Section 148.510  Reimbursement

When a hospital or ambulance provider furnishes emergency services, a hospital or health care professional or laboratory provides follow-up healthcare, or a pharmacy dispenses prescribed medications to any sexual assault survivor who is neither eligible to receive those services under the Illinois Public Aid Code [305 ILCS 5/5] nor covered for those services by a policy of insurance, the hospital, ambulance provider, health care professional, laboratory or pharmacy shall furnish the services without charge to that person, and shall be entitled to be reimbursed in providing the services, under the following conditions:

a)         An Illinois hospital shall be eligible for reimbursement only after receiving Department of Public Health approval for participation as a Sexual Assault Treatment Facility or as a Sexual Assault Transfer Facility.

b)         Charges for outpatient emergency care, physician, and ambulance transportation, and other related charges, shall be reimbursed as described in this subsection (b):

1)         Physicians, ambulance providers, and other miscellaneous medical providers rendering services in the hospital emergency department shall be directly reimbursed by the Department of Healthcare and Family Services.

2)         Charges for inpatient care shall not be reimbursed.

3)         Charges must be directly related to care rendered for examinations, injuries, or trauma resulting from a sexual assault and/or the completion of sexual assault evidence collection through the use and application of the Illinois State Police Sexual Assault Evidence Collection Kit.

4)         Emergency services must have been provided within the hospital emergency department or under the direction of an attending emergency room physician at the facility who supervised or provided the hospital emergency care of the sexual assault survivor, or during the ambulance transport of the sexual assault survivor.

5)         Charges may include, but are not limited to, outpatient emergency care, physician, laboratory, x-ray, pharmacy and ambulance services, including charges for follow-up visits to the emergency department that are related to the sexual assault and occur within 90 days after the initial visit.

6)         Services provided to sexual assault survivors shall be reimbursed at the Department's reimbursement rates.

7)         Claims must be received by the Department within 180 days from the date of service to be eligible for payment pursuant to 89 Ill. Adm. Code 140.20.

c)         The hospital shall maintain sufficient records to document its charges for services to each sexual assault survivor.  The records shall be available for the Department's review upon its request and shall contain at least the following:

1)         Sexual assault survivor's name, address, date of birth, Social Security Number, marital status, sex, employer and name of parent or guardian (if minor patient);

2)         Date of service;

3)         Hospital patient number and name of attending physician;

4)         List of services provided;

5)         Charges for each service;

6)         Any documentation concerning the sexual assault survivor's insurance coverage; and

7)         A report outlining each service provided and paid for by the Department and the services available to sexual assault survivors.

d)         The hospital outpatient-billing department shall submit the following documentation in order to be considered for reimbursement:

1)         Documentation of any insurance payment that has been received, or a copy of the denial from the insurance carrier; and

2)         A properly completed Universal Billing (UB) Form.

e)         The health care professional who provides follow-up healthcare, the laboratory that furnishes follow-up services, and the pharmacy that dispenses related prescribed medications to a sexual assault survivor are responsible for submitting the request for reimbursement for follow-up healthcare, laboratory services or pharmacy services to the Illinois Sexual Assault Emergency Treatment Program under the Department of Healthcare and Family Services.  Health care professionals, laboratories and pharmacies are to be reimbursed at the Department's reimbursement rates.

f)         Under no circumstances shall a sexual assault survivor be billed for outpatient hospital care, emergency room care, follow-up health care or transportation services when the services are directly related to the sexual assault.

g)         A request for reimbursement that is rejected by the Department shall be returned to the requestor and accompanied by an explanation that specifies the basis for rejection. Corrected or amended requests may be resubmitted to the Department within 180 days from the date of service pursuant to 89 Ill. Adm. Code 140.20.

(Source:  Amended at 37 Ill. Reg. 10432, effective June 27, 2013)