"Prior Authorization for Gender-Affirming Services" - Illinois

Prior Authorization for Gender-Affirming Services is a legal document that was released by the Illinois Department of Healthcare and Family Services - a government authority operating within Illinois.

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Fee-for-Service Submittal Detail
Forms should be submitted via email:
hfs.ga-service@illinois.gov
Prior Authorization for Gender-Affirming Services
1. CLIENT INFORMATION
Client First and Last Name:
Date of Birth:
RIN:
Sex Assigned at Birth
Identifying Gender:
Address:
City:
State:
Zip Code:
County:
None
Personal Representative*
Minor*
Phone Number:
Guardianship Status:
*If Personal Representative or Minor selected, complete Parent or Guardian Info below.
Parent
Guardian
First and Last Name:
Relationship to Client:
Phone Number:
Parent or
Guardian
Address:
City:
State:
Zip Code:
County:
Info.
2. DIAGNOSIS: List all known relevant diagnosis information for the client.
Code
DSM-5 Name
Code
ICD-10 Name
DSM-5 Diagnosis:
ICD- 10 Diagnosis:
Primary
3. TREATMENT SERVICES REQUIRING PRIOR AUTHORIZATION
Service / Procedure
Code
ICD – 10 Name
Requested Treatment
ICD- 10 Procedure:
Genital Surgery
Yes
No
Yes
No
Yes
No
Yes
No
4. RECIPIENT’S TREATMENT TEAM: List additional providers on a separate document and submit as an attachment.
Primary Care Physician (PCP)
Organization Name
Contact Name
Phone:
Email:
Physician Leading Treatment
Organization Name
Contact Name
Phone:
Same as PCP
Email:
LPHA Name
Organization Name
Contact Name
Phone:
Email:
5. FORM SIGNATURE
Staff Completing (print name)
Credentials
Staff Responsible for Completing Form
Phone Number:
Signature
Date (mm/dd/yyyy)
Provider Name:
NPI:
HFS Provider ID:
Page 1 of 3
Fee-for-Service Submittal Detail
Forms should be submitted via email:
hfs.ga-service@illinois.gov
Prior Authorization for Gender-Affirming Services
1. CLIENT INFORMATION
Client First and Last Name:
Date of Birth:
RIN:
Sex Assigned at Birth
Identifying Gender:
Address:
City:
State:
Zip Code:
County:
None
Personal Representative*
Minor*
Phone Number:
Guardianship Status:
*If Personal Representative or Minor selected, complete Parent or Guardian Info below.
Parent
Guardian
First and Last Name:
Relationship to Client:
Phone Number:
Parent or
Guardian
Address:
City:
State:
Zip Code:
County:
Info.
2. DIAGNOSIS: List all known relevant diagnosis information for the client.
Code
DSM-5 Name
Code
ICD-10 Name
DSM-5 Diagnosis:
ICD- 10 Diagnosis:
Primary
3. TREATMENT SERVICES REQUIRING PRIOR AUTHORIZATION
Service / Procedure
Code
ICD – 10 Name
Requested Treatment
ICD- 10 Procedure:
Genital Surgery
Yes
No
Yes
No
Yes
No
Yes
No
4. RECIPIENT’S TREATMENT TEAM: List additional providers on a separate document and submit as an attachment.
Primary Care Physician (PCP)
Organization Name
Contact Name
Phone:
Email:
Physician Leading Treatment
Organization Name
Contact Name
Phone:
Same as PCP
Email:
LPHA Name
Organization Name
Contact Name
Phone:
Email:
5. FORM SIGNATURE
Staff Completing (print name)
Credentials
Staff Responsible for Completing Form
Phone Number:
Signature
Date (mm/dd/yyyy)
Provider Name:
NPI:
HFS Provider ID:
Page 1 of 3
Fee-for-Service Submittal Detail
Forms should be submitted via email:
hfs.ga-service@illinois.gov
6. ATTESTATION 1 – PHYSICIAN
MANDATORY: Primary Care Physician or Physician Leading Client’s Gender-related Healthcare Component
My signature below certifies that the individual named in Section 1 of this document:
1.
Is at least 21 years of age; or
s under 21 years of age but clearly demonstrates sufficient medical necessity for the treatment being requested in Section 3
I
of this document as detailed in my written summary attached to this form;
2.
