As a result of Public Act 097-0689 (pdf), referred to as the Save Medicaid Access and Resources Together (SMART) Act, HFS will begin requiring prior approval for all surgeries for morbid obesity.
Effective with dates of service October 1, 2012, and after, providers will be required to request prior approval for surgeries for morbid obesity. Payment for this service may be made only in those cases in which the physician determines that obesity is exogenous in nature, the recipient has had the benefit of other therapy with no success, endocrine disorders have been ruled out, and the body mass index (BMI) is 40 or higher, or 35 to 39.9 with serious medical complications.
Providers must submit requests on Form HFS 1409, Prior Approval Request. In addition to the Form HFS 1409, providers must submit the following documentation:
Documentation of review of systems (history and physical) with letter of medical necessity;
Client height, weight and BMI;
Listing of co-morbidities;
Patient weight loss attempts including participation in six months of a medically supervised weight loss program under guidance of the primary care physician working in conjunction with a registered dietitian within two years prior to the surgery.
Current and complete psychiatric evaluation indicating the patient is an appropriate candidate for weight loss surgery;
Documentation of nutritional counseling.
In addition, the patient must have follow up visits by a registered dietitian after weight loss surgery to assure positive outcomes.
The signed copy of the HFS 1409 and supporting documentation may be mailed or faxed to:
Illinois Department of Healthcare and Family Services
Bureau of Comprehensive Health Services
Post Office Box 19124
Springfield, Illinois 62794-9124
217-524-0099 Monday through Friday, 8:30 a.m. – 5 p.m., excepting holidays
Providers wishing to receive e-mail notification, when new provider information is posted by the department, may register at the following HFS Web site.
Questions regarding this notice may be directed to the Bureau of Comprehensive Health Services at 1-877-782-5565.
Theresa A. Eagleson, Administrator
Division of Medical Programs