Part 140: MEDICAL PAYMENT

Section 140.1001 Registration Conditions for Alternate Payees a) In order to participate, alternate payees must meet the following conditions: 1) Hold a valid, appropriate license when State law requires licensure of medical practitioners, agencies, institutions and other medical…

Section 140.1002 Participation Requirements for Alternate Payees In order for an individual practitioner to designate that payments that may be due to the practitioner be made to a specific alternate payee, there must be a written alternate payee agreement between the individual …

Section 140.1003 Recovery of Money for Alternate Payees a) An individual practitioner and its designated alternate payee shall be jointly and severally liable to the Department for payments made to the alternate payee on behalf of that individual practitioner. b) Department actio…

Section 140.1004 Conditional Registration for Alternate Payees a) Registration as an alternate payee in the Illinois Medical Assistance Program shall be conditional. At any time, the Department may deny or cancel an alternate payee's registration in the Illinois Medical Assistanc…

Section 140.1005 Revocation of an Alternate Payee a) The Department may seek a revocation of any alternate payee that has participated in the Program, and all owners, officers, a partners, and individuals with management responsibility for the alternate payee shall be permanently…

Section 140.101 Transplants (Recodified) (Source: Recodified to 89 Ill. Adm. Code 148.80 at 13 Ill. Reg. 9497)

Section 140.1010 Mandatory Enrollment in MCOs a) To the extent allowed by federal law and regulations, the Department may require individuals to enroll with a Managed Care Organization (MCO) under contract with the Department and to receive some or all of their medical benefits t…

Section 140.102 Heart Transplants (Recodified) (Source: Recodified to 89 Ill. Adm. Code 148.90 at 13 Ill. Reg. 9497)

Section 140.103 Liver Transplants (Recodified) (Source: Recodified to 89 Ill. Adm. Code 148.100 at 13 Ill. Reg. 9497)

Section 140.104 Bone Marrow Transplants (Recodified) (Source: Recodified to 89 Ill. Adm. Code 148.110 at 13 Ill. Reg. 9497)

Section 140.11 Enrollment Conditions for Medical Providers a) In order to enroll for participation, providers shall: 1) Hold a valid, appropriate license where State law requires licensure of medical practitioners, agencies, institutions and other medical vendors. 2) Be certified…

Section 140.110 Disproportionate Share Hospital Adjustments (Recodified) (Source: Recodified to 89 Ill. Adm. Code 148.120 at 13 Ill. Reg. 12118)

Section 140.116 Payment for Inpatient Services for GA (Recodified) (Source: Recodified to 89 Ill. Adm. Code 148.130 at 13 Ill. Reg. 9497)

Section 140.117 Hospital Outpatient and Clinic Services (Recodified) (Source: Recodified to 89 Ill. Adm. Code 148.140 at 13 Ill. Reg. 9497)

Section 140.12 Participation Requirements for Medical Providers The provider shall agree to: a) Verify eligibility of recipients prior to providing each service; b) Allow recipients the choice of accepting or rejecting medical or surgical care or treatment; c) Provide supplies an…

Section 140.13 Definitions "Abuse". For purposes of this Part and 89 Ill. Adm. Code 104, "abuse" means provider practices that are inconsistent with sound fiscal, business or medical practices and that result in an unnecessary cost to the Medical Assistance Program or in reimburs…

Section 140.1300 Definitions This Subpart adopts the definitions set forth in 89 Ill. Adm. Code 104.910. (Source: Added at 36 Ill. Reg. 7545, effective May 7, 2012)

Section 140.1310 Recovery of Money a) The Department shall recover any and all State and federal monies that the Director, by his or her final administrative decision, has determined were improperly and erroneously paid by: 1) direct payment to the Department; 2) recoupment from …

Section 140.1320 Penalties a) The Department may recover a civil penalty in an amount not to exceed $2,000 for each benefit or payment received, in addition to any other penalties provided by law. b) A written notice of penalty assessment shall be sent to the person against whom …

Section 140.1330 Enforcement a) Upon entry of a final administrative decision for repayment of any unauthorized medical benefits or payments, or for any civil penalties assessed: 1) any unpaid amount of repayment or penalty will constitute a debt due and owing to the Department; …

Section 140.14 Denial of Application to Participate in the Medical Assistance Program a) The Department may deny an application to participate in the Medical Assistance Program if the vendor has engaged in activities which constitute grounds for termination, suspension or exclusi…

Section 140.15 Suspension and Denial of Payment, Recovery of Money and Penalties a) Effective July 1, 2012, theDepartment may suspend or deny payment, in whole or in part, to a vendor or the vendor's alternate payee if the payment would be improper or erroneous or would otherwise…

Section 140.16 Termination, Suspension or Exclusion of a Vendor's Eligibility to Participate in the Medical Assistance Program a) The Department may terminate or suspend a vendor's eligibility to participate in the Medical Assistance Program, terminate or not renew a vendor's pro…

Section 140.17 Suspension of a Vendor's Eligibility to Participate in the Medical Assistance Program In actions based on Section 140.16 in which the Notice states an intent to terminate, the final administrative decision may result in suspension for a specific time, which shall n…

Section 140.18 Effect of Termination, Suspension, Exclusion or Revocation on Persons Associated with Vendor a) Upon termination, suspension or exclusion of a vendor of goods or services from participation in the Medical Assistance Program, a person with management responsibility …

Section 140.19 Application to Participate or for Reinstatement Subsequent to Termination, Suspension, Exclusion or Barring a) A vendor that has been terminated, suspended or excluded from the Medical Assistance Program may not apply to participate for at least one year after the …

Section 140.2 Medical Assistance Programs a) Under the Medical Assistance Programs, the Department pays participating providers for necessary medical services, specified in Section 140.3 through 140.7 for: 1) persons eligible for financial assistance under the Aid to the Aged, Bl…

Section 140.20 Submittal of Claims a) When claims for payment are submitted to the Department, providers shall: 1) Use Department designated billing forms or electronic format for submittal of charges; and 2) Certify that: A) They have personally rendered the services and provide…

Section 140.200 Payment for Hospital Services During Fiscal Year 1982 (Recodified) (Source: Recodified to 89 Ill. Adm. Code 148.150 at 13 Ill. Reg. 9497)

Section 140.201 Payment for Hospital Services After June 30, 1982 (Repealed) (Source: Repealed at 9 Ill. Reg. 9564, effective June 5, 1985)

Section 140.202 Payment for Hospital Services During Fiscal Year 1983 (Recodified) (Source: Recodified to 89 Ill. Adm. Code 148.160 at 13 Ill. Reg. 9497)

Section 140.203 Limits on Length of Stay by Diagnosis (Recodified) (Source: Recodified to 89 Ill. Adm. Code 148.170 at 13 Ill. Reg. 9497)

Section 140.21 Reimbursement for QMB Eligible Medical Assistance Recipients and QMB Eligible Only Recipients and Individuals Who Are Entitled to Medicare Part A or Part B and Are Eligible for Some Form of Medicaid Benefits a) In order to be qualified to receive reimbursement for …

Section 140.22 Magnetic Tape Billings (Repealed) (Source: Repealed at 25 Ill. Reg. 3897, effective March 1, 2001)

Section 140.23 Payment Of Claims a) The Department shall pay only for those services and supplies that: 1) Meet the U.S. Department of Health, Education and Welfare's definition of medical service (42 U.S.C. 1396d); 2) Can be paid by vendor payment; and 3) Are specified in the in…

Section 140.24 Payment Procedures a) Payment of valid claims will be made by a State warrant (check) issued through the Office of the State Comptroller. b) All providers of medical services must designate a payee when enrolling in the Department's Medical Assistance Program. 1) P…

Section 140.25 Overpayment or Underpayment of Claims a) When the Department, the provider, or the designated alternate payee has determined that an overpayment has been made, the provider or the alternate payee shall reimburse the Department for the overpayment. The Department sh…

Section 140.26 Payment to Factors Prohibited a) Payment for any care or service furnished to an individual by a provider will not be made to or through a factor, either directly or by virtue of a power of attorney given by the provider to the factor. In addition, transfers by pro…

Section 140.27 Assignment of Vendor Payments a) Except as provided in this Section, vendor payments and the right to receive such payments are absolutely inalienable by assignment, sale, attachment, garnishment or otherwise. b) A medical vendor may use his or her right to receive…

Section 140.28 Record Requirements for Medical Providers a) Providers shall maintain in the regular course of business the following: 1) Any and all business records that may indicate financial arrangements between the provider and other providers in the program or other entities…

Section 140.3 Covered Services Under Medical Assistance Programs a) As described in this Section, medical services shall be covered for: 1) recipients of financial assistance under the AABD (Aid to the Aged, Blind or Disabled), TANF (Temporary Assistance to Needy Families), or Re…

Section 140.30 Audits a) Effective July 1, 2012, whether pre-payment or post-payment, all services for which charges are made to the Department are subject to audit. During a review audit, the provider shall furnish to the Department or to its authorized representative, pertinent…

Section 140.300 Payment for Pre-operative Days and Services Which Can Be Performed in an Outpatient Setting (Recodified) (Source: Recodified to 89 Ill. Adm. Code 148.180 at 13 Ill. Reg. 9497)

Section 140.31 Emergency Services Audits a) All emergency services for which charges are made to the Department and are provided to a recipient who does not require admission as an inpatient are subject to audit. b) An emergency services audit shall be limited to a review of reco…

Section 140.32 Prohibition on Participation, and Special Permission for Participation a) Prohibition on Participation by Terminated, Suspended, Excluded or Barred Entities 1) Upon being terminated, suspended, excluded or barred, and while the disability from Medical Assistance Pr…

Section 140.33 Publication of List of Sanctioned Entities a) The Department shall publish a list of every entity that is currently terminated, suspended or barred from participation in the Medical Assistance Program and shall include every alternate payee that has been revoked, a…

Section 140.35 False Reporting and Other Fraudulent Activities a) Providers are subject to Section 12-13.1 of the Illinois Public Aid Code, pertaining to penalties for vendor fraud and kickbacks. b) Providers are also subject to Section 1909 (42 U.S.C. 1396h) of the Social Securi…