SB 2325

Abstract

Amends the Medical Assistance Article of the Illinois Public Aid Code. In a provision requiring the Department of Healthcare and Family Services to establish, by rule, a process by which a provider of ambulance services can appeal a denied request for payment of ambulance services (rather than payment of non-emergency transportation by means of ground ambulance service), provides that for all appeals concerning ambulance services provided on and after December 15, 2012, the provider shall establish the medical necessity of the transport utilizing the patient care report and any other materials available in accordance with specified criteria established under the Code. Provides that a Physician Certification Statement, Certificate of Transportation Services, or Medical Certification for Non-Emergency Ambulance form is not necessary to establish subject matter jurisdiction for appeal or medical necessity on appeal but may be considered if available. Provides that all Department rules, or parts thereof, in conflict with the provisions of the amendatory Act shall not apply. Provides that nothing in the amendatory Act shall be construed to affect any rights, actions, or causes of action that accrued prior to the effective date of the amendatory Act, except that the non-necessity of a Physician Certification Statement, Certificate of Transportation Services, or Medical Certification for Non-Emergency Ambulance form as provided in the amendatory Act shall be retroactively applied to the full extent permissible. Senate Floor Amendment No. 1 Replaces everything after the enacting clause. Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that for all claims concerning ambulance services provided to fee-for-service Medicaid beneficiaries denied for failure of submittal of a valid Physician Certification Statement, Certificate of Transportation Services, or Medical Certification for Non-Emergency Ambulance provided on and after December 15, 2012, the provider shall be able to appeal such denial and establish the medical necessity of the transport utilizing the patient care report and any other materials available in accordance with specified criteria established under the Code. Provides that a Physician Certification Statement, Certificate of Transportation Services, or Medical Certification for Non-Emergency Ambulance form is not necessary to establish subject matter jurisdiction for appeal or medical necessity on appeal but may be considered if available. Provides that all Department rules, or parts thereof, in conflict with the provisions of the amendatory Act shall not apply. Provides that nothing in the amendatory Act shall be construed to affect any rights, actions, or causes of action that accrued prior to the effective date of the amendatory Act, except that the non-necessity of a Physician Certification Statement, Certificate of Transportation Services, or Medical Certification for Non-Emergency Ambulance form as provided in the amendatory Act shall be retroactively applied to the full extent permissible, including allowing any claims denied for failure to 4procure such form which were not appealed at the time of denial to have an opportunity for proper appeal. House Floor Amendment No. 1 Replaces everything after the enacting clause. Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that for non-emergency ground ambulance claims properly denied under the policy of the Department of Healthcare and Family Services at the time the claim is filed due to failure to submit a valid Medical Certification for Non-Emergency Ambulance on and after December 15, 2012 and prior to January 1, 2021, the Department shall allot $2,000,000 to a pool to reimburse such claims if the provider proves medical necessity for the service by other means. Requires providers to submit any such denied claims for which they seek compensation to the Department no later than December 31, 2021 along with documentation of medical necessity. Provides that no later than May 31, 2022, the Department shall determine for which claims medical necessity was established. Provides that such claims for which medical necessity was established shall 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. Provides that if the pool is not sufficient, claims shall be paid at a uniform percentage of the applicable rate such that the pool of $2,000,000 is exhausted. Provides that the appeal process described in a specified provision of the Code shall not be applicable to the Department's determinations. Effective immediately.