How to Fill Out and Submit HFS 1409: Attachments, Submission, and Appeals

Illinois Medicaid providers use the HFS 1409 prior approval request form to get advance authorization from the Department of Healthcare and Family Services before delivering certain services, equipment, or drugs under the fee-for-service program. You complete the form, attach documentation that proves medical necessity, and send the packet by mail or fax to the Bureau of Professional and Ancillary Services. A clean submission moves faster; a missing field or a mismatched quantity sends it back.

Before you start, confirm your patient’s coverage on the MEDI website.1Illinois Department of Healthcare and Family Services. Non-Emergency Transportation The HFS 1409 is only for fee-for-service participants. If the patient is enrolled in a Medicaid managed care organization, that plan runs its own prior authorization process with its own forms, and an HFS 1409 will not get you anywhere.

When You Need to Submit One

HFS has broad authority to require prior approval for any service or item it chooses to review in advance.2Illinois General Assembly. Illinois Administrative Code Title 89 Part 140 – Medical Payment The categories that most often trigger an HFS 1409 are:

Emergency procedures are carved out. The prior approval rule applies when the procedure is planned and is the primary reason for the encounter.4Acentra Health. Prior Authorization Resources – Illinois Medicaid

The Medical Necessity Standard Reviewers Apply

Every request is tested against four criteria. The service or item must be non-experimental, appropriate to the patient’s needs, necessary to avoid institutional care, and medically necessary to preserve health, alleviate sickness, or correct a handicapping condition.5Cornell Law Institute. Illinois Admin Code tit 89, 140.40 – Prior Approval for Medical Services or Items Reviewers also look at whether what you are asking for is the most cost-effective option for the clinical picture. A request that only partially satisfies the test will be denied or scaled back.

Getting the Form

Download the HFS 1409 and its instruction sheet, HFS 1409i, from the HFS Medical Prior Approval Criteria page.3Illinois Department of Healthcare and Family Services. Medical Prior Approval Criteria The form also appears on the department’s numeric medical forms listing.6Illinois Department of Healthcare and Family Services. Medical Forms Numeric Listing

Completing the Form

Every field is required unless the instructions say otherwise.7Illinois Department of Healthcare and Family Services. Instructions for Completion of the HFS 1409 Prior Approval Request Form A blank slot or a typo is one of the fastest ways to get the form returned without a decision.

Patient Information

  • Field 1, Recipient ID Number: the nine-digit Medicaid identification number.
  • Field 2, Recipient Name: the patient’s full name as it appears on the Medicaid card.
  • Field 3, Birth Date: the patient’s date of birth.
  • Field 15, Patient Height/Weight: required for DME, supply requests, and gastric bypass procedures.

Provider and Physician Information

  • Field 4, Provider/NPI Number: your Illinois HFS provider number from your Provider Information Sheet, plus the ten-digit NPI issued by CMS.
  • Field 5, Provider Telephone Number: your office phone.
  • Field 6, Provider Name: the provider who will deliver the service or item.
  • Field 7, Physician Name: the physician or other provider who signed the order or prescription.
  • Fields 8 and 10, Provider Address: street, city, state, and ZIP of the rendering provider.
  • Fields 9 and 11, Physician Address: street, city, state, and ZIP of the ordering practitioner.

Diagnosis and Procedure Codes

  • Field 12, Diagnosis Code: the ICD-10 code that matches the description in Field 14. Use ICD-9-CM only for dates of service that predate the ICD-10 transition.
  • Field 13, Additional Diagnosis: any secondary ICD-10 codes.
  • Field 14, Diagnosis Description: a written description matching Field 12.
  • Field 16, Procedure Code: the five-digit HCPCS or CPT code for the specific item or service. For in-home shift nursing, use G0156, G0299, or G0300. For podiatry requests involving bilateral items, list the specific HCPCS code first and 99199 for the second.

