeglasses within one year unless lost or broken
Services offered at no charge by private or governmental agencies (e.g., speech therapy/correction classes offered by school districts)
Those items/drugs which are not listed in the DPA Handbook for which no prior approval has been obtained.
F. PRIOR APPROVAL PROCESS |
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1. DPA
Prior approval by DPA is required for certain Medicaid eligible services/items in order for payment to be made. The prior approval is an authorization for the provider to bill for these services. Services/items requiring prior approval are identified in Sections D and F and in the DCFS Prior Approval Handbook. The appropriate forms to be used for requesting prior approval are explained in Section D of these procedures and the Handbook.
Providers are responsible for obtaining DPA prior approval for Medicaid eligible services/items. Approval is not transferable; only the provider who submitted the request may provide the approved services/items.
In cases of emergency the provider can request oral prior approval by telephoning the appropriate DPA Prior Approval Unit. If the child's condition is so severe that his or her life is endangered and there is not enough time to seek approval by telephone, or the service is needed at a time when DPA's office is closed, the service may be provided before obtaining prior approval. When an emergency approval is obtained by telephone or the service is provided before obtaining prior approval, the provider must still submit the request in order to receive an approval authorization for billing purposes.
The provider and the child's caretaker will receive notification of the action taken on a prior approval request. When the request is denied, the child's caretaker will be advised of his/her right to appeal the decision and to have a fair hearing. The provider may not appeal, but is to be advised that the request for an appeal will be referred to DCFS for consideration.
2. Services Requiring DPA Prior Approval: Abortion, sterilization, hysterectomy and surgery for morbid obesity require prior approval. Additionally the following services require prior approval:
a. Continuous treatment for the same diagnosis involving more than six visits
b. Continuous treatment for the same diagnosis exceeding a period of 21 days
a. Space management therapy
b. Crowns
c. Root canal therapy - front teeth only
d. Periapical services
e. Periodontal treatment
f. Dentures - partial and complete
g. Fixed prosthodontics (bridge pontics and crowns)
h. Surgical extraction of impacted teeth
i. Alveoloplasty
j. Removal of cysts and neoplasms
k. Frenulectomy
l. Comprehensive orthodontic treatment
m. Analgesia (anesthesia)
a. Hearing aids
b. Hearing aid repair when cost will exceed $100.00
a. Orthomechanics
b. Multiple surgery (or procedures) for bilateral bunion corrections with osteotomies of the first metatarsals
c. Surgical procedures within six-month period following original surgery
d. Services and/or procedures not specifically identified in DPA Handbook for Podiatrists
Therapy Services (Physical, Occupational, Speech)
All therapy services except those therapy services provided in the 30 calendar day period immediately following hospital discharge if the patient was already receiving therapy while hospitalized.
Prior approval is required by DCFS prior to the provision of transportation services to and from the source of medical care, except for emergency ambulance service.
Prior approval is required for the provision of all medical equipment/supplies.
Pharmacies
Any item that is not listed in the DPA Handbook for Pharmacies which a physician deems essential for treatment of the ward. Prior approval for drugs not listed in the DPA Pharmacy Handbook may be obtained for a DCFS category 98 child when the required drug is by prescription from a physician. The pharmacist or physician must call the DPA Pharmacy and Drug Prior Approval Unit at 1-800-252-8942 during regular business hours.
a. Soft/hard contact lens
b. Contact lens service
c. Gas permeable
d. Custom-made artificial eye(s)
e. Low vision device
a. Prior approval is not required for outpatient physical rehabilitation.
b. DPA prior approval is not required for the first 30 days of inpatient physical rehabilitation, but if more than 30 days of inpatient services are required, prior approval is needed.
3. DCFS
Prior approval by DCFS' Regional Medical Liaison is required for certain services/supplies which are ineligible under the Medicaid program, but are required for DCFS category 98 children. The provider must submit the prior approval request on the appropriate DPA prior approval request form. When prior approval is granted, it is not transferable to another service provider.
