WAG 20-03-01: Prior Approval

PM 20-03-01.

Decisions on requests for prior approval must be made and the notice sent within the time limits for the requested service or item. If the notice is not dated and sent to the client by the last day of the time limit, the request for prior approval is automatically approved.

  1. (FCRC) Check to be sure that the form has been filled out completely.
  2. (FCRC) Contact the provider to get the information, if items are not readable or correct, and the Family Community Resource Center does not have the needed information.
  3. (FCRC) Return the request only if there is not enough information to make a decision.
  4. (FCRC) Batch all prior approval requests that require central approval and mail daily to:

    Bureau of Comprehensive Health Services
    P.O. Box 19124
    Springfield, IL 62763-0001 

  5. (FCRC) Date stamp a prior approval request and immediately send it to the correct office, if it is received and the Family Community Resource Center is not the office that should approve the request.

    NOTE: The time limit for making a decision on a request starts the day it is received by HFS, even if the request is sent to the wrong office. 

  6. (CO) Enters information from prior approval request forms into the Medicaid Management Information System (MMIS). When an item/service requires prior approval, only a bill that MMIS shows has received prior approval will be paid.
  7. (CO or FCRC) The appropriate approval authority processes prior approval requests for spenddown clients. It does not matter if the client is in "met" or "unmet" status.
  8. (CO) Sends a computer generated notice of approval:
    • Prior Approval Notification (Form 3076) to the client and provider to tell them that all requests, except for drugs or supplies, have been approved; or
    • Notice of Decision on Request for Pharmaceutical Service/Item (Form 2744) for requests for prescription drugs or supplies.
  9. (CO or FCRC) Send Notice of Decision on Request for Medical Service/Item (Form 2352) to the client and provider for all denials and when Form 3076 or Form 2744 cannot be sent.
  10. (CO or FCRC) Use Form 2352 to deny a transportation request.
  11. (CO) Sends a copy of the notice to the Family Community Resource Center when denying a request for prior approval or approving a lesser service or item, or approving the request.