Date: January 31, 2023
To: Enrolled Ambulance Providers
Re: NETSPAP Informal Ambulance Appeal Review Timely Filing Reminder
This notice is a reminder to all enrolled ambulance providers regarding the requirements for filing an informal ambulance appeal review for denied services under the Medicaid fee-for-service (FFS) program.
All entities must follow administrative rule 89 Ill. Admin. Code Section 104.205 regarding timely informal ambulance appeal review filing requirements. The informal appeal review request must be filed within 90 calendar days from the date of transport and must include a copy of the prior approval decision issued by the Department or its authorized agent, as well as a brief statement of the appeal issue and all documentation supporting the appeal request. This includes documents supporting medical necessity and/or proof that a Physician Certification Statement was requested (see administrative rule 89 Ill. Admin. Code Section 140.491 for additional information).
No exceptions will be made by the Department or its authorized agents regarding the time frame for requesting an informal review of a denied ambulance transport. Providers should direct these informal ambulance appeal review requests to the attention of First Transit's NETSPAP Appeals Unit, either by fax at 630-403-7529, or in writing to the following address:
Attention: NETSPAP Appeals Unit
799 Roosevelt Rd, Bldg. 4 Suite 200
Glen Ellyn, Illinois 60137
First Transit will conduct an informal review of the request for appeal and will issue a written decision (the '205(d) decision') to reverse, modify or affirm the Department's initial decision within 60 calendar days of the date the informal review request was received. If the Department's initial decision following the informal review remains denied, the provider may request a hearing in writing on the Department's 205(d) decision to the Illinois Department of Healthcare and Family Services (HFS), Bureau of Administrative Hearings, 69 West Washington, 4th Floor, Chicago, IL 60602. This request must be received by the Department by the deadline date noted in the 205(d) decision letter received by the provider.
To help avoid potential issues with these timelines, all providers are required to request prior authorization preferably five to seven business days prior to the transport occurring to ensure approval of the transport. If this is not possible due to time constraints for the transport, providers are reminded that they should file post authorization requests within 30 calendar days from the trip date of service. If the provider is enrolled in First Transit's Passport system, please check Passport within five to seven business days after filing the post authorization request to obtain the final determination status. If a provider is not enrolled in First Transit's Passport system, a post authorization determination letter will be mailed to the provider.
Providers are strongly encouraged to enroll in First Transit's Passport system to allow for electronic submission of prior or post authorization medical transports, as well as to receive timely electronic notification of the disposition of all transport requests. This will help to ensure the ambulance provider can meet the 90-day timeframe to request an informal review for a denied ambulance transport request.
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