Illinois Medicaid (fee-for-service) physical therapy coverage: limits and prior authorization
The short answerIllinois HFS fee-for-service requires prior approval for therapy, with no adult annual visit cap since Public Act 098-0651. The handbook is dated July 2016, so check current HFS notices and the member's MCO.
By Javier Alvarez · Updated · 1 min read
1 row: Medicaid (by state) · Illinois. Public policy, not the member's benefits.
Illinois Medicaid (fee-for-service)
HFS Handbook for Therapy Providers, Chapter J-200 (issued July 2016) · Illinois
| Visit limits | The 2012 limit of 20 visits per year per discipline for adults was later removed by Public Act 098-0651, which still required prior approval for all therapy services. [1] |
|---|---|
| Prior authorization | Per the HFS therapy handbook (July 2016), fee-for-service prior approval is required for all therapy services except a therapy evaluation visit, services approved by Medicare, services paid by an MCO, and speech therapy for children through age 20. HFS has required it for adults since July 1, 2012, and for PT and OT for children through age 20 since November 16, 2015. Services billed without required approval are not paid. [1] |
| Managed care plans | If a participant joins an MCO or MCCN during an approved period, the HFS prior approval no longer applies from the managed care enrollment date, and requests go to the plan. [1] |
What Illinois Medicaid (fee-for-service)'s documents say
The table above has every field we found for Illinois Medicaid (fee-for-service), with numbered sources. In short:
- Prior authorization. Per the HFS therapy handbook (July 2016), fee-for-service prior approval is required for all therapy services except a therapy evaluation visit, services approved by Medicare, services paid by an MCO, and speech therapy for children through age 20. HFS has required it for adults since July 1, 2012, and for PT and OT for children through age 20 since November 16, 2015. Services billed without required approval are not paid.
- Visit limits. The 2012 limit of 20 visits per year per discipline for adults was later removed by Public Act 098-0651, which still required prior approval for all therapy services.
Check Illinois Medicaid (fee-for-service)'s claim against the row
Before the claim goes out, compare it with the row above: the evaluation code matches the complexity you documented, the timed codes fit the minutes, any prior authorization covers the visit, and the plan of care is signed when the payer asks for it. The physical therapy table compares Medicaid with every other payer we checked.