Ill. Admin. Code tit. 89 § 104.205

Current through Register Vol. 48, No. 45, November 8, 2024

Section 104.205 - Notice of Informal Review of the Request for Appeal for Ambulance Service Provider

a) Requests for informal review of the request for appeals filed by an Ambulance Service Provider under 89 Ill. Adm. Code 140.491(j) shall proceed pursuant to this Section.

b) The informal review of the request for appeal process is initiated by the Ambulance Service Provider filing a written, signed request for an informal review of the request for appeal with the Department's Bureau of Professional and Ancillary Services or its authorized agent, within 90 calendar days after the date of service pursuant to 89 Ill. Adm. Code 140.491(j).

c) The request for informal review of the request for appeal shall include:

1) a copy of the decision issued by the Department or its authorized agent pursuant to 89 Ill. Adm. Code 140.491(j);

2) a brief statement of the issue on appeal; and

3) documentation supporting the appeal request. The Department shall consider any documentation supporting medical necessity, including documentation not previously submitted. Any documentation that was not previously submitted to the Department or its authorized agent prior to the decision rendered in 89 Ill. Adm. Code 140.491(j) must be designated as not having been previously submitted.

d) The Bureau of Professional and Ancillary Services or its authorized prior approval agent shall conduct an informal review of the request for appeal, including a review of all documentation submitted under subsection (c) and within 60 calendar days issue the Department's written decision (the 205(d) decision) to reverse, modify or affirm the Department's initial decision.

e) If the Department's initial decision is affirmed, the Ambulance Service Provider may request a hearing on the Department's 205(d) decision in accordance with Section 104.210 by filing a written, signed request for a hearing with the Office of General Counsel-Bureau of Administrative Hearings-Medical Vendor Hearings Section and the Office of Inspector General-Office of Counsel to the Inspector General.

1) This request for hearing must be received by the Department within 10 calendar days after the date on which the Department's 205(d) decision is received by the Ambulance Service Provider. If such a request is not received by the Department within 10 calendar days, or is received but later withdrawn, the Department's 205(d) decision shall be a final and binding administrative determination.

2) Upon timely request for hearing, the Bureau of Administrative Hearings shall conduct an administrative hearing in accordance with Sections 104.220 through 104.295, as applicable.

3) The hearing shall be conducted de novo (anew). Documentary evidence submitted for the hearing shall not be limited to documents submitted to the Department or its authorized agent for informal review in accordance with Section 104.205(d).

Ill. Admin. Code tit. 89, § 104.205

Expedited correction at 37 Ill. Reg. 16034, effective July 24, 2013

Amended at 41 Ill. Reg. 4263, effective 3/30/2017