Has the capacity to make a fully informed decisions and to consent to the treatment being requested in Section 3 of this
document;
3.
Has the diagnosis of Gender Dysphoria;
4.
Has no other significant medical or mental health conditions that would be a contraindication to the gender-affirming
surgery, service or procedure; or
Has one or more other significant medical or mental health conditions that would be a contraindication to the gender-
affirming surgery, service or procedure but such conditions are reasonably well-controlled;
5.
Has received hormone therapy appropriate to the individual’s gender goals since: ______/ ______/ ______________, a period
minimally covering 12 months if the individual is seeking genital surgery;
Has not received hormone therapy as it is contraindicated;
Has not received hormone therapy as the individual is unable to take hormones; or
Not applicable, as the requested treatment service does not include genital surgery; and
6.
Has lived continuously, for a period minimally covering 12 months, in the gender role congruent with the individual’s gender
identity since: ______/ ______/ ______________; or
Not applicable, as the requested treatment service is not Genital Surgery.
Furthermore, I certify that:
1.
I have sought to identify and communicate with the individual’s other medical provider(s) regarding the proposed surgery,
service, or procedure;
2.
The service(s) being requested in Section 3 of this document is/are, in my medical opinion, medically necessary; and
3.
I have detailed the following recommendations for post-operative care with the client:
ATTACHMENT
This document must be accompanied by the:
1. Physician letter; and
2. Supporting medical documentation.
NPI #
Physician (print name)
Credentials
Primary Care Physician or Physician Leading Client’s Gender-related Healthcare
Signature
Date (mm/dd/yyyy)
Page 2 of 3
Fee-for-Service Submittal Detail
Forms should be submitted via email:
hfs.ga-service@illinois.gov
7. ATTESTATION 2 – LPHA
LPHA Component – Required ONLY for Genital Surgery
My signature below certifies that the individual named in Section 1 of this document:
1.
Is at least 21 years of age; or
s under 21 years of age but clearly demonstrates sufficient medical necessity for the treatment being requested in Section 3
I
of this document as detailed in my written summary attached to this form;
2.
Has the capacity to make fully informed decisions and to consent to the treatment being requested in Section 3 of this document;
3.
Has the diagnosis of Gender Dysphoria;
Has no other significant medical or mental health conditions that would be a contraindication to the gender-affirming
4.
surgery, service or procedure; or
Has one or more other significant medical or mental health conditions that would be a contraindication to the gender-
affirming surgery, service or procedure but such conditions are reasonably well-controlled;
5.
Has participated in the following services provided by, or administered by, myself:
A comprehensive mental health assessment,
Psychotherapy, if clinically appropriate, and
Education and counseling of treatment options and implications of receiving the services detailed in Section 3 of this
document.
ATTACHMENT
This document must be accompanied by the:
1. LPHA letter; and
2. A copy of the client’s mental health assessment.
NPI #
LPHA (print name)
Credentials
LPHA Component – Required for Genital Surgery
Signature
Date (mm/dd/yyyy)
Page 3 of 3
Instructions for the Submission of the Prior Authorization Request for Gender-Affirming Services
INSTRUCTIONS
Required for ALL gender-affirmation treatment and services
Section 1 – Client Information
1.
Client First and Last Name. Enter the full name, first and last, of the individual seeking the service.
2.
Date of Birth. Enter the date of birth of the individual seeking the service.
3.
RIN. Enter the State of Illinois recipient identification number (RIN) of the individual seeking the service.
4.
Sex Assigned at Birth. Provide the sex designation of the individual seeking the service.
5.
Identifying Gender. Provide the gender of the individual seeking the service that the individual actively identifies with.
6.
Address. The street address of the residence of the individual seeking the service.
7.
City. The city of the residence of the individual seeking the service.
8.
State. The state of the residence of the individual seeking the service.
9.
Zip Code. The zip code of the residence of the individual seeking the service.
10. County. The county of the residence of the individual seeking the service.
11. Phone Number. The phone number of the individual seeking the service.
12. Guardianship Status. The guardianship status of the individual seeking service.
13. Parent or Guardian Info. Only used for individuals seeking service that have selected “Personal Representative” or “Minor,” the Parent or Guardian
Information section should detail the: name (first and last), relationship to client, phone number, and residential address (address, city, state, zip code,
and county) of the individual capable of making medical decisions and consenting to services on behalf of individual seeking service.