Prior approval for Medicaid eligible transportation for DCFS category 98 youth will be authorized by DCFS Regional Staff.
The DCFS prior approval process is designed to ensure:
- access to Medicaid ineligible services for DCFS category 98 youth,
- reimbursement to Medicaid enrolled or registered providers through DPA's payment system, and
- reimbursement at a rate in accordance with Title XIX guidelines or DCFS approved rates.
Service providers requesting DCFS prior approval must follow these specific guidelines:
A) Be Medicaid enrolled or licensed/certified according to applicable state laws.
B) Ensure that the needed service is not a Medicaid eligible service in accordance with the DPA Provider Handbook.
C) Complete the appropriate DPA prior approval request form.
D) Submit the prior approval request form to the DCFS Regional office in the area where the child is served.
The DCFS Regional Medical Liaison shall review the prior approval request form for accuracy and completeness. The decision to approve or deny the requested service shall be determined by individual case circumstances, caseworker consultation as appropriate, the need for the service and shall not conflict with the child's service plan. Decisions to approve or deny the prior approval request shall be made as soon as possible, but no later than five (5) working days after receipt.
Approved Requests |
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Payment to the service provider is not guaranteed unless the prior approval request is approved by the DCFS Regional Medical Liaison. The DCFS approval authorizes the provider to bill DPA and payment will be made in accordance with the Medicaid or DCFS authorized rates.
When prior approval is granted, the DCFS Regional Medical Liaison staff shall assign an authorization number (from the designated set of numbers) on the prior approval form and complete the appropriate data boxes. All approved requests shall be separated by service type; i.e., dental, optometry, podiatry, etc., before being batched and forwarded to DPA on a daily basis. The prior approvals shall be mailed in an envelope which has been clearly marked/stamped in red ink "DCFS Prior Approvals" to Department of Public Aid, P.O. Box 4071, Springfield, IL 62708.
After receipt, DPA will data enter the authorized prior approvals into their system and subsequently notify the provider that prior approval has been granted.
Denied Requests |
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When a prior approval request is denied by DCFS, the DCFS Regional Medical Liaison shall notify the service provider, the ward and foster parent/caretaker by letter, stating the reason for denial. The ward and foster parent/caretaker shall be advised of their right to appeal the decision in accordance with Part 309, Review and Appeal Process.
Emergency Prior Approvals |
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A medical provider may obtain authorization for an emergency DCFS prior approval for a Medicaid ineligible service via telephone to the appropriate DCFS Regional Medical Liaison. An "emergency" is defined as a medical condition or situation which threatens the life of the child; may cause permanent damage to the child; requires services to relieve immediate or significant pain and suffering; or is a service or item necessary for the timely release of the child from acute hospital care.
If the child's condition is so severe that his/her life is threatened and there is not sufficient time to request DCFS prior approval by telephone or the emergency occurs during non-working hours, the service may be provided without prior approval. The service provider must submit the appropriate prior approval request form to the DCFS Regional office on the next working day when an emergency prior approval was granted via telephone or when emergency service was provided (as described above) and prior approval was not secured. The service provider must document that the service was provided as an emergency. Emergency prior approvals shall be completed/processed as noted under Approved Requests.
4. Medicaid Ineligible Services Requiring DCFS Prior Approval
Payment for certain Medicaid ineligible services/supplies can be authorized through the DCFS prior approval process when required for the health and well-being of a category 98 child. Reimbursement to the service provider will be made by DPA following receipt of a prior approval authorization from a DCFS Regional Medical Liaison or appropriate billing forms with DCFS authorization. When services/supplies are needed but Medicaid eligibility cannot be determined, contact the DCFS Medical Liaison in your Region.
Medical services/supplies which are covered via DCFS prior approval include, but are not limited to:
a. Medical examinations required for entrance into educational or vocational programs
b. Autopsy examinations
c. Preventive services, except those provided through the Healthy Kids Program for children through age 20, and required school examinations
d. Routine examinations when required for placement purposes
e. Medical or surgical procedures performed for cosmetic purposes
f. Preparation of routine records, forms and reports
a. Medical Equipment/Supplies
1. Stock orthopedic shoes
2. Medical equipment and supplies for category 98 wards who are residents of long-term care facilities when the item is necessary for the continuous care and exclusive use of the ward to meet an unusual medical need and the item is not Medicaid eligible
3. Bracing and prosthesis when not Medicaid eligible and recommended by a licensed/certified amputee clinic or rehabilitation center.
b. Laboratory Services
1. Laboratory services when not specifically required by the condition for which the ward is being treated (e.g., court-ordered)
2. Laboratory tests which are not available without charge from the Illinois Department of Public Health or other private and governmental agencies (e.g., urine/blood test)
3. Tests and study of specimens referred as a result of an autopsy examination
4. Tests which have not been performed on the laboratory's premises, by the laboratory's staff, using the laboratory's equipment and supplies (e.g., urine/blood tests)
5. The collection and handling of specimens obtained for referral to another laboratory
c. Physicians
1. Examinations required for the determination of disability or incapacity
d. Dental Services
1. Full mouth X-rays more than once every 3 years, when required
2. Root canal treatment and apicoectomies for other than front teeth
3. Complete dentures
e. Chiropractic Services
1. Diagnostic office visits (screening)
2. X-rays and laboratory tests provided in office
f. Medical Transportation
1. Services of a paramedic, emergency medical technician, or nurse in cases of extreme emergencies
2. Charges for mileage other than loaded miles, only under extreme circumstances
3. Transportation of a deceased child
4. Charges for meals, lodging, parking, tolls
5. Transportation provided by vehicle other than those owned or leased and operated by the provider
6. Transportation cost for foster parent when the child must be accompanied to/from the source of medical care.
g. Podiatry Services
1. Preventive or reconstructive services
2. Screening for foot problems
3. Provider transportation cost
4. X-rays and laboratory procedures performed at a location other than the podiatrist's own office
5. Routine post-operative visits
6. Treatment of flat feet, non-involved sprains or strains and minor skin condition, including services directed toward the care or correction of these conditions
7. Any services billed in association with non-covered services, such as X-ray, laboratory, routine visits
8. Repeat surgery performed because original surgery was not successful
9. Podiatric consultations
h. Optician/Optometrist Services
1. Non-standard frames when determined necessary
2. Second pair of eyeglasses within one year as a replacement or due to changes in prescription
i. Pharmacy Items
Those items/drugs which are not listed in the DPA Handbook for Pharmacies, and other DCFS authorized medications/drugs which are deemed necessary. This does not include desi-ineffective drugs.
j. Psychological Services
Evaluations/assessments to diagnose a particular problem related to the suitability of a current or new placement, but not ongoing therapy to treat the problem. NOTE: This service is not available to DCFS wards in the home of parent(s). The evaluation/assessment may be court-ordered or may be needed prior to or in conjunction with psychological tests related to placement planning. The provider is limited to five (5) sessions to complete the evaluation/assessment. Requires authorization by Field Office Supervisor or Unit Supervisor unless the service(s) is court-ordered.
a. MANG spend-down medical expenses incurred by a ward if the ward does not reach the required spend-down amount within the six month period.
b. Payments to Illinois dental or optical providers or any out-of-state providers who provide services to DCFS category 98 wards but who are not enrolled as approved DPA providers.
c. Inpatient psychiatric hospitalization that exceeds the length of stay limitations established by DPA and DMH/DD.
d. Outpatient psychiatric hospital visits that exceed the limitations established by DPA and DMH/DD.
e. Psychological tests, evaluations/assessments for the ward's family member(s) and/or caretaker(s) for placement planning purposes. (Excludes wards in the home of parent.)
f. Any other medical service or item that DPA has excluded or does not cover but is determined by a physician to be essential to the health and well-being of the child for which DCFS has provided authorization.
