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Provider Notice Issued 01/25/2022

Date:   January 25, 2022

To:       Enrolled Transportation Providers; Hospitals; and Long Term Care (LTC) Facilities

Re:      Reinstatement of Physician Certification Statement (PCS) Form Requirement Effective February 1, 2022


This notice informs providers of the Department's decision to reinstate the HFS 2270 - Physician Certification Statement (PCS) form as a required transportation document effective February 1, 2022. This change applies to prior approval requests and claims for participants covered under fee-for-service (FFS), as well as HealthChoice Illinois managed care organization (MCO) plans and the Medicare/Medicaid Alignment Initiative (MMAI) plans.  

This notice supersedes the Department's previous notice dated April 8, 2020 that temporarily waived the PCS form during the Public Health Emergency. In an effort to address capacity issues and ensure non-emergency ambulance services are targeted to those most in need of these services, the Department will require the PCS form effective February 1, 2022, for non-emergency ambulance and medicar transports originating from hospitals and LTC facilities.

The transportation provider should not complete the PCS. This certification must be completed prior to transport by appropriate hospital or LTC facility medical staff and a copy provided to the transportation provider at the time of transport.

Some reminders regarding the PCS:

  • The PCS is required for repetitive trips. One PCS form may be valid for recurring ground ambulance transports for up to 60 days, while one PCS form may be valid for recurring medicar/wheelchair van and service car transports for up to 180 days. However, if medical necessity or the level of transportation changes, a new PCS form will be required.
  • LTC facilities and hospitals must maintain a copy of the PCS and, upon request, furnish assistance to the transportation provider in the completion of the form if the PCS is incomplete.
  • The licensed medical professional that signs the PCS must check the appropriate box indicating their certification. Per recent Centers for Medicare & Medicaid Services revisions, the following additional staff may now sign the PCS form: Licensed Practical Nurses (LPN), Licensed Vocational Nurses (LVN), Social Workers, and Case Workers. Other medical staff authorized to sign the form include:  Physician – MD/DO, Physician Assistant, Clinical Nurse Specialist, Registered Nurse, Nurse Practitioner, Discharge Planner and LTC Medical Director.    
  • The PCS is only required when a patient is being transported from a facility and requires non-emergency transportation. The PCS is not required prior to transport if a delay in transport can be expected to negatively affect the patient outcome. In these cases, the form must be provided at no charge within 10 calendar days of the request to the transportation provider. It is the responsibility of authorized medical staff from the originating nursing facility or hospital to complete and return the form within this timeframe.
  • Providers can access an informational document that includes instructions and guidance for correct completion of the PCS form at the following website location:

Questions regarding this notice may be directed to the Bureau of Professional and Ancillary Services at 877-782-5565 for FFS Medicaid participants, or to the applicable HealthChoice Illinois MCO or MMAI plan.

Kelly Cunningham, Administrator
Division of Medical Programs


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