Section 2 – Diagnosis
1.
DSM-5 Diagnosis. List all known, relevant DSM diagnoses of the individual seeking service.
2.
ICD-10 Diagnosis. List all known, relevant ICD-10 diagnoses of the individual seeking service.
3.
Primary Indicator. Please indicate, from the list of diagnoses provided, the primary diagnosis that necessitating the services being requested.
Section 3 – Treatment Services Requiring Prior Authorization
1.
Requested Treatment. Under the heading of “Service / Procedure,” please list the name of the procedure(s) that the individual seeking service has
consented to have performed and requires Prior Authorization.
2.
ICD-10 Procedure. Please Provide the ICD code and name for the procedure(s) to be performed under the heading “Code” and “ICD-10 Name,”
respectively.
3.
Genital Surgery. In the event that the service or procedure being sought includes genital surgery, please indicate “Yes” under the heading “Genital
Surgery”. In the event that the service or procedure being sought does not include genital surgery, please indicate “No”.
Section 4 – Recipient’s Treatment Team
1.
Primary Care Physician. Please list the name (first and last) of the individual’s Primary Care Physician (PCP).
2.
Organization Name. If the Practitioner works for a medical group, practice group, community mental health center, hospital, or other entity, please
provide the name of the entity.
3.
Contact Name. Please provide the name (first and last) of the most appropriate person to contact (e.g. receptionist, assistant, nurse) when seeking to
talk with named Practitioner.
4.
Phone. Please provide the most appropriate phone number to contact the listed Practitioner.
5.
Email. Please provide the most appropriate email to contact the listed Practitioner.
6.
Physician Leading Treatment. Please list the name (first and last) of the physician leading the gender-affirming services. In the event that this
Practitioner is the same as the PCP listed in the line above it, the “Same as PCP” box may be selected and the Name, Organizational Name, Phone and
Email for the Physician Leading Treatment may be skipped.
7.
LPHA Name. Please provide the name (first and last) of the Licensed Practitioner of the Healing Arts (LPHA) that is participating on the treatment team.
An LPHA may not always be required. However, when the request for prior authorization includes services that include genital surgery, an LPHA is
required to be listed in this box/section.
See Note on Qualifying LPHA’s found in the “Section 7 – Attestation 2 – LPHA” instructions.
Note: All additional treatment team practitioners should be provided on an additional sheet of paper as an attachment to submitted document.
Section 5 – Form Signature
1.
Staff Completing. Please list the name (first and last) of the individual completing the form.
2.
Credentials. Please list the credentials associated with the individual completing the form, if the individual is a licensed practitioner in the state in
which they are employed. If the individual completing the form is not a licensed practitioner, please provide the role that the individual completing the
form holds within their organization (e.g. UM Nurse, Records Associate, etc.).
3.
Phone Number. Please provide the most appropriate phone number to contact the individual completing the form.
4.
Signature. The person completing the form must sign the document in this box.
5.
Date. The person completing the form must provide the date that they signed the form.
6.
Provider Name. The name of the entity or practitioner that the person completing the form is representing in the submission of the Prior Authorization
request.
7.
NPI. The National Provider Identification number for the entity listed in the “Provider Name” box.
8.
HFS Provider ID. The provider identification number for the entity listed in the “Provider Name” box, as assigned by HFS at the point of enrollment in
the Illinois Medical Assistance program. This number is usually a combination of the provider’s 9-digit FEIN and a three digit location code assigned by
HFS.
Instructions Page: 1
Instructions for the Submission of the Prior Authorization Request for Gender-Affirming Services
Section 6 – Attestation 1 – Physician
Note: All gender-affirming services require the completion of this section.
1.
Check Boxes. The physician must construct an attestation using the various, pre-defined options under each item number. Each selection must be
clearly and visibly marked on the form. Any section item that is not clearly marked or left incomplete may result in a slowed review, required contact
with the Prior Authorization Agent, or a denial of the request.
2.
Supply Dates. Some of the check box options provided requires the physician to insert a corresponding date. In these instance, the physician should
provide the date that satisfies the statement being made in the following format:
When Month = m, Day = d, and Year = y; dates should be supplied as: mm/ dd/ yyyy.
3.
