X. Service Authorization and Prior Approval

A. General Requirements

DHS must authorize all waiver services. Waiver services may not be initiated for an individual before an award letter or written authorization from DHS, Division of Developmental Disabilities is received. The Department is not financially liable for services prior to the effective date of the award letter/written authorization, including meeting all of the terms and conditions stated in the award letter.

Providers must submit the application information packets to the ISC agency. ISC agencies must submit application packets for the requested services to the Region Facilitator when requesting service authorization. Providers and ISC agencies should address questions about service authorizations to the Region Facilitators and Representatives.

The application packets include:

CILA packets in accordance with the CILA Individual Rate Determination Model.
Application for Individual Service Authorization (pdf) (IL462-1248) and packet for Home-Based Support Services (HBS), Community Day Services, Children's Support Waiver services, Child Group Home services, and other fee-for service programs.

Providers electronically transmit the following additional information to DHS Central Office prior to service authorization:

The ISC agency must transmit the determination the individual meets the waiver eligibility criteria. The effective date on the Reporting of Community Services (ROCS) system is the date the determination was made as documented on the Determination of Developmental Disability and Associated Treatment needs (DDPAS-5 (pdf)).

Note: DHS will not process fee-for-service bills for payment unless this information is transmitted timely, the SSN is correct, and the effective date of the service authorization is on or before the service date on the bill.

Providers must complete and transmit client case information in the Reporting of Community Services (ROCS) system.

Note: The provider must transmit acceptable client case information in ROCS before any fee-for service programs may be paid.

Providers must complete the following forms at the time of initial service authorization and maintain them in the individual's file:

Release of Information (pdf) (IL462-1214) completed annually or as needed and maintained by the primary direct service provider (i.e., CILA, CDS, or SDA provider).).
Notice of Individual Right to Appeal (pdf) (IL462-1202) or equivalent, completed as needed and maintained by the primary direct service provider.
Rights of Individuals (pdf) (IL462-1201) or equivalent, completed as needed and maintained by the primary direct service provider.
Choice of Supports and Services (pdf) (IL462-1238) completed and maintained by the ISC agency.

B. Prior Approval Requirements by Service Type

Some waiver services (Supported Employment, Adult Day Care, Enhanced Residential Day Program, Other Day Program, Temporary Intensive Staffing, Occupational Therapy, Physical Therapy, Speech Therapy, Adaptive Equipment, Assistive Technology, Vehicle Modifications, Home Accessibility Modifications, Remote Support, and Crisis Services) have additional prior approval requirements. Prior approval requirements for each of these service types are detailed below and on the DHS website, please see Becoming New Developmental Disability Provider.

The Department will mail an award letter or a denial letter with appeal rights with the results of its consideration of the prior approval request. The letters are sent to the individual, guardian, if applicable, ISC agency, and provider agency.

Supported Employment Program

Individuals in the Adult Waiver seeking Supported Employment Program (SEP) Individual services and funding must first achieve successful case closure from the Division of Rehabilitation Services Vocational Rehabilitation (DRS VR) Program. In most cases, individuals with a disability are presumed eligible for DRS VR Services but must be determined capable of benefiting from the service.

DRS VR offices can be found by using the IDHS Office Locator and referrals can be made online via the DRS Web Referral. If DRS VR personnel determine an individual is both eligible for, and capable of benefitting from, DRS VR services, an Individualized Plan for Employment (IPE) may be developed which describes the intended employment outcome and parties responsible for various service components of the IPE, such as Counselling and Guidance, Information and Referral, Placement and others.

DRS VR services, supports and funding are short term and time limited. As the DRS VR case progresses and individuals obtain Competitive Integrated Employment, consistent with the IPE, and demonstrate stability on the job, consideration should be given to requesting long-term employment supports through the Adults with Developmental Disabilities Home and Community Based Services Waiver via the Division of Developmental Disabilities Supported Employment Program.

Individuals in the Adults with Developmental Disabilities Home and Community Based Services Waiver seeking Supported Employment Program (SEP) Group services and funding are not required to achieve a successful DRS VR outcome as this service is not available from DRS.

Requests for Supported Employment Program services and funding through the Division of Developmental Disabilities must be submitted, by the provider, to the Independent Service Coordination (ISC) agency assigned to the individual. The request must include fully complete and accurate versions of the following:

Alternative Day Program Request (ADPR)
Supported Employment Questionnaire
DRS Closure Notification (only required for Supported Employment Program Individual and must be successful closure)

Adult Day Program and Virtual Day Services

Requests for prior approval for Adult Day Care, Enhanced Residential and Virtual Day Services must be submitted to Region Representatives using the Alternative Day Program Request Form (IL462-0285). The prior approval requests must include:

An explanation of why the individual is appropriate for and needs these services, including diagnoses, age, health/medical issues, and behavioral issues, if any.
An explanation of why Community Day Services or Supported Employment program options are not appropriate, including the individual's special needs that cannot be met by a traditional day program.
Names of providers who were contacted and the reasons each provider gave for declining to serve the individual. If applicable, include reasons why the individual and/or guardian, if applicable, rejected day programs.
For Enhanced Residential Day Program, an individual program plan that describes the services the individual will receive. The plan should provide a detailed weekly schedule that includes the time staff are directly working with the individual. If the individual has been rejected for or refuses to attend traditional day services, the plan should include goals that would transition the individual into an appropriate day program.
Statement of support for the request from the ISC agency.

Temporary or Long-Term Intensive Staffing

Prior approval requests submitted to the Region Representative must include documentation of the individual's behavioral or medical needs for which Temporary or Long-Term Intensive Staffing is required.

Physical Therapy, Occupational Therapy, and Speech Therapy

The Medicaid State Plan covers some therapy services for Medicaid beneficiaries. These services typically include assessments and short-term restorative services.

Adult Waiver individuals may be eligible to receive additional PT, OT, or Speech Therapy services under the Waiver with prior approval. Therapy authorizations under the waiver are generally continued across state fiscal years as long as the individual needs and is receiving the services.

Therapy Services Received Under the Medicaid State Plan

The Medicaid State Plan, in addition to the Waiver Program, covers the following therapy services for Medicaid beneficiaries of all ages:

Therapy evaluations, as needed, for individuals who are enrolled in Medicaid without prior approval. The Medicaid State Plan enrolled therapist does the evaluation and submits the bill directly to the Department of Healthcare and Family Services (HFS) according to HFS procedures.
Ongoing therapy services that are restorative in nature, such as those needed after an injury or hospitalization or another specific cause to restore the individual to a previous level of functioning. Prior approval from the HFS Bureau of Comprehensive Health Services is required before the Department of Healthcare and Family Services (HFS) will pay bills for ongoing physical therapy, occupational therapy, and speech therapy services.

Questions about HFS Medicaid State Plan requirements and procedures should be directed to the HFS Bureau of Comprehensive Health Services at (217) 782-5565 or on the HFS website. Copies of the manuals for therapists that contain instructions and sample forms are available upon requests from the HFS Provider Participation Unit at (217) 782-0538.

Prior Approval Requirements for Therapy Services Received Under the Adult DD Waiver

Prior Approval Requirements for Therapy Services Received Under the Adult DD Waiver

Waiver-funded physical therapy, occupational therapy, and speech therapy services require prior approval from the Division of DD. The provider must submit the Medicaid Waiver Therapy Prior Approval Request (pdf) found at the Region Representative webpage.

The provider may not initiate waiver-funded physical therapy, occupational therapy, or speech therapy services for an individual before receiving written confirmation of service authorization. Questions about Division of DD service authorization should be directed to the ISC agency you reside in and then the Region Facilitators and Representatives.

A waiver prior approval request for up to 26 hours of therapy per state fiscal year must include:

A completed and signed copy of the Medicaid Waiver Therapy Prior Approval Request (pdf) (IL462-1302) form.
A signed and dated evaluation completed by a licensed physical therapist, occupational therapist, or speech therapist. The evaluation must identify needed services and the reason(s) the individual needs the services because of chronic conditions related to his/her developmental disability. If HFS is terminating the individual from HFS funded restorative services because the individual is making no further progress, the evaluation should include this information and a copy of the HFS denial of further services should be attached.
A copy of the physician's therapy order.
An HFS denial, only if the Division initially denied the requested therapy services as restorative and referred the individual to HFS. In such cases, the therapist may resubmit prior approval requests with documentation that HFS has denied the services under the Medicaid State Plan.

A waiver prior approval request for up to 52 hours of therapy per state fiscal year must include:

1. A completed and signed copy of the Medicaid Waiver Therapy Prior Approval Request (pdf) (IL462-1302) form.
2. A signed and dated evaluation completed by a licensed physical therapist, occupational therapist, or speech therapist. The evaluation must identify needed services and the reason(s) the individual needs the services because of chronic conditions related to his/her developmental disability. If HFS is terminating the individual from HFS funded restorative services because the individual is making no further progress, the evaluation should include this information and an HFS denial of further services should be attached.
3. A letter from the physician describing the individual's needs and expected improvement due to the additional hours to justify why 26 hours of therapy are insufficient.
4. A Department of Healthcare and Family Services (HFS) denial, only if the Division initially denied the requested therapy services as restorative and referred the individual to HFS. In such cases, the therapist may resubmit prior approval requests with documentation that HFS has denied the services under the Medicaid State Plan.
5. A copy of the current, complete, signed and dated personal plan.
Adaptive Equipment, Assistive Technology, Vehicle Modifications, Home Accessibility Modifications, and Remote Support

When a need for adaptive equipment (program code 53E), assistive technology (program code 53T), vehicle modifications (program code 53V), home accessibility modifications (program code 53H), or remote supports (program code 53E or 53T) has been identified, the service must be reflected in the Person-Centered Planning documents. The Independent Service Coordination (ISC) agency will ensure the request for service is complete and submitted to the Division of Developmental Disabilities (DDD). The ISC should also explain the process and criteria, as outlined in this document, to the individual, guardian, if applicable, and/or family.

DDD Waiver funding for adaptive equipment, assistive technology, vehicle modifications, home accessibility modifications, and remote support require prior approval from the DDD. A description of each of these can be found in VI. Waiver Activities and Services. Equipment should not be purchased, and work should not begin until an award letter has been received. Potential vendors should access the Provider Enrollment page at for information on the enrollment process. Payment will not be made until the vendor has become an enrolled Medicaid Waiver provider. The Department is not liable for any financial obligation for items purchased without an award letter, for funding beyond the amount in the award letter, or from a vendor or contractor who is not enrolled as a Medicaid Waiver provider. The Department is a possible source of funding, but the Department is not a party to the contract for services between the individual, guardian, if applicable, and/or family and the vendor. Therefore, the Department is not responsible for accepting the equipment or modifications from the vendor or contractor, nor is the Department responsible for enforcement of any warranty or the quality of workmanship provided by a contractor or vendor.

For each person in a DDD Waiver, there is a $15,000 maximum per five-year period, for any combination of adaptive equipment, assistive technology, vehicle modifications, home accessibility modifications, and/or remote support. For rented or leased homes, there is a $5,000 maximum (per address) within the five-year period, for permanent home modifications. When a request is approved, the Division will award the least expensive estimate or bid provided in the request. The award letter will be mailed to the DDD Waiver individual, guardian, if applicable, ISC agency, and the provider agency, as applicable. If the request is not approved, the Division will mail a denial letter along with the individual's appeal rights. This letter will be sent to the individual, guardian, if applicable, ISC agency, and the provider agency, as applicable. When a request is not approved, the ISC must inform the individual, guardian, if applicable, and/or family of their right to appeal this decision.

C. Approval and Submission Guidelines for Adaptive Equipment, Assistive Technology, Vehicle Modifications, Home Accessibility Modifications, and Remote Support

Approval Criteria

Adaptive equipment, assistive technology, vehicle modifications, home accessibility modifications, and remote support must meet general criteria for prior approval per Administrative Code, Part 120 (commonly known as Rule 120, Section 120.40, c).

Requested equipment or modifications must:

Be essential to address needs brought about by the developmental disability and must be for direct benefit to the individual.
Be necessary to prevent institutional placement, to deinstitutionalize an individual or to enable the individual to participate in specialized habilitative services for individuals with developmental disabilities.
Increase independence and decrease reliance on supports and services provided by either paid or unpaid workers.
Be usable by the individual throughout the year and may not be for back-up or secondary use, except for back-up generators, if necessary, to ensure continuous operation of disability-related electrical equipment.
Be the most cost-effective way to address the developmental disability-related needs of the individual.
Be included in the Personal Plan.

General utility items or items perceived by the general taxpaying public as a luxury are excluded from coverage.

