Date: November 23, 2021
To: Enrolled Transportation Providers
Re: Reconsideration of Previously Denied Ground Ambulance Claims per Public Act 102-0650
Pursuant to the recent passage of Public Act 102-0650 (Senate Bill 2325), the Illinois Department of Healthcare and Family Services (HFS) is allowing the reconsideration of non-emergency ground ambulance claims that were previously denied due to the provider's failure to submit a valid Medical Certification for Non-Emergency Ambulance (MCA) or Physician Certification Statement (PCS). This applies only to claims billed under HFS' fee-for-service program.
For non-emergency ground ambulance claims properly denied under HFS policy at the time the claim was filed, due to failure to submit a valid MCA or PCS form on and after December 15, 2012 and prior to January 1, 2021, HFS will allot $2,000,000 to a pool to reimburse such ground ambulance claims if the provider provides medical necessity documentation for the appropriate level of service by other means. Should the pool not be sufficient, claims will be paid at a uniform percentage of the applicable rate until the pool of $2,000,000 is exhausted.
The appeals process provided for under 305 ILCS 5/5-4.2(f) shall not be available for these claims if providers choose this option. For reconsideration, providers must submit each denied trip for which they seek compensation to HFS no later than December 31, 2021 via secured email to the HFS Transportation Mailbox at HFS.Transportation@Illinois.gov.
The subject line of each email should state: "Reconsideration of Ambulance Appeal –Ambulance Provider Name and RTN Number of Specific Request." Providers should send these requests individually and must ensure that all pertinent information is provided for reconsideration, including but not limited to:
- Cover sheet. This should notate the customer's name, Recipient Identification Number, date of service and RTN number.
- MCA or PCS form (if obtained)
- Documentation of denial
- Supporting documentation of medical necessity for non-emergency ground ambulance (category of service 051) utilization (i.e. hospital discharge face sheet, medical documentation, etc.).
- Completed NETSPAP trip form
- Run report
- Any other pertinent information
Partial requests with insufficient information will not be reviewed or allowed to be held for additional information.
No later than May 31, 2022, HFS will determine claims for which medical necessity was established. These claims will be paid at the rate in effect at the time of the service, provided the $2,000,000 is sufficient to pay at those rates.
Ground ambulance fee for service transports that occurred on and after January 1, 2021 to current that were denied will need to follow the current guidelines in 89 Ill. Admin. Code Section 140.491.
Questions regarding this notice may be directed to the Bureau of Professional and Ancillary Services at 877-782-5565.
Kelly Cunningham, Administrator
Division of Medical Programs