Post-operative Care Detail. In the event that the individual seeking services requires post-operative care, such post-operative care should be detailed
on the lines provided. In the event that the post-operative care detail requires more space than available on the form, please provide the additional
detail on a separate sheet of paper as an attachment to this document.
4.
Attachments. Minimally, the attestation signed by the physician should be accompanied by the physician’s written letter and medical documentation
supporting the overall medical necessity of the services being requested. Documents may include a pre-op treatment report, treatment plan, clinical
notes, or other elements needed to support the request for treatment.
5.
Signature. The physician must sign the attestation and provide their: name (first and last), credentials, National Provider Identification number (NPI),
and provide the date of signature in the mm/ dd/ yyyy format, as detailed above in these instructions.
Required for gender-affirmation treatment and services resulting in genital surgery
Note: With any completed Gender-affirming Service Prior Authorization Request that details one or more procedures that includes genital surgery,
this section is REQUIRED. For Gender-affirming Service Prior Authorization Requests that DO NOT include genital surgery, this section is not required.
In the event that services requested on the submitted prior authorization request form includes genital surgery and this section is not completed – the
Prior Authorization Request will be denied on the basis of “Insufficient documentation supplied”.
Section 7 – Attestation 2 – LPHA
Note on Qualifying LPHA’s: For the purposes of Gender-affirmation Service delivery and requests for Prior Authorization of Gender-affirmation
Services, qualified LPHA’s are detailed in 89 Ill. Adm. Code 140.453 (a-d, f) as:
1.
A physician who holds a valid license in the state of practice and is legally authorized under state law or rule to practice medicine in all its
branches, so long as that practice is not in conflict with the Medical Practice Act of l987;
2.
An advanced practice nurse with psychiatric specialty that holds a valid license in the state of practice and is legally authorized under state law or
rule to practice as an advanced practice nurse, so long as that practice is not in conflict with the Illinois Nurse Practice Act or the Medical Practice
Act of 1987;
3.
A clinical psychologist who holds a valid license in the state of practice and is legally authorized under state law or rule to practice as a clinical
psychologist, so long as that practice is not in conflict with the Clinical Psychologist Licensing Act;
4.
A licensed clinical professional counselor possessing a master's degree who holds a valid license in the state of practice and is legally authorized
under state law or rule to practice as a licensed clinical professional counselor, so long as that practice is not in conflict with the Professional
Counselor and Clinical Professional Counselor Licensing Act [225 ILCS 107]; or
5.
A clinical social worker possessing a master's or doctoral degree who holds a valid license in the state of practice and is legally authorized under
state law or rule to practice as a social worker, so long as that practice is not in conflict with the Clinical Social Work and Social Work Practice Act.
Note: The Illinois Administrative Code on Gender-affirming services requires the submission of two (2) letters of medical necessity, in the event that
the individual seeking services elects to receive a service that includes genital surgery. As multiple, independent letters are required to support the
request for genital surgery, the Physician providing the Physician Attestation cannot also qualify as the treatment team LPHA for the purposes of
completing the LPHA Attestation.
1.
Check Boxes. The LPHA must construct an attestation using the various, pre-defined options under each item number. Each selection must be clearly
and visibly marked on the form. Any section item that is not clearly marked or left incomplete may result in a slowed review, required contact with the
Prior Authorization Agent, or a denial of the request.
2.
Attachments. Minimally, the attestation signed by the LPHA should be accompanied by the LPHA’s written letter and a copy of the comprehensive
mental health assessment for the individual seeking services, as supporting medical documentation to this request.
3.
Signature. The LPHA must sign the attestation and provide their: name (first and last), credentials, National Provider Identification number (NPI), and
provide the date of signature in the mm/ dd/ yyyy format, as detailed above in these instructions.
Note: If the services being provided include genital surgery that may result in the sterilization of the individual seeking services, the Gender-affirming Services
Prior Authorization Request must be submitted with a completed HFS Form: HFS 2189, as an attachment to the request. The HFS 2189 can be found at the
following location:
https://www.illinois.gov/hfs/SiteCollectionDocuments/hfs2189.pdf.
Submittal of Request
Upon the completion of the Gender-affirmation Services Prior Authorization Form, the gathering and/ or development of all necessary documentation and
attachments, and signature of attestations by appropriate licensed practitioners – the document should be submitted to HFS and its review agent via email at:
hfs.ga-service@illinois.gov
Instructions Page: 2