Part 140: MEDICAL PAYMENT

Section 140.432 Limitations on Independent Clinical Laboratory Services The Department shall pay for the following services only when they are provided in accordance with the limitations specified: a) Vitamin B-12 testing – only in those cases in which a completed blood count has…

Section 140.433 Payment for Clinical Laboratory Services a) Payment for allowable laboratory services includes payment for collection and handling of specimens by laboratory personnel, use of laboratory equipment and supplies, and the written report of test results to the referri…

Section 140.434 Record Requirements for Independent Clinical Laboratories a) In addition to the record requirements specified in Section 140.28, independent clinical laboratories must comply with the administrative rules of the Illinois Department of Public Health governing the m…

Section 140.435 Advanced Practice Registered Nurse Services a) For purposes of enrollment in the Medical Assistance Program, an advanced practice registered nurse (APRN) means a person who is licensed as a registered professional nurse, holds a valid license in the state of pract…

Section 140.436 Limitations on Advanced Practice Registered Nurse Services The following will not be reimbursed, unless specifically authorized by rule during a Public Health Emergency: a) Nursing services provided in the role of physician assistant; b) Mileage to and from place …

Section 140.438 Diagnostic Imaging Services a) Payment for diagnostic and imaging services may be made to the following providers that are independent of both a physician's office and a hospital: 1) Imaging Centers that are distinct entities operating primarily for the purpose of…

Section 140.439 Critical Access Care Pharmacy Payment a) To be eligible to receive a Critical Access Care Pharmacy Payment (CAP Payment), a pharmacy provider must: 1) Attest to meeting all the following criteria for the entire previous fiscal quarter: A) Pharmacy is physically lo…

Section 140.44 Withholding of Payments Due to Fraud or Misrepresentation a) Effective July 1, 2012, payments on pending and subsequently submitted bills may be withheld, in whole or in part, to a provider or alternate payee, when there is credible evidence from State or federal l…

Section 140.440 Pharmacy Services a) Payment shall be made only to pharmacies. b) The following conditions apply to pharmacy participation: 1) The pharmacy must hold a current Drug Enforcement Administration (DEA) registration issued by the United States Drug Enforcement Administ…

Section 140.441 Pharmacy Services Not Covered Items excluded from coverage include the following: a) Drug products manufactured by drug manufacturers not meeting the rebate requirements of Section 140.440(d); b) Anorectic drugs or combinations including such drugs; c) Biologicals…

Section 140.442 Drug Product Prior Approval and the Preferred Drug List a) The Department may require prior approval for the reimbursement of any drug product, except as provided in this Section. Determinations of whether a drug product is listed as preferred on the Preferred Dru…

Section 140.443 Filling of Prescriptions a) The prescription must contain the information required under Section 3(e) of the Pharmacy Practice Act of 1987 [225 ILCS 85/3(e)], 68 Ill. Adm. Code 1330 and 42 USC 1936(i)(23) and also contain the prescriber's: 1) Drug Enforcement Admi…

Section 140.444 Compounded Prescriptions a) Pharmacy charges for compounded prescriptions shall be billed at the per ingredient charge to the general public. b) Reimbursement will be at the lower of the pharmacy's charge or the Department's maximum for each ingredient. (Source: A…

Section 140.445 Prescribed Drugs a) Effective July 15, 2019, for prescribed drugs, including prescription and over the counter drugs, the Department shall pay the lower of: 1) the pharmacy's usual and customary charge to the general public; 2) the Department's maximum price plus …

Section 140.446 Over-the-Counter Items (Repealed) (Source: Repealed at 46 Ill. Reg. 2046, effective January 21, 2022)

Section 140.447 Reimbursement a) The calculation of average wholesale price in the determination of the Department's maximum price (Section 140.445(b)) is made using the standard package size. b) If a pharmacy gives discounts to the general public, it must provide the same to Pub…

Section 140.448 Returned Pharmacy Items The Department shall not pay for an unused pharmacy item returned to the dispensing pharmacy by or on behalf of a recipient, due to a change in prescription, death of a recipient, etc., when the item can be accepted by the pharmacy in accor…

Section 140.449 Payment of Pharmacy Items a) The Department shall pay no more for charges submitted than the maximum permitted by federal regulations. b) Explanation of Drug Restrictions 1) Group Care Restricted − The drug is available to all recipient categories except individua…

Section 140.45 Withholding of Payments Upon Provider Audit, Quality of Care Review, Credible Allegation of Fraud or Failure to Cooperate a) Effective July 1, 2012, the Department may withhold payments, in whole or in part, to a provider or alternate payee upon: 1) initiation of a…

Section 140.450 Record Requirements for Pharmacies a) Pharmacies shall retain the following basic records: 1) All original prescriptions for Public Aid recipients; 2) All invoices from all suppliers from which the pharmacy acquires goods for which charges are made to the Departme…

Section 140.451 Prospective Drug Review and Patient Counseling Each pharmacy must ensure that: a) The requirements for patient counseling established by the Illinois Department of Professional Regulation at 68 Ill. Adm. Code 1330.65, including the requirements of confidentiality …

Section 140.452 Community-based Mental Health Providers Qualified for Payment a) Payment will be made for community-based mental health services provided by providers enrolled in the Illinois Medical Assistance Program as: 1) A Community Mental Health Center. Community Mental Hea…

Section 140.453 Community-based Mental Health Service Definitions and Professional Qualifications a) Inter-Departmental Collaboration and Administration. The Department of Human Services-Division of Mental Health (DHS-DMH) and the Department of Children and Family Services (DCFS)…

