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DOCUMENTATION FOR MEDICAID WAIVER APPEALS (Lake Land College)

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State of Illinois
Department of Human Services
DOCUMENTATION FOR MEDICAID WAIVER APPEALS
IL444-0171 (N-12-16) Documentation for Medicaid Waiver Appeals
Printed by Authority of the State of Illinois -0- Copies
Page 1 of 4
The information below is to be completed by a Qualified Intellectual Disabilities Professional (QIDP) at an Independent Service
Coordination/Individual Service and Support Advocacy (ISC/ISSA) Agency on behalf of an individual seeking to appeal a denial,
reduction, suspension, or termination of Medicaid Waiver services for persons with developmental disabilities. Individuals are to
be informed of their right to appeal such actions through the Notice of Individual's Right to Appeal Form (IL 462-1202). The
appeals and fair hearings policies and procedures are addressed in the Illinois Administrative Code, Title 59, Chapter I, Part
120.110.
Information must be typed and complete or this document and accompanying materials will be returned to the ISC/ISSA agency
for additional information. The form must be signed and dated by the QIDP. See accompanying instructions for additional
information on completing this form.
Section I:
Individual's Name:
Individual's Address:
Individual's City/State/Zip:
Individual's Phone: Individual's Fax:
Individual's E-mail Address:
Individual's Date of Birth:Individual's Social Security Number (Last 4):
Representative's City/State/Zip:
Representative's Address:
Representative's Name:
Representative's E-mail Address:
Representative's Fax:Representative's Phone:
Representative's Relationship to Individual: Guardian Relative Other
If "Relative" or "Other" is marked above, specify:
QIDP's Name at ISC/ISSA Agency:
ISC/ISSA Agency Name:
QIDP's Fax:QIDP's Phone:
QIDP's E-mail Address:
Provider Agency Contact:
Provider Agency Name:
DHS Region Staff:
DHS Region:
State of Illinois
Department of Human Services
DOCUMENTATION FOR MEDICAID WAIVER APPEALS
IL444-0171 (N-12-16) Documentation for Medicaid Waiver Appeals
Printed by Authority of the State of Illinois -0- Copies
Page 2 of 4
Section II:
Indicate the type below that best describes the reason for this appeal:
Refusal to accept an application
Denial of service base on eligibility
Termination of service
Suspension or reduction of service
Denial of one-time funding request(s) (e.g., adaptive equipment or home modifications
Other, specify
Specify type of service being denied, terminated, reduced or suspended:
Is this appeal related to the submission of a Crisis Transition Plan and Funding Request (Form IL462-1040)?
Yes
No
Has a Clinical Administrative Review Team (CART), or Service and Support Team (SST) or Short-term Stabilization Home (SSH)
been involved with this action or request?
Yes
No
CART SST SSH
Contract Number:
Section III:
In order for the Division of Developmental Disabilities to complete a review of the action being appealed, attach all applicable
documents:
A signed request by the individual or guardian for the appeal.
A copy of the notice informing the individual or guardian of the action being appealed. (This notice should include the
basis for the action being taken.) Include any related documentation (e.g., correspondence between the Independent
Service Coordination (ISC) Agency and the Division of Developmental Disabilities.)
A copy of the Individual Service Plan. (Applicable for termination, one-time funding denials, and denials of service change
requests)
A psychological evaluation (meeting the requirements of the Developmental Disabilities Pre-Admission Screening (PAS)
Manual) of the individual. (Applicable primarily for eligibility appeals.)
The most recent ICAP (Inventory for Client and Agency Planning).
Any clinical evaluations of the individual. (Applicable primarily for eligibility appeals and, in some cases, terminations and
one-time funding denials.)
A copy of the Crisis Transition Plan and Funding Request Form, if checked "Yes" in the previous section.
Documentation from the CART, SST, or SSH activity, including the SST evaluation and plan, if checked "Yes" in the
previous section. Please include the contact information.
Documentation from the direct service provider in support of its actions. (Applicable for terminations, suspensions, and
reductions of services.
A copy of the entire packet of a One Time Funding Request denial or any other documentation to inform the review.
State of Illinois
Department of Human Services
DOCUMENTATION FOR MEDICAID WAIVER APPEALS
IL444-0171 (N-12-16) Documentation for Medicaid Waiver Appeals
Printed by Authority of the State of Illinois -0- Copies
Page 3 of 4
Section IV:
Section V:
Submit this form and accompanying documentation to:
DHS Division of Developmental Disabilities
Appeals Unit
600 East Ash St., 3rd Floor, Building 400
Springfield, IL 62703
Or via facsimile to 217-558-2799
What is the basis for the appeal? That is, why does the individual or guardian believe the action to be wrong?
Any Additional comments from the ISC/ISSA Agency that might inform the review.
ISC/ISSA QIDP Name
ISC/ISSA QIDP Signature
Date
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signature
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State of Illinois
Department of Human Services
DOCUMENTATION FOR MEDICAID WAIVER APPEALS
IL444-0171 (N-12-16) Documentation for Medicaid Waiver Appeals
Printed by Authority of the State of Illinois -0- Copies
Page 4 of 4
Additional Instructions for Form
The information on the form is to be completed by a Qualified Intellectual Disabilities Professional (QIDP) at an
Independent Service Coordination/Individual Service and Support Advocacy (ISC/ISSA) Agency on behalf of an
individual seeking to appeal a denial, reduction, suspension, or termination of Medicaid Waiver services for persons
with developmental disabilities.
Individuals are to be informed of their right to appeal such actions through the Notice of Individual's Right to Appeal
Form (IL 462-1202). The appeals and fair hearings policies and procedures are addressed in the Illinois
Administrative Code, Title 59, Chapter I, Part 120.110.
Information must be typed and complete or this document and accompanying materials will be returned to the ISC/
ISSA agency for additional information.
The form must be signed and dated by the QIDP.
The QIDP must complete all the boxes on the form.
The boxes on the form should be self-explanatory, but specific issues are highlighted below to ensure sufficient
information is provided to complete the review in a timely manner:
• In Section II, be specific in specifying the type of service being denied, terminated, reduced, or suspended.
Some examples are CILA, Adult HBS, physical therapy, and adaptive equipment. If a one-time funding
request for adaptive equipment or home or vehicle modifications is involved, please include the type of
request, e.g., ramp, lift, etc.
• In Section III, use the checklist to ensure all necessary documentation is submitted with the appeal.
Incomplete submissions will be returned by the Division for additional information without completing the
review.
• In Section III, examples of “clinical evaluations” or “other documentation” may include:
o For eligibility determinations:
§ Psychiatric Evaluation (for persons with Autism)
§ Medical History, Medication Review, and Physical Examination (for persons with Epilepsy or
Cerebral Palsy)
o For terminations due to behavior issues:
§ Psychiatric Evaluation (if individual has a dual diagnosis of mental illness)
§ Behavior Plan and any summary data available of behaviors
o For terminations due to medical issues:
§ Medical History
§ Medication Review
§ Occupational Therapy and/or Physical Therapy Evaluations
§ Dietitian Recommendations
o For denials of one-time funding requests:
§ Behavior Plan (if the requested item was to be used to address behavior issues)
§ Occupational Therapy Evaluation (if the requested item was to be used to address sensory
needs or fine motor skills)
§ Physical Therapy Evaluation (if the requested item was to be used to address gross motor
needs or sensory integration)
§ Speech and Language Assessment (if the requested item was to be used to address
communication issues)
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DOCUMENTATION FOR MEDICAID WAIVER APPEALS (Lake Land College)

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Completed 10 March 2021

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