Medical Prior Approval Criteria

Welcome to the Illinois Department of Healthcare and Family Services (HFS) Durable Medical Equipment (DME) Prior Approval Webpage. The Prior Approval Unit handles durable medical equipment, therapeutic supplies, mobility devices, therapies, home health, and bariatric surgery request for the Illinois Department of Health Care & Family Services.  The department will use this page to communicate prior approval information to our providers.

Forms

• HFS3701T Therapy Prior Approval Request Form (pdf)
• Instruction for HFS 3701TI (pdf)
• HFS3701H Seating/Mobility Evaluation (pdf)
• HFS3701K Power Mobility/Custom Manual Wheelchair Physician Form (pdf)
• Instructions for HFS3701H and K (pdf)
• HFS1409 Prior Authorization Request Form (pdf)
• Instructions for HFS1409 Authorization Request Form (pdf)

Medical Prior Approval Criteria

• Standing Device Criteria (pdf) )
• External Defibrillator Criteria (pdf) (html)
• Pediatric Specialty Beds Criteria (pdf) (html)
• Bariatric Surgery (pdf) (html)
• Home and Long Term Care (LTC Oxygen) Therapy (pdf) (html)
• Home Phototherapy (pdf) (html)

Handbook Links 

• Handbook for Providers of Medical Equipment and Supplies
• Handbook for Providers of Medical Services
• Home Health Agencies
• Therapy Services Handbook
• Audiology Handbook
• Podiatrist Handbook

Questionnaires

• Informed Consent for Future LifeVest Rental Related to Compliance with Cumulative Wear Time (pdf)
• Augmentative Communication Systems Assessment Review Checklist (pdf)
• Augmentative Communication Systems Client Assessment Report (pdf)
• Questionnaire For Tens Unit (pdf)
• C-Pap/Bipap Renewal Questionnaire (pdf)
• Special Decubitus Mattress Questionnaire (pdf)
• Standard Manual Wheelchair Questionnaire (pdf)
• Questionnaire for Food Thickeners (pdf)
• Questionnaire for Enteral Nutrition (pdf)
• Questionnaire for Negative Pressure Wound Therapy (pdf)
• Progress Report for Negative Pressure Wound Therapy (pdf)
• Motorized Wheelchair Evaluation Form (pdf)
• Hospital Bed Questionnaire (pdf)
• Air Fluidized Bed Questionnaire (pdf)
• Certificate of Medical Necessity for Continuation of External Insulin Infusion Pump (pdf)
• Certificate of Medical Necessity for External Insulin Infusion Pump (pdf)
• Compression/Burn Garments Questionnaire (pdf)
• Knee Brace Questionnaire (pdf)
• Questionnaire and Order for Cranial Remolding Orthosis or Cranial Cervical Orthosis Congenital Torticollis Type (pdf)
• Questionnaire and Order for Neuromuscular Electrical Stimulator (NMES) (pdf)
• Questionnaire for Airway Clearance Device (pdf)
• Questionnaire for Continued Rental of Airway Clearance Device (pdf)
• Questionnaire for Home Apnea Monitor (pdf)
• Questionnaire for Orthosis (pdf)
• Questionnaire for Home Phototherapy (pdf)
• Questionnaire for Prosthesis (pdf)
• Wound Measurement Assessment Form (pdf)

Other Resource Links

• Illinois Administrative Code Title 89
• DME Information Notices
• Claims Processing System Issues
• Fee Schedules
• Medical Electronic Data Interchange
• Non-Institutional Providers
• Pharmacy Criteria and Forms
• Pharmacy Drug Prior Approval Information
• Illinois Medical Necessity for Nursing Services Reference Manual
• MFTD and NPCS Monthly Nursing Service Allocation Ranges

Contact Information

If you have additional questions regarding Durable Medical Equipment Prior Approval, please call 1-877-782-5565, follow the prompts to the Prior Approval Unit.

For questions regarding Negative Pressure Wound Therapy, please call 217-785-1295 for additional instructions.

Submission of Prior Approval Request:

Submit by fax only –

• For New: 217-524-0099. 

• For Reviews/Specials: 217-558-4359. 

• Medical Program phone directory.
• Illinois State Agency Directory.