Section 140.454 Types of Mental Health Services The specific types of mental health services for which payment will be made are: a) Mental health services meeting the standards in 89 Ill. Adm. Code 140.453; b) The screening and assessment authorized under 59 Ill. Adm. Code 131.40…

Section 140.455 Payment for Mental Health Services a) The amount approved for payment for mental health services described in Section 140.454 shall be based on the type and amount of service required by and actually delivered, and provided consistent with any service limitations,…

Section 140.456 Hearings The Department shall initiate administrative proceedings pursuant to 89 Ill. Adm. Code 104, Subpart C, and Sections 140.13 through 140.19 to suspend or terminate the eligibility of providers of mental health services to participate in the Illinois Medical…

Section 140.457 Therapy Services a) For purposes of enrollment as a provider in the Medical Assistance Program, a physical, speech/language or occupational therapist must be licensed by the Illinois Department of Financial and Professional Regulation or equivalent licensing body …

Section 140.458 Prior Approval for Therapy Services a) Effective July 1, 2012 through September 30, 2014, prior approval is required for the provision of services by an independent speech/language, physical or occupational therapist or by a community health agency, unless: 1) the…

Section 140.459 Payment for Therapy Services a) Therapy services shall be paid at an all-inclusive rate that shall be the lower of the following. The rate shall not exceed the upper limits set in federal regulations at 42 CFR 447.321 (2012) and reimbursement is based upon the app…

Section 140.460 Clinic Services a) The following types of clinics are eligible to receive payment for clinic services: 1) Hospital-based organized clinics; 2) Encounter rate clinics; 3) Federally Qualified Health Centers (FQHC): 4) Rural health clinics; and 5) Maternal and Child …

Section 140.461 Clinic Participation, Data and Certification Requirements a) Hospital-based organized clinics must: 1) Have an administrative structure, staff program, physical setting, and equipment to provide comprehensive medical care. 2) Agree to assume complete responsibilit…

Section 140.462 Covered Services in Clinics Payment shall be made to clinics for the following types of services when provided by, or under the direction of, a physician: a) Hospital-Based Organized Clinics. Covered services are those described in 89 Ill. Adm. Code 148. b) Encoun…

Section 140.463 Clinic Service Payment a) Definitions "Behavioral Health Services", for the purposes of this Section, means services provided by a licensed clinical psychologist, licensed clinical social worker or licensed clinical professional counselor. "Center", for the purpos…

Section 140.464 Hospital-Based and Encounter Rate Clinic Payments a) Hospital-based organized clinics, as described in Section 140.461(a), shall be paid in accordance with 89 Ill. Adm. Code 148.140. b) Encounter Rate Clinics Encounter rate clinics, as described at Section 140.461…

Section 140.465 Adaptive Behavior Support Services a) Payment for Adaptive Behavior Support (ABS) Services. 1) Payment for ABS services shall be made to providers enrolled in the Illinois Medical Assistance Program as: A) A Behavioral Health Clinic (BHC), pursuant to Section 140.…

Section 140.466 Rural Health Clinics (Repealed) (Source: Repealed at 26 Ill. Reg. 4781, effective March 15, 2002)

Section 140.467 Independent Clinics a) Payment for all other Medicaid covered services provided by an independent clinic will be made on a fee-for-service basis, that is, the lower of charges or the Department's established maximum for the service, not to exceed the lowest Medica…

Section 140.469 Hospice a) Hospice is a continuum of palliative and supportive care, directed and coordinated by a team of professionals and volunteer workers who provide care to terminally ill persons to: 1) reduce or abate pain or other symptoms of mental or physical distress; …

Section 140.470 Eligible Home Health Care, Nursing and Public Health Providers Effective July 1, 2012: a) The following classes of providers may enroll with the Department as home health care providers: 1) A Medicare-certified home health agency licensed by the Department of Publ…

Section 140.471 Description of Home Health Care Services a) Home health services are services provided for participants in their places of residence and are aimed at facilitating the transition from a more acute level of care to the home. b) Services provided shall be of a curati…

Section 140.472 Home Health Care Services The services and items for which payment can be made are: a) Intermittent skilled nursing in the home for the purpose of completing an assessment, evaluation or administration. b) Shift nursing care in the home for the purpose of caring f…

Section 140.473 Prior Approval for Home Health Care Services a) Prior approval is required for the provision of home health services described in Section 140.472. The decision to approve or deny a request for prior approval will be made within 21 days after the date the request i…

Section 140.474 Payment for Home Health Care Services a) Effective July 1, 2012, except for services described in subsection (b), home health agencies will be paid an all inclusive, per visit rate that shall be the lowest of the: 1) Agency's usual and customary charge for the ser…

Section 140.475 Medical Equipment, Supplies, Prosthetic Devices and Orthotic Devices a) Payment for the provision of medical equipment, supplies, prosthetic devices and orthotic devices shall be made only to participating providers who are licensed or exempt from licensure under …

Section 140.476 Medical Equipment, Supplies, Prosthetic Devices and Orthotic Devices for Which Payment Will Not Be Made Payment shall not be made for: a) Items or repair of items for residents of long term care facilities, when such items are: 1) Durable medical equipment or supp…

Section 140.477 Limitations on Equipment, Prosthetic Devices and Orthotic Devices a) Effective July 1, 2012, prior approval for the purchase, repair or rental of certain medical equipment, prosthetic devices and orthotic devices is required except when: 1) The client is a Medicar…

Section 140.478 Prior Approval for Medical Equipment, Supplies, Prosthetic Devices and Orthotic Devices a) The following time frames shall be adhered to by the Department when prior approval is required for medical equipment, prosthetic devices and orthotic devices (see also Sect…