Illinois Department of Human Services
Division of Developmental Disabilities
To provide guidance on the Illinois Department of Human Services (IDHS) Division of Developmental Disabilities (DDD) appeals process: Specifically, what issues are appealable, how to properly file an appeal, what information is required in the appeal packet, and who to contact with questions /concerns.
Process & Procedures:
Section 14 of the Independent Service Coordination (ISC) Manual provides guidelines for how an appeal should be filed. Section C below documents what is required to be included in the appeals packet.
Section 14: Appeal Process
Any individual requesting or receiving Medicaid waiver-funded services has the right to appeal the following actions: a denial of clinical eligibility, termination, suspension, or reduction of waiver-funded services, denial of a one-time funding request, or discharge from a DD facility or program. For example, this could be a provider notifying an individual they are no longer eligible for waiver funded services or discharge from a CILA residence or Community Day Service program. It could also include a reduction or termination of a particular service an individual is receiving.
- The ISC, DDD or provider agency, whichever entity took the above-mentioned action, will notify the individual and/or guardian in writing of the action taken and the process to appeal. Note: this should occur after meeting(s) have been held with the entities and individual/guardian where discussions and potential solutions have been discussed.
- The individual and/or guardian will be provided with a notice that includes the action, whether or not services will continue and a copy of the Notice of Individual's Right to Appeal Medicaid Waiver Determinations [IL462-1202].
- If the individual and/or guardian decide to appeal the action they must discuss the situation with their ISC agency and decide if an appeal makes sense for the individual or if other services will meet the individual's needs.
- If the individual and/or guardian, in conjunction with the ISC agency, agree that an appeal should be filed the ISC is responsible for submitting:
- A complete appeal checklist,
- A completed Documentation For Medicaid Waiver Appeals form [IL444-0171] ,
- An appeal packet of documentation/information that will be used in the DDD informal review process for a determination regarding the specifics of the appeal case,
- The appeal packet must include a signed written request to appeal by the individual and/or guardian.
- The appeal packet must be submitted to DDD within 60 calendar days of the date that the individual receives the Notice of Individual's Right to Appeal Medicaid Waiver Determinations [IL462-1202]. The 60-calendar day limitation does not apply if the DDD provider agency, the ISC, DDD, whichever entity or agency took the action, fails to notify the individual in writing of the action or the time limit.
- The Division has 30 working days to complete an informal review of the appeal case and another 10 working days to notify the individual and/or guardian of the informal review decision. Should the individual and/or guardian disagree with the determination by the DDD, they have 10 days to request an administrative hearing with the Illinois Department of Healthcare and Family Services (HFS) to review the DDD's informal review decision.
- Details of the grounds for appeal, notification requirements and appeal process are contained in the Administrative Rule: Medicaid Home and Community-Based Services Waiver Program for Individuals with Developmental Disabilities, Section 120.110 Appeals and Fair Hearings (59 Ill. Adm. Code 120.110).
Appeals packet can be sent via:
- encrypted email: email@example.com
- fax: 217-558-2799 attn Mike Vespa
- mail: DHS-DD - Program Development Unit - Attn. Mike Vespa
- 600 E. Ash St. Bldg 400, 3rd Floor South
- Springfield, IL 62703
For questions pertaining to specific appeals, please reach out to the Program Development Specialist assigned to the appeal.
For any other questions please contact Mike Vespa at 217-785-6171 or firstname.lastname@example.org
September 10, 2020