Illinois Compiled Statutes 305 ILCS 5/5F-32 – Non-emergency prior approval and appeal
Current as of: 2024 | Check for updates
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(a) MCOs must have a method of receiving prior approval requests 24 hours a day, 7 days a week, 365 days a year from nursing home residents, physicians, or providers. If a response is not provided within 24 hours of the request and the nursing home is required by regulation to provide a service because a physician ordered it, the MCO must pay for the service if it is a covered service under the MCO’s contract in the Demonstration Project, provided that the request is consistent with the policies and procedures of the MCO.
In a non-emergency situation, notwithstanding any provisions in State law to the contrary, in the event a resident‘s physician orders a service, treatment, or test that is not approved by the MCO, the enrollee, physician, or provider may utilize an expedited appeal to the MCO.
If an enrollee, physician, or provider requests an expedited appeal pursuant to 42 C.F.R. § 438.410, the MCO shall notify the individual filing the appeal, whether it is the enrollee, physician, or provider, within 24 hours after the submission of the appeal of all information from the enrollee, physician, or provider that the MCO requires to evaluate the appeal. The MCO shall notify the individual filing the appeal of the MCO’s decision on an expedited appeal within 24 hours after receipt of the required information.
(b) While the appeal is pending or if the ordered service, treatment, or test is denied after appeal, the Department of Public Health may not cite the nursing home for failure to provide the ordered service, treatment, or test. The nursing home shall not be liable or responsible for an injury in any regulatory proceeding for the following:
(1) failure to follow the appealed or denied order;
In a non-emergency situation, notwithstanding any provisions in State law to the contrary, in the event a resident‘s physician orders a service, treatment, or test that is not approved by the MCO, the enrollee, physician, or provider may utilize an expedited appeal to the MCO.
Terms Used In Illinois Compiled Statutes 305 ILCS 5/5F-32
- Appeal: means any of the procedures that deal with the review of adverse organization determinations on the health care services the enrollee believes he or she is entitled to receive, including delay in providing, arranging for, or approving the health care services, such that a delay would adversely affect the health of the enrollee or on any amounts the enrollee must pay for a service, as defined under 42 C. See Illinois Compiled Statutes 305 ILCS 5/5F-15
- Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
- Contract: A legal written agreement that becomes binding when signed.
- Demonstration Project: means the nursing home component of the Medicare-Medicaid Alignment Initiative Demonstration Project. See Illinois Compiled Statutes 305 ILCS 5/5F-15
- Department: means the Department of Healthcare and Family Services. See Illinois Compiled Statutes 305 ILCS 5/5F-15
- Enrollee: means an individual who resides in a nursing home or is qualified to be admitted to a nursing home and is enrolled with a managed care organization participating in the Demonstration Project. See Illinois Compiled Statutes 305 ILCS 5/5F-15
- individual: shall include every infant member of the species homo sapiens who is born alive at any stage of development. See Illinois Compiled Statutes 5 ILCS 70/1.36
- MCO: means an entity that meets the definition of health maintenance organization as defined in the Health Maintenance Organization Act, is licensed, regulated and in good standing with the Department of Insurance, and is authorized to participate in the nursing home component of the Medicare-Medicaid Alignment Initiative Demonstration Project by a 3-way contract with the Department of Healthcare and Family Services and the Centers for Medicare and Medicaid Services. See Illinois Compiled Statutes 305 ILCS 5/5F-15
- Nursing home: means a facility licensed under the Nursing Home Care Act. See Illinois Compiled Statutes 305 ILCS 5/5F-15
- Physician: means an individual licensed to practice in all branches of medicine under the Medical Practice Act of 1987. See Illinois Compiled Statutes 305 ILCS 5/5F-15
- Resident: means an enrollee who is receiving personal or medical care, including, but not limited to, mental health treatment, psychiatric rehabilitation, physical rehabilitation, and assistance with activities of daily living, from a nursing home. See Illinois Compiled Statutes 305 ILCS 5/5F-15
- State: when applied to different parts of the United States, may be construed to include the District of Columbia and the several territories, and the words "United States" may be construed to include the said district and territories. See Illinois Compiled Statutes 5 ILCS 70/1.14
If an enrollee, physician, or provider requests an expedited appeal pursuant to 42 C.F.R. § 438.410, the MCO shall notify the individual filing the appeal, whether it is the enrollee, physician, or provider, within 24 hours after the submission of the appeal of all information from the enrollee, physician, or provider that the MCO requires to evaluate the appeal. The MCO shall notify the individual filing the appeal of the MCO’s decision on an expedited appeal within 24 hours after receipt of the required information.
(b) While the appeal is pending or if the ordered service, treatment, or test is denied after appeal, the Department of Public Health may not cite the nursing home for failure to provide the ordered service, treatment, or test. The nursing home shall not be liable or responsible for an injury in any regulatory proceeding for the following:
(1) failure to follow the appealed or denied order;
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or
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(2) injury to the extent it was caused by the delay
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or failure to perform the appealed or denied service, treatment, or test.
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Provided however, a nursing home shall continue to monitor, document, and ensure the patient’s safety. Nothing in this subsection (b) is intended to otherwise change the nursing home’s existing obligations under State and federal law to appropriately care for its residents.