Some healthcare services, tests, procedures, or medications need approval from YouthCare before your provider can give them to you. This approval is called Prior Authorization, or PA.

Prior authorization helps make sure:

• The care you get is medically necessary
• You receive the right care at the right time
• Services follow Illinois Medicaid rules and your plan benefits

No, you do not need to submit any paperwork yourself.

Your doctor or healthcare provider is responsible for requesting prior authorization from YouthCare when it is needed. You do not need to submit any paperwork yourself.

No referral is needed.

You do not need a referral from your Primary Care Provider (PCP) to see a specialist. However, some specialist services may still require prior authorization. Your provider has a list of care that needs prior authorization. If you need a care service that requires PA, your provider needs to fill out a Prior Authorization Request Form and send it to us.

Some services need prior authorization before they can be covered. Examples include (but are not limited to):

• Inpatient hospital stays
• Certain outpatient hospital services
• Some surgeries and procedures
• High-cost imaging (like MRIs or CT scans)
• Home health care services
• Hospice care
• Certain medical equipment and supplies
• Some therapy services (physical, occupational, speech)
• Some prescription medications

Not all services need prior authorization, and emergency care never requires prior authorization.

For a full list of medical services covered by the plan, see the YouthCare Member Handbook.

YouthCare does not require prior authorization for the following services (prior authorization may be required for out-of-network providers):

• Crisis stabilization care (outpatient mental health services for no less than 30 days post-crisis)*
• Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services
• Emergency services, including emergency medical screening
• Family planning and reproductive health services
• Local health department services
• Pediatric Palliative Care Program (PPCP) services
• Preventive prenatal, perinatal, and postpartum services
• School dental programs
• School-based health centers

*Notification requirements may apply. See MindCare Mental Health Services and Support for more details.

YouthCare covers certain services only for members who are in a Home and Community Based Service Waiver program. Prior authorization is not required for approved services for members with these waivers:

• Persons with Disability
• Supportive Living Facility
• Brain Injury
• HIV/AIDS

For a full list of medical and waiver services covered by the plan, see the YouthCare Member Handbook.

Mental health services are healthcare. These services offer emotional support, treatment, counseling, and guidance. Mental health care is covered at no cost through YouthCare MindCare. Each member is unique. And we’re ready to help address their needs.

For more details on your benefits, see MindCare mental health services and support.

At YouthCare, our goal is to provide the right drug coverage for our members. We work closely with doctors and pharmacists to make sure we offer medications that treat a range of conditions and illