Appeals Process

Purpose:

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 17 of the Independent Service Coordination (ISC) Manual provides guidelines for how an appeal should be filed. Section D below documents what is required to be included in the appeals packet.

Section 17: Appeal Process

1. Any individual requesting or receiving Medicaid waiver-funded services, the individual's guardian or representative, has the right to appeal the following certain actions including the following:
   1. A denial of services or a determination of ineligibility for services from an ISC agency or the Division;
   2.  A termination, suspension, or reduction of waiver-funded services by a provider agency or by the Division.
   3. See Rule 120, Section 120.110 Appeals and fair hearings, for more information on appeals.
2. The ISC, DDD or provider agency, whichever entity took the above-mentioned action, must provide the individual and/or guardian a written notice of the action taken and the process to appeal. The notice must include:
   1. The action to be taken,
   2. Whether or not services will continue, and
   3. A copy of the Notice of Individual's Right to Appeal Medicaid Waiver Determinations form [IL462-1202], pdf.
3. If the individual and/or guardian decide to appeal the action, they must communicate this to the ISC within 10 working days after the date they receive the notice of action. The communication must be followed by a written request to appeal signed by the individual, guardian or individual's representative.
4. The individual and/or guardian decide to appeal the action, the ISC agency is responsible for gathering and submitting:
   1. A complete appeal checklist.
   2. The written request to appeal signed by the individual, guardian, or individual's representative.
   3.  A completed Documentation for Medicaid Waiver Appeals form [IL444-0171].
   4.  An appeal packet of documentation/information that will be used in the informal review process for a determination regarding the specifics of the appeal case.
   5. Documents from the provider agency, if applicable, to support its decision to suspend, terminate, or reduce services.
   6. Any additional documentation relevant to the appeal.
5. The appeal packet must be submitted within 45 calendar days after receiving notification to appeal. 
6.  The Division has 30 working days to complete an informal review of the appeal case.
   1. The DDD must then notify the individual and/or guardian of the informal review decision within 10 working days of that determination.
   2. Should the individual and/or guardian disagree with the determination by the DDD, they have the option of requesting within 10 days, an administrative hearing with the Department of Healthcare and Family Services (HFS) to review the DDD's informal review decision.
7. 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:

For questions pertaining to specific appeals, please reach out to the Program Development Specialist assigned to the appeal.

For any other questions please contact Ashley Kjos at ashley.kjos@illinois.gov

Effective Date:

June 17, 2024