G. PAYMENT PROCEDURES - MEDICAID ELIGIBLE SERVICES |
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All medical bills for Medicaid eligible services which are incurred on behalf of a DCFS category 98 child through the DPA medical card (DPA 469--Regular Medical Eligibility card or DPA 469D--Temporary Medical Eligibility card) will be processed through DPA's payment system. Bills for Medicaid eligible services must be submitted on the appropriate DPA billing forms to the Department of Public Aid.
When medical services are billed to DPA, the child's Recipient Identification Number (RIN) must be entered on the DPA billing form before submittal. The child's RIN is listed on the Regular Medical Card-DPA 469. However, when services are provided through the Temporary Medical card-DPA 469D, the provider can obtain the child's RIN by telephoning the DCFS Central Office Eligibility Unit at 1-800-228-6544.
Payment procedures for Medicaid-ineligible services are covered in Section H.
When psychological tests are required for a DCFS category 98 child, approval shall be authorized via the Field Office Supervisor except when court ordered. The Field Office Supervisor or Unit Supervisor shall send a referral letter to the selected psychologist which explains the circumstances or need for tests. Simultaneously, a copy of the referral letter shall be forwarded to the appropriate Regional Medical Liaison.
Charges for psychological tests which are administered by a registered psychologist for the purpose of determining a DCFS category 98 child's functioning related to the continuing suitability of a current living arrangement or need to secure a new living arrangement must be submitted to DPA. The C-13 (Invoice Voucher) and the DPA 2734 (Statement of Psychological Services Rendered) will be used for billing purposes and must be completed in accordance with the following instructions:
o DPA 2734
The DPA 2734 must be completed by the service provider in accordance with instructions on the form. An individual form must be completed for each child served, but it is permissible to bill a series of charges for the same child and the same type service on one (1) form. All information related to the child and/or tests given must be typed or legibly printed. The provider's FEIN or Social Security number and an Illinois or out-of-state Registration number must be entered under item 2 and 3 respectively. Item 6 must contain the name of the child to whom the test(s) was given. The completed form must contain the provider's original signature and be forwarded to the Regional Medical Liaison in the Region with service responsibility for the category 98 ward. NOTE: Out-of-state providers must attach a copy of their state registration. After receipt by the Regional Medical Liaison, the form shall be reviewed for accuracy of information and charges.
The DPA 2734 shall not be forwarded to DPA when there are discrepancies, but when the information is correct, the Medical Liaison shall sign and date the form (items 19 and 20) and forward it with the C-13 to DPA. The Regional Medical Liaison must also enter his/her Region in item 21.
o C-13
The Regional Medical Liaison shall ensure that the correct information is entered on the C-13, Invoice Voucher. All entries must be typed:
Item 1 -- Enter name and location of state agency as
Department of Public Aid, 628 East Adams,
Springfield, Illinois 62708.
Item 2 -- Enter the provider's FEIN or Social Security
number and zip code.
Item 3 -- Enter provider's name (last name first) and address
(city, state, zip).
Item 10 - Enter the statement: "DCFS Authorized Services
for:" child's name and child's 98 case identification number. Directly below this information, enter "Date(s) of Services". When the child has received several tests during the same month, enter only the first (1st) date of service in that month (e.g. tests were administered on March 3rd, 5th, and 6th, enter March 3, 1986). DO NOT ENTER the name/type of test nor the fee from the DPA 2734; DPA staff will complete this information. Directly below the Date(s) of Services, enter "Needs Code: 210," and below the Needs Code, enter "DO NOT RECOUP". Use needs code 210 for psychological tests administered to DCFS category 98 wards for placement purposes, and initiated by DCFS or court-ordered.
