WAG 17-03-03-a: Reimbursement of Medical Expenses

PM 17-03-03-a

revised textEach month, the Bureau of Program and Performance Management (BP&PM), formerly called the Bureau of Research and Analysis, determines whether or not medical applicants whose applications were delayed qualify for reimbursement of medical expenses paid while their application was delayed.

  1. (BP&PM) Produces and sends monthly lists to local offices that had dispositions (approval or denial) for the calendar month that exceeded the 45 or 60-day time limit.
  2. (FCRC) Take the following actions for each case on the list.
    • Review the case file to determine if the disposition was not made within the correct time limit because of "Department delay."
    • Complete Status Report Late Applications Disposition (Form 2354), stating whether or not the cause for the late disposition was "Department delay."
    • Send a completed Form 2354 to BP&PM for each case on the list within 10 days of receipt of the list.
  3. (BP&PM) For each month, based on the information submitted on Form 2354, determines if the Department's percent of timely dispositions meets the court ordered standard of 96%.

    NOTE: If the percent of timely dispositions does not meet the 96%, certain persons can qualify for reimbursement of medical expenses. 

  4. (BP&PM) Sends Notice of Possible Eligibility for Payment (Form 2379), to each applicant identified on Form 2354 as having their application disposition delayed by the Department, when the Department's delayed disposition rate exceeded the 96% standard. Sends a copy of the Form 2379 to the FCRC.

    Form 2379 notifies the person that they may be entitled to a reimbursement of paid medical expenses. new textForm 2379 is sent to the applicant on the last workday of the month following the month that the disposition was made.

  5. (Client) Contacts the FCRC in response to Form 2379 and provides proof that:
    • a medical service(s) was provided; and
    • the service was provided between the date of application and the approval date on Form 360C or Form 458; and
    • the payment was made by the applicant, or by someone on their behalf, other than a payment or credit made by the provider of the service or any employee, officer, owner, or agent of the service provider; and
    • the payment was made between the first day the application exceeded the federal time limit and the date of approval on Form 360C or Form 458.

      There is no time limit by which the client must request the reimbursement. 

  6. (FCRC) Review the information provided by the client to make sure it meets the criteria in Step 5.

    Use any of the following sources or combination of the sources to verify the claim: 

    • canceled check,
    • medical billing statement,
    • written statement from the provider,
    • receipt, or
    • any other verification that establishes that payment within the required limit was made by or on behalf of the client for a covered service.

      Only those expenses for services covered by medical benefits are reimbursable. Services provided by a medical vendor not approved by the Department are reimbursable. The Department will not reimburse for a service that has been paid by a TPL resource, such as an insurance company.

  7. (FCRC) Based on the information provided take one of the following actions.
    1. If the person does not provide proof, or if the proof does not verify the claim, do not approve a reimbursement.

      Send Notice of Denial of Request for Compensatory Payment (Form 2380) to the client to deny the claim. 

    2. If the information verifies the client's claim, authorize the reimbursement as follows.
  8. (FCRC) Ask the client to sign and date a C-13, Invoice Voucher.
  9. (FCRC) Make a copy of the proof provided by the client.
  10. (FCRC) revised textSend a memorandum to BP&PM at: Harris II, 2nd floor, 100 S. Grand Avenue East, Springfield, IL 62762, requesting that a reimbursement be made to the client. Attach the C-13 and the supporting information to the memorandum. Place a copy of the verification in the case record.
  11. (FCRC) Tell the client that Springfield will notify them of the decision on the request.
  12. (BP&PM) Notifies the client of the decision as follows:
    • For denials, sends Form 2380.
    • If approved, sends the client the reimbursement.

Long Term Care Cases

Long term care clients can qualify for a reimbursement of medical expenses:

  • because of Department delay in making a disposition, or
  • for non-spenddown case, if authorization for billing is not sent within 10 calendar days of:
    • the approval date of the resident's medical application, if screening is not required, or
    • if screening is required, the date the screening document is received.

The reimbursement is for the amount that has been paid by or on behalf of the resident for covered medical services provided between:

  • the date billing should have been authorized, and
  • the date the billing form was actually issued.