Prior Authorization
Prior Authorization Resources Page
Select the resource you need by clicking the topic.
HFS Attachment List A-F May 2024
Click the link below to download HFS' Attachment List A-F
The procedure codes listed for Prior Authorization are on Attachment F ONLY
Prior Authorization of Elective Procedures Provider Manual
The Provider Manual is a comprehensive guide of the requirements for Prior Authorization of elective procedures. It contains review templates for communication between the hospital and attending (surgeon) physician, as well as a reconsideration request form.
PLEASE NOTE: If a Prior Authorization is denied, a request for Reconsideration may be submitted by either the hospital or surgeon/physician within 10 business days from the date of the denial notice, before admission for the procedure. Previously, we had 10 calendar days.
Click the link below to download the Provider Manual:
HFS Hospital Informational Notice
Click here to download HFS' Informational Notice
Acentra Health Communications
Click the link below to download Acentra's Provider Update:
| Provider Update | Date of Notice |
| HFS Adds Prior Authorization Review Requirement | 2.5.2014 |
Reconsideration Process
If the hospital or physician disagrees with the adverse determination made by Acentra Health, a request for an expedited reconsideration may be submitted. Information regarding the prior authorization reconsideration process can be found in the Provider Manual on page 10.
IMPORTANT: A request must be received within 10 business days of the denial notice and prior to the admission.
Click on the links below to download the form and instructions:
Important Third Party Notice: As we conveyed in our Provider Notice dated May 11, 2010, third-party contractors may request a reconsideration and submit information on behalf of the hospital or physician; however, as contracted by the Department of Healthcare and Family Services, all Acentra Health notifications and conversations are directed to the designated hospital personnel and/or treating physician.
Hospital Contact Information
Healthcare and Family Service Medicaid program requires vital communication with hospital personnel. It is important to have current contact information for the following members on the Hospital Contact Form:
| Hospital CEO or CFO |
The hospital CEO or CFO information is used as appropriate approval for assigning the Acentra Health Liaison at each facility. The contact information may also be used in targeted communications. |
| Hospital CMO or Medical Director | The hospital CMO or MD's contact information is used only for targeted communications. |
| Acentra Liaison | The Acentra health (Medicaid) Liaison is selected by a member of hospital administration. His/her role is to be the primary contact between Acentra Health and the hospital. All provider communications, notifications, and letters are sent to the liaison. |
| Acentra Quality Contact |
The Acentra Health Quality contact is selected by a member of hospital administration. His/her role is to be the primary contact between Acentra Health and the hospital regarding quality of care. |
| Web Administrator | To access Acentra Health's Web-based system and provider-specific reports, each hospital may register for a free Web account and must designate a Web Administrator. The Web Administrator is responsible for assigning access rights and maintaining login ID's for Acentra Health Web users at their facility.
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Need to add/update your hospital contacts?
Click HERE to download the Hospital Contact Form.
Prior Authorization Template and Instructions
The Prior Authorization Template can be used by hospitals as a tool to gather all the pertinent clinical information from the attending (surgeon) physician prior to submitting a request via eQSuite. The Prior Authorization Template is optional, hospitals are not required to submit the form to Acentra Health.
Click on the links below to download the template and instructions:
eQSuite® is our proprietary web-based, HIPAA compliant system that offers 24/7 online availability to:
- Submit prior authorization review requests
- Obtain real-time status updates of your prior authorization review requests
- Respond to requests for additional information for pended reviews
- Submit online helpline queries
- View or print provider-specific notification/determination letters
- Access provider-specific data reports
Please download the following documents for minimum IT requirements and suggestions to optimize your user experience:
Click on the web user guides below to learn the web review functions:
- eQSuite® User Guide-CABG: A comprehensive user guide for submitting CABG review requests online.
- eQSuite® User Guide-BACK: A comprehensive user guide for submitting back surgery review requests online.
- Web Admin User Guide: A resource guide for responsibilities of the hospital Acentra Health Web Administrator role.
- eQSuite® MENUBAR: A resource guide for the additional features available to eQSuite users.
- Provider Web Reports: A summary of the 7 Provider reports capturing data relating to Prior Authorization.
We offer free training sessions on a monthly basis to instruct Providers how to use the Web-based review system to submit prior authorization requests and run hospital-specific data reports.
For your individual education or training needs, please contact Rose Serno, Provider Outreach and Education Representative at rserno@eqhs.org
Educational Presentations
Prior Authorization PowerPoint Presentations:
Prior Authorization-FAQ's
Frequently Asked Questions
The hospital is responsible for submitting review requests to Acentra Health. To assist hospitals, a template has been created to communicate with the physician office what pertinent clinical information is needed for review. The Prior Authorization Template - CABG and the Prior Authorization Template-Back Surgery are located under the PriorAuthResources/Provider Forms Tab on our Website.
As with other types of utilization review, certain HFS exceptions to this approval process may apply, if:
- A participant’s eligibility was backdated to cover the hospitalization.
- Medicare Part A coverage exhausted while the patient was in the hospital, but the hospital was not aware that Part A exhausted.
- Discrepancies associated with the patient’s Managed Care Organization (MCO) enrollment occurred at the time of admission.
- Other – the hospital must provide narrative description.
Please contact a UB-04 Billing Consultant at HFS at 1-877-782-5565 if the hospital believes one of the above exceptions applies.
Yes. HFS’ Provider Informational Notice was issued to all hospitals and Medicaid physicians. In addition, the notice is posted on the HFS Website. Providers wishing to receive e-mail notification, when new provider information is posted by the department, may register at the following: http://hfs.illinois.gov/provrel.
Prior to rendering an adverse determination, the Acentra Health Physician Reviewer will make one attempt to contact the physician/surgeon. NOTE: If consent has been granted by the surgeon, the surgeon may assign either a registered nurse (RN) or a physician assistant (PA) to be the primary contact when a peer-to-peer interaction occurs. Hospitals must update the physician’s contact information in eQSuite™ (on Start tab) if the telephone number differs from that of the physician.
To download a pdf file or print the Frequently Asked Questions, click here.