Submission Requirements

Request for adaptive equipment, assistive technology, vehicle modifications, home accessibility modifications, and remote support must include all the following:

1. Completed and signed copy of the Adaptive Equipment / Assistive Technology / Home and Vehicle Modification / Remote Support Request Cover Sheet (pdf) [IL462-1301]. This must be completed and signed by the ISC agency. When a provider agency assists with the request, they should also sign this document.
2. Detailed description of the requested item or modification. The description must address the reason the item(s) or modification are necessary and how they are related to the developmental disability. The ISC or provider agency shall develop this description. If there is no provider agency associated with the request, the ISC must develop the description.
3. Two detailed cost estimates/bids. For each item, the individual, family, guardian, if applicable, or provider agency should obtain detailed estimates or bids for the equipment or work to be completed. Itemized costs must be given for all items requested or for each part of the modification. For example, separate or itemize the costs for a roll-in shower, door widening and grab bars, as opposed to providing one estimate for bathroom accessibility remodeling. Once complete, the individual, family, guardian, if applicable, or provider agency should forward this information to the ISC.
4. Payee Designation/Authorization Form (pdf), IL462-1180], if the vendor chooses to designate an alternate payee to receive the payment. If the vendor or contractor is not yet known, the payee designation form may be submitted after the award letter is received, but before the payee agency submits bills. The process and guidelines for establishing an alternative payee can be found on the Waiver Service Billing Guidance.
Additional Guidelines and Required Information by Service Type

In addition to the approval criteria and submission requirements above, prior approval requests for Adaptive Equipment, Assistive Technology, Vehicle Modification, Home Accessibility Modification, and Remote Support must also follow the Additional Guidelines by Service Type outlined below. The individual, family, guardian, if applicable, or provider agency should obtain the Required Information below, and submit it to the ISC.

-	Additional Guidelines by Service Type	Required Information (Request must include the following)
Adaptive Equipment and Assistive Technology	1. The item must not be covered under the State Medicaid Plan. (Adaptive equipment paid by DDD is not available to meet medical needs such as requests related to diabetes, allergies, obesity or respiratory problems requiring oxygen and special medical equipment or supplies. These types of equipment should be requested through Medicaid medical benefits.) 2. The item must be based on an assessment by a physician, physical therapist, occupational therapist, or speech therapist, as appropriate to the disability. DDD reserves the right to request a copy of the assessment as part of its review for approval. 3. The item must be the property of the individual or the individual's family and be for the individual's use.	1. Information on whether the item is to be purchased, rented or repaired, and whether it is a new item or a replacement for a currently owned item. 2. A written denial from the Department of Healthcare and Family Services (HFS) for communication devices and wheelchairs. DHS reserves the right to require a written denial from HFS for other adaptive equipment or assistive technology. 3. A physician's order or an assessment by a physical therapist, occupational therapist, or speech therapist, as related to the disability, if requested by DHS.
Home Accessibility Modification	1. Modifications must be in accordance with state or local building codes. 2. For CILA homes, modifications must comply with the requirements of the CILA Start-Up Guidelines which is available online. 3. Homes must be the primary residence of the individual and the individual is expected to live in the home for a period of at least one year. 4. For rented or leased homes, individuals must have written permission from the landlord to make the modifications.	1. Information on whether the individual owns, rents, or leases the home. 2. Information on whether the modification is being done to an existing structure or if the home is all new construction. 3. Written permission from the landlord if the individual rents or leases the home. The written permission must include a statement the landlord understands the modifications are permanent and the Department bears no responsibility for the home modification or for returning the building to its previous condition. The permission should also stipulate the landlord will not change the rent due to the modifications. The modification for rented or leased homes is capped at $5,000.00. 4. Proof of home ownership if the home request exceeds $5,000. For agency-owned or controlled homes, see the CILA Start-Up Guidelines on the DHS website.
Vehicle Modification	1. The vehicle must be the property of the individual or the individual's family and be for the individual's use. 2. The vehicle must be the individual's primary vehicle for basic transportation. 3. Vehicles that are five or more years old must have sufficient remaining useful life, as determined by a mechanic, to justify the investment of the requested modifications. 4. Vehicle modifications will not be funded more than once in a five-year period. Replacement or repair of broken or worn out individual components of a lift mechanism may be considered on a case-by-case basis within the five-year period when not covered by a warranty or insurance. *Vehicle modifications do not include necessary general vehicle repairs, such as struts, shock absorbers, electrical system, tires, engine, transmission, muffler, brakes, or body work.	1. Information on whether the item is to be purchased, rented or repaired, and whether it is a new item or a replacement for a currently owned item. 2. An evaluation by a mechanic that determines the estimated remaining useful life of the vehicle.
Remote Support	1. Installation of equipment must be in accordance with state or local building codes. 2. Homes must be the primary residence of the individual and the individual is expected to live in the home for a period of at least one year. 3. The item must not be covered under the Medicaid State Plan. 4. The item must be the property of the individual and be for the individual's use	1. Information on whether the individual owns, rents, or leases the home. 2. Written permission from the landlord if the individual rents or leases the home. The written permission must include a statement the landlord understands the modifications may be permanent and the Department bears no responsibility for the installation of the equipment or for returning the building to its previous condition.

Additional Guidelines by Service Type

Required Information

(Request must include the following)

Adaptive Equipment

and

Assistive Technology

1. The item must not be covered under the State Medicaid Plan. (Adaptive equipment paid by DDD is not available to meet medical needs such as requests related to diabetes, allergies, obesity or respiratory problems requiring oxygen and special medical equipment or supplies. These types of equipment should be requested through Medicaid medical benefits.)

2. The item must be based on an assessment by a physician, physical therapist, occupational therapist, or speech therapist, as appropriate to the disability. DDD reserves the right to request a copy of the assessment as part of its review for approval.

3. The item must be the property of the individual or the individual's family and be for the individual's use.

1. Information on whether the item is to be purchased, rented or repaired, and whether it is a new item or a replacement for a currently owned item.

2. A written denial from the Department of Healthcare and Family Services (HFS) for communication devices and wheelchairs. DHS reserves the right to require a written denial from HFS for other adaptive equipment or assistive technology.

3. A physician's order or an assessment by a physical therapist, occupational therapist, or speech therapist, as related to the disability, if requested by DHS.

Home Accessibility Modification

1. Modifications must be in accordance with state or local building codes.

2. For CILA homes, modifications must comply with the requirements of the CILA Start-Up Guidelines which is available online.

3. Homes must be the primary residence of the individual and the individual is expected to live in the home for a period of at least one year.

4. For rented or leased homes, individuals must have written permission from the landlord to make the modifications.

1. Information on whether the individual owns, rents, or leases the home.

2. Information on whether the modification is being done to an existing structure or if the home is all new construction.

3. Written permission from the landlord if the individual rents or leases the home. The written permission must include a statement the landlord understands the modifications are permanent and the Department bears no responsibility for the home modification or for returning the building to its previous condition. The permission should also stipulate the landlord will not change the rent due to the modifications. The modification for rented or leased homes is capped at $5,000.00.

4. Proof of home ownership if the home request exceeds $5,000. For agency-owned or controlled homes, see the CILA Start-Up Guidelines on the DHS website.

Vehicle Modification

1. The vehicle must be the property of the individual or the individual's family and be for the individual's use. 2. The vehicle must be the individual's primary vehicle for basic transportation. 3. Vehicles that are five or more years old must have sufficient remaining useful life, as determined by a mechanic, to justify the investment of the requested modifications. 4. Vehicle modifications will not be funded more than once in a five-year period. Replacement or repair of broken or worn out individual components of a lift mechanism may be considered on a case-by-case basis within the five-year period when not covered by a warranty or insurance. *Vehicle modifications do not include necessary general vehicle repairs, such as struts, shock absorbers, electrical system, tires, engine, transmission, muffler, brakes, or body work.

1. Information on whether the item is to be purchased, rented or repaired, and whether it is a new item or a replacement for a currently owned item.

2. An evaluation by a mechanic that determines the estimated remaining useful life of the vehicle.

Remote Support

1. Installation of equipment must be in accordance with state or local building codes.

2. Homes must be the primary residence of the individual and the individual is expected to live in the home for a period of at least one year.

3. The item must not be covered under the Medicaid State Plan.

4. The item must be the property of the individual and be for the individual's use

1. Information on whether the individual owns, rents, or leases the home.

2. Written permission from the landlord if the individual rents or leases the home. The written permission must include a statement the landlord understands the modifications may be permanent and the Department bears no responsibility for the installation of the equipment or for returning the building to its previous condition.

Waiver coverage for adaptive equipment, assistive technology, vehicle modifications, home accessibility modifications, and remote support require prior approval. Equipment should not be purchased, and work should not begin until an award letter has been received. The Department is not liable for any financial obligation for items purchased without an award letter, or for funding beyond the amount in the award letter, or from a vendor or contractor who is not enrolled as a Medicaid waiver provider.

The Department is a possible source of funding, but the Department is not a party to the contract for services between the individual, guardian, if applicable, and/or family and the vendor. Therefore, the Department is not responsible for accepting the equipment or modifications from the vendor or contractor, nor is the Department responsible for enforcement of any warranty or the quality of workmanship provided by a contractor or vendor.