Since the C-13 will be used for provider payment, it is important to ensure accuracy on the form. When entering the provider's FEIN/Social Security number in Item 2, do not leave any spaces between numbers. In Item 10, charges for more than one child may be entered when the psychological tests were administered by the same psychologist to several DCFS category 98 wards. The number of entries should never exceed seven (7) and the Needs Codes (210 and 211) cannot be mixed on a C-13 Voucher. If a DPA 2734 shows psychological services administered under both categories (210 and 211) a separate C-13 must be used for each category of services. DCFS staff shall sign and date the C-13 as Receiving Officer in Item 26. When the C-13 has been completed, attach the DPA 2734 and any other appropriate documentation (copy of out-of-state registration) and mail to Department of Public Aid, Claims Processing Unit, 931 East Washington, Springfield, Illinois 62763, Att: Carole Luttrell.
To be eligible for DPA payment consideration, a provider's claim or bill must be received by DPA no later than six (6) months from the date on which medical goods or services were provided. Exceptions to this requirement will be permitted only for the following circumstances:
a. The provider was not informed of the child's eligibility for medical assistance.
b. A third party billing was made within six (6) months following the date of service and the third party did not adjudicate such billing in sufficient time to allow for the provider's timely submittal of the remaining unpaid charges. In such cases, a claim for the remaining charges must be received by DPA no later than six months from the final adjudication by the third party.
A claim may be resubmitted to DPA for payment consideration only when the initial claim was submitted within six (6) months of the date of service and the claim has been:
a. Reported by DPA on the Remittance Advice as being rejected for payment, and the condition that caused the rejection can be and has been corrected.
The resubmitted claim must be received by DPA no later than twelve (12) months following the date of service or, if applicable, twelve (12) months following the date of the DPA notice of decision on an application, or twelve (12) months following the date of third party final adjudication.
b. Never reported by DPA on a Remittance Advice as being paid, suspended or rejected, and the provider has made written inquiry to DPA within six (6) months of the date of service regarding the status of the specifically described, unreported claim.
A resubmitted claim must be received not later than twelve (12) months from the date of service and will be considered for payment only if there is attached to the claim a copy of the provider's timely letter of inquiry to DPA regarding the status of the previously submitted, unreported claim.
c. Rejected because of errors in completing the DPA billing form. The errors should be corrected and the billing form resubmitted to DPA for payment.
a. Hospitals
Inpatient
DPA will pay for inpatient hospitalization services at the hospital's established DPA Title XIX inpatient per diem rate. This rate includes all services provided by the hospital.
DPA will pay the established DPA Title XIX outpatient per unit rate. The outpatient per unit rate is multiplied by the number of different units used by the patient on the one visit (e.g., lab, X-ray, EKG, emergency room). Each unit may only be counted as one unit regardless of how many times that unit is used.
If the out-of-state hospital is enrolled as an Illinois DPA provider, DPA will pay the established Title XIX rates.
b. Psychological Tests
The rate of payment to a registered psychologist for psychological tests related to placement will be in accordance with established Medicaid rates for Registered Psychologists.
c. Other Services/Supplies
All other medical services/supplies which are Medicaid eligible will be paid at the Title XIX rate.
H. PAYMENT PROCEDURES - MEDICAID INELIGIBLE SERVICES/PROVIDERS |
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Payment for certain Medicaid ineligible services/supplies provided on behalf of a DCFS category 98 child may be paid from DCFS funds through the Department of Public Aid's payment system. When medical services/supplies cannot be covered as Medicaid eligible or DCFS authorized through DPA, the cost must be paid from DCFS Regional dollars. (Refer to Section 359.9 D, E and F to determine which medical services/supplies are Medicaid eligible or which may be DCFS authorized through DPA.)
The charges for DCFS prior approval services/supplies must be submitted to DPA through the DCFS Regional Medical Liaison. The charges must be on or attached to DPA billing forms. Some charges will be submitted on a C-13, (Invoice Voucher) with a DPA billing form attached. All provider claims/bills must be received by DPA within six (6) months of the date that the service was delivered. Billing instructions for all services/supplies authorized for payment through DPA are contained in these procedures and/or in the DCFS Prior Approval Handbook.
The following procedures shall be used for completing and/or submitting bills to DPA for Medicaid ineligible services which are DCFS prior approved.
a. Psychological Services
When psychological services (tests, evaluations/assessments) are required for DCFS category 98 youth or for substitute caretakers/family members, approval must be authorized via the Field Office Supervisor or Unit Supervisor, unless court-ordered. A letter of referral shall be sent to the selected provider to explain the reason(s) for the requested services and a copy sent simultaneously to the appropriate Regional Medical Liaison. Psychological tests for the child and/or for family members/caretakers must be administered by a registered psychologist. Evaluations/assessments may be provided by persons other than registered psychologists and DPA Medicaid enrolled providers.
o DCFS Category 98 Youth
Payment can be authorized through DPA for evaluations/ assessments to diagnose a particular problem(s) to determine the child's functioning related to the suitability of the current placement or a new placement, but not ongoing therapy to treat the problem(s). An evaluation/assessment may be court-ordered or may be needed prior to or in conjunction with other psychological tests related to placement planning. The provider is limited to five (5) sessions to complete the assessment. This service is not available to a DCFS ward in the home of parent.
o Family Member/Caretaker
Psychological tests, evaluations/assessments may be provided to the child's substitute caretaker(s) or family member(s). Psychological tests for DPA 04, 06, 93 and DCFS 98 categorical cases are Medicaid eligible and may be billed as a 210 service. All other psychological services are Medicaid ineligible and must be billed as a code 211 service. These services must be placement related and conform with the criteria listed above.
The provider billing form, DPA 2734, for psychological services shall be completed as noted for Medicaid eligible services in Section G. 2. above, with the following exception:
Item 6 must contain the name of the individual to whom service(s) was provided and their relationship to the category 98 child when services are for family members and/or caretakers.
The C-13 shall be completed with the correct information. All entries shall be typed:
Item 1 - Enter name and location of state agency as
Department of Public Aid, 628 East Adams, Springfield, Illinois 62708.
Item 2 -- Enter the provider's FEIN or Social Security number and zip code.
Item 3 -- Enter provider's name (last name first) and address (city, state, zip).
Item 10 --Enter the statement: "DCFS Authorized Services
for: "child's name and category 98 case identification number. Directly below this information, enter the "Date(s) of Services", using only the first date of services in each month. DO NOT ENTER the name/type of test nor the fee from the DPA 2734, even though the test was administered to an individual other than the DCFS category 98 ward. DPA will complete the process for all psychological tests. Enter the DPA 2734 information (including charges) for psychological evaluations and assessments of the category 98 ward and/or other family member(s) on the C-13. Next, enter "Needs Code: 211" and "DO NOT RECOUP". (Use Needs Code 211 for all evaluations/assessments and for psychological tests when the individual is not active on a category 04, 06, 93 or 98 case.)
When completing the C-13, do not leave any spaces between the the provider's FEIN/Social Security number. Charges for more than one individual may be entered on the C-13 when the same psychological services are administered by the same provider. Only individual Needs Codes (210 or 211) can be entered on the C-13; they cannot be mixed. DCFS staff shall sign the C-13 in Item 26 as the Receiving Officer and the date of signature. The completed C-13 shall be attached to the DPA 2734 and any other documentation (out-of-state provider registration) and mailed to the Department of Public Aid, Bureau of Claims Processing, 931 East Washington, Springfield, Illinois 62763, Attention: Carole Luttrell.
Psychological tests must be administered by a registered psychologist; evaluations/assessments may be administered by a registered psychologist, therapist, counselor, practicing MSW, etc. When services are provided by an out-of-state provider, a copy of his/her state registration must be submitted with the bill.
Payment rates for psychological tests related to placement will be in accordance with DPA's Medicaid rate for Registered Psychologists. The C-13 (Invoice Voucher) and the DPA 2734 (Statement of Services/Supplies Provided) will be used to bill DPA. Evaluations/assessments can be paid at usual and customary rates.
When psychological services are Medicaid ineligible, they must be coded with NEEDS CODE 211 and PROCEDURE CODE 69999 on the C-13.
b. Optical Services
When a DCFS category 98 ward requires Medicaid ineligible optical services, the cost for such services or optical items will be paid from DCFS allocated funds through DPA's payment system. The ineligible service(s) requires DCFS prior approval. DPA no longer requires prior approval for eyeglasses but the limit of one (1) pair per twelve (12) month period is still effective. Although DPA has discontinued the prior approval process, DCFS will continue to utilize the prior approval process for a "required" second pair of eyeglasses. Additionally, DPA and DOC (Department of Corrections) have entered into an agreement for fabrication/distribution of eyeglasses for all medical card recipients and DPA has requested that DCFS comply with this change and use the DOC process whenever possible. When a situation occurs which requires that a DCFS ward be provided a second pair of eyeglasses immediately, DCFS Medical Liaisons shall utilize procedures for obtaining the needed eyeglasses through the most expeditious means.
The service provider must complete the DPA 1409 (Prior Approval Request) and submit it to the appropriate DCFS Regional Medical Liaison for review and subsequent approval or denial.When approved, the Regional Medical Liaison must assign a prior approval number and complete the approving authority's portion of the DPA 1409 as noted in the DCFS Prior Approval Handbook. Only approved DPA 1409's are to be submitted to DPA for processing. The mailing envelope must be clearly marked in red ink "DCFS Prior Approvals," and mailed to:
Illinois Department of Public Aid
Post Office Box 4071
Springfield, Illinois 62708
DPA will process the DPA 1409 and notify the medical provider by returning the original copy of the DPA 1409. This copy provides the prior approval number and notes that the bill can be submitted directly to DPA for payment. DPA will process the claim and reimburse the medical provider upon receipt of the appropriate billing invoice and any other documentation required.
If denied by the DCFS Region, the Medical Liaison must state the reason for denial in the Service Section of the DPA 1409; forward a copy of the DPA 1409 to the requesting Medical provider; notify the child's foster parent(s)/caretaker of the decision via the client notification letter and maintain a copy of the approved or denied DPA 1409 for audit and inquiry purposes.
c. Dental Services
When Medicaid ineligible dental or orthodontic services are needed for a DCFS category 98 ward, the dentist or orthodontist must submit a completed DPA 2242 to the appropriate DCFS Regional Medical Liaison. The DPA 2242 shall be reviewed for appropriateness and when approved, the Medical Liaison shall complete the DCFS authorization and submit it to:
Speci-Care Consolidated, Inc.
5400 North Milwaukee Avenue
Chicago, Illinois 60630
Speci-Care reviews and prices the service and submits the DPA 2242 to DPA for processing. DPA notifies the medical provider and the child's caretaker. Upon receipt of the notification from DPA, the provider can submit his/her bill directly to DPA for payment.
Payment to non-DPA enrolled providers within the State of Illinois includes providers of psychological evaluations/assessments, optical and dental services. Out-of-state providers who are not DPA-enrolled may be paid for any DCFS prior approved service for the category 98 child. Payment can be made only by a C-13, even though the services may be Medicaid eligible. When the provider is not DPA enrolled, the payment cannot be processed through the Medicaid payment system. This includes both Illinois and out-of-state providers.
The request for service(s) must be submitted to the DCFS Medical Liaison for prior approval. When approval is granted, the provider shall be notified by DCFS. Following service provision, the provider must submit his/her charges on office letterhead/ stationery to the appropriate Regional Medical Liaison. Regional staff shall ensure that the C-13's are completed in accordance with instructions in these procedures and Section 5 of the Prior Approval Handbook. All C-13's must be submitted to DPA at P.O. Box 4071, Springfield, Illinois 62763, for processing and payment.
a. All Medicaid Eligible Services and Items
All Medicaid eligible medical services and items shall be priced according to the Illinois Department of Public Aid's Title XIX structured rates. The Department of Public Aid issues rates for all covered medical services. DCFS staff shall compare the DPA established rate to the fee submitted by the provider. DCFS shall authorize payment for the lesser of the two charges since the DPA rate is the maximum that can be paid.
b. Non-Covered and Excluded Medical Services and Items
When a medical service or item is not Medicaid eligible under the Illinois DPA Title XIX Medicaid Program, DCFS shall authorize payment at the provider's usual and customary rate.
The following services may be secured for any DCFS ward through Regional approval when such services cannot be obtained through the process described under the above Sections. Payment for these Regional approved services must be paid from DCFS Regional monies and not from DPA Medicaid or DCFS funds allocated to DPA.
a. Physician Services
Account Code: 001-41817-4400-08-00
001-41817-4400-09-00
684-41817-4400-00-99
001-41803-4400-02-00
001-41825-4400-01-00
001-41817-4400-05-00
Type Service Code: 1107 - Physician Services
1103 - Unwed Mothers
1101 - Abuse/Neglect
0303 - Adoption/Medical
Payment Documents: CFS 932-1 (Purchase Authorization) and
DPA 2360 or PH0600
Approval Level: Regional Administrator or designee
Instructions: Bills/claims are to be priced in accordance with Section H, 3. Refer to Section D, 1 for description of physician services and Section D, 20 for description of Healthy Kids Program services.
b. Chiropractic Services
Account Code: 001-41817-4400-08-00
684-41817-4400-00-99
001-41803-4400-02-00
001-41817-4400-05-00
Type Service Code: 1113
0303 - Adoption/Medical
Payment Documents: CFS 932-1 (Purchase Authorization) and
DPA 1443
Approval Level: Regional Administrator or designee
Instructions: Bills/claims are to be priced in accordance with Section H, 3. Refer to Section D, 2 for description of chiropractic services.
c. Dental Services
Account Code: 001-41817-4400-08-00
684-41817-4400-00-99
001-41803-4400-02-00
001-41817-4400-05-00
Type Service Code: 1110 - Orthodontic Services
1111 - Other Dental Services
0303 - Adoption/Medical
Payment Documents: CFS 932-1 (Purchase Authorization) and
DPA 134
Approval Level: Regional Administrator or his designee
Instructions: Bills/claims are to be priced in accordance with Section H, 3. Refer to Section D, 3 for description of dental services.
d. Audiological Services
Account Code: 001-41817-4400-08-00
684-41817-4400-00-99
001-41803-4400-02-00
001-41817-4400-05-00
Type Service Code: 1119
0303 - Adoption/Medical
Payment Documents: CFS 932-1 (Purchase Authorization) and
DPA 1443
Approval Level: Regional Administrator or designee
Instructions: Bills/claims are to be priced in accordance with Section H, 3. Refer to Section D, 4 for description of audiological services.
e. Podiatry Services
Account Code: 001-41817-4400-08-00
684-41817-4400-00-99
001-41803-4400-02-00
001-41817-4400-05-00
Type Service Code: 1112
0303 - Adoption/Medical
Payment Documents: CFS 932-1 (Purchase Authorization) and DPA 1443.
Approval Level: Regional Administrator or designee
Instructions: Bills/claims are to be priced in accordance with Section H, 3. Refer to Section D, 5 for description of podiatry services.
f. Optician and Optometrist Services
Account Code: 001-41817-4400-08-00
684-41817-4400-00-99
001-41803-4400-02-00
001-41817-4400-05-00
Type Service Code: 1108 - Eyeglasses
1109 - Other Optical Services
0303 - Adoption/Medical
Payment Documents: CFS 932-1 (Purchase Authorization) and
DPA 1443
Approval Level: Regional Administrator or designee
Instructions: Bills/claims are to be priced in accordance with Section H, 3. Refer to Section D, 6 for description of optician and optometrist services.
g. Therapy Services
Account Code: 001-41817-4400-08-00
684-41817-4400-00-99
001-41803-4400-02-00
001-41817-4400-05-00
Type Service Code: 1120
0303 - Adoption/Medical
Payment Documents: CFS 932-1 (Purchase Authorization) and