Service Details

  • Description: a brief account of the service, item, or materials. For home health services, state whether the request is for intermittent visits or hourly in-home shift nursing, and include your workweek schedule for shift nursing. For home health therapy, include frequency, duration, and timeframes.
  • Quantity: the number of items dispensed within the time period of the request, or the number of times the service will be performed. For home health therapy, enter the number of visits.
  • Category of Service: the two-digit COS code.
  • Provider Charge: the total you will charge for the requested item.
  • Approved HFS Amount: leave blank. HFS fills this in during review.
  • Begin Date: the date the item or service was delivered if it already has been, otherwise the anticipated start date.

The quantity on the form must match the physician’s order or prescription exactly. A mismatch between the form and the underlying order is one of the most common reasons for an administrative rejection.7Illinois Department of Healthcare and Family Services. Instructions for Completion of the HFS 1409 Prior Approval Request Form

What to Attach

The form says what you want; the attachments say why the patient needs it. The small “Additional Medical Necessity” text box rarely holds enough to make a convincing case, so build a packet. Standard attachments include clinical progress notes, evaluation reports, and a signed physician order with the medical rationale stated clearly.

For DME, include a therapist or specialist assessment explaining why standard alternatives are not sufficient. The Medical Prior Approval Criteria page hosts item-specific criteria documents covering equipment categories from standing devices to oxygen therapy to pediatric specialty beds, and each one lists the data points reviewers expect to see.3Illinois Department of Healthcare and Family Services. Medical Prior Approval Criteria Pull the relevant criteria document before you assemble the packet.

Where to Send It

There is no online upload portal. Submit by mail or fax, and route to the right destination for your service type.

Mail

Illinois Department of Healthcare and Family Services
Bureau of Professional and Ancillary Services
Post Office Box 19124
Springfield, Illinois 62794-91247Illinois Department of Healthcare and Family Services. Instructions for Completion of the HFS 1409 Prior Approval Request Form

Fax

Faxing is faster and gives you a transmission confirmation for your records. Sending to the wrong fax line delays the review while the request is rerouted to the correct team.

Questions about a DME prior approval go to the Prior Approval Unit at 1-877-782-5565.3Illinois Department of Healthcare and Family Services. Medical Prior Approval Criteria

After You Submit

For home health care requests, the administrative code requires a decision within 21 days of receiving the request, or within 21 days of receiving any additional information HFS asks for, whichever is later.2Illinois General Assembly. Illinois Administrative Code Title 89 Part 140 – Medical Payment Other service categories may run on different timelines, but the workflow is the same.

HFS mails the decision — approval, partial approval, or denial — to both the provider and the patient.7Illinois Department of Healthcare and Family Services. Instructions for Completion of the HFS 1409 Prior Approval Request Form A partial approval means HFS authorized some but not all of what you asked for. A denial notice lists the reasons.

If the Request Is Denied

You have two options: reconsideration or a formal fair hearing.

Reconsideration

Submit a reconsideration request within 10 business days of the denial notice and before the patient is admitted for the procedure.4Acentra Health. Prior Authorization Resources – Illinois Medicaid This is your opportunity to add clinical documentation or clarify information the reviewer found insufficient. It is faster than a hearing and often the right first step when the original packet simply did not contain enough evidence.

State Fair Hearing

Federal law guarantees Medicaid recipients the right to request a fair hearing when a service is denied, reduced, or delayed.8eCFR. 42 CFR 431.221 The recipient has up to 90 days from the date the denial notice is mailed to file. Send written medical-services hearing requests to:9Illinois Department of Healthcare and Family Services. How Illinois Medicaid MCO Enrollees Can File Grievance or Appeals

Illinois Department of Healthcare and Family Services
Bureau of Administrative Hearings
69 W. Washington Street, 4th Floor
Chicago, IL 60602
Fax: (312) 793-2005
Email: HFS.FairHearing@illinois.gov
Phone: 1-855-418-4421

Mental health, substance abuse, and waiver program hearing requests go instead to the Illinois Department of Human Services Bureau of Hearings at the same address, fax (312) 793-3387, or email DHS.BAH@illinois.gov.9Illinois Department of Healthcare and Family Services. How Illinois Medicaid MCO Enrollees Can File Grievance or Appeals To keep services running during the appeal, file the hearing request within 10 days of the denial notice. Filing later preserves your hearing right but will not maintain services in the meantime.