Prior Authorization Policy and Dispute Processes
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Governs prior authorization requirements, timelines, exclusions, and dispute resolution processes that Illinois Medicaid managed care plans must follow; affects Providers, Contractors, and Enrollees under the Department of Healthcare and Family Services contract.
No material clinical or coverage changes in this revision.
Prior Authorization Coverage and Exceptions
Prior Authorization Coverage and Exceptions
Department contract mandates specific situations where prior authorization is not required or where specific timelines/requirements apply.
Exceptions where prior authorization is NOT required
- Anticonvulsant medications (all brand and generic antiseizure/epilepsy drugs) when a diagnosis of an anti-seizure disorder is present in the claim record — no prior authorization or exception review may be applied.
- Inpatient newborn claims for newborns who are retroactively enrolled — Contractor shall not require prior authorization.
- Emergency Services — prior authorization is not required.
- Services provided by contracted school-based health centers recognized by the Department of Public Health and local health departments with which the Contractor has contracts — Contractor shall not require prior authorization or a referral as a condition of payment.
- Family planning and reproductive healthcare services — Contractor policies shall not present barriers such as prior authorizations or step-failure therapy requirements.
- Mobile Crisis Response Services — crisis and stabilization services shall not require prior authorization for an established period post-crisis of at least 30 days.
Nursing facility and MLTSS-specific rule
- For MLTSS Enrollees residing in a nursing facility, if Contractor does not provide a response to an authorization request within 24 hours and the facility is required by regulation to provide a physician-ordered service, the Contractor must pay for the service if it is a Covered Service and the request is consistent with Contractor policies and procedures.
Authorization timelines and expedited review
- Ordinary prior authorization requests shall be reviewed and decided within 4 days of receipt, with a possible extension of up to 4 additional days if requested by the Enrollee or if additional documentation is needed and the Enrollee will not be harmed by the extension.
- If following the ordinary review timeframe could seriously jeopardize the Enrollee's life or health, Contractor shall decide no later than 48 hours after receipt (expedited review).
- Prior authorization decisions for pharmacy services shall be made no later than 24 hours after receipt of the request.
Codes and Code-Based Rules
| All anticonvulsant medications (brand and generic) must be accessible without prior authorization when diagnosis of anti-seizure disorder is in the claim record. |
Provider Requirements, Timelines, and Exemptions
Establish and Respond to Service Authorization Disputes
Plans must establish a service authorization dispute process that allows Providers to contest an authorization denial or a reduction, suspension or termination of a previously authorized service; Plans must provide a substantive written response intended to resolve the dispute within thirty (30) business days after receipt of the dispute request.
Authorization Decision Timelines and Expedited Review
Requests for authorizations shall ordinarily be reviewed and decided within four (4) days after receipt, with a possible extension of up to four (4) additional days; if life or health is jeopardized, decisions must be made within forty-eight (48) hours. Prior authorization decisions for pharmacy services must be made no later than twenty-four (24) hours after receipt.
No PA for Retroactively Enrolled Newborn Inpatient Claims
Contractor shall not require prior authorization for inpatient newborn claims for newborns who are retroactively enrolled.
Nursing Facility 24‑Hour Response and Payment Requirement
For MLTSS enrollees residing in a nursing facility, if Contractor does not provide a response to an authorization request within twenty-four (24) hours and the facility is required by regulation to provide a physician-ordered service, the Contractor must pay for the service if it is a Covered Service and the request is consistent with Contractor policies and procedures.
Emergency Services Are Exempt from Prior Authorization
Prior authorization is not required for Emergency Services.
No PA or Referral Required for Contracted School‑Based Health Centers
Contractor shall not require prior authorization or a referral as a condition of payment for services provided by contracted school-based health centers recognized by the Department of Public Health.
No PA or Referral Required for Contracted Local Health Departments
Contractor shall not require prior authorization or a referral as a condition of payment for services provided by contracted local health departments recognized by the Department of Public Health.
Family Planning — No Prior Authorization or Step‑Therapy Barriers
Contractor policies shall not present barriers or restrictions to access to family planning and reproductive healthcare, such as prior authorizations or step‑failure therapy requirements.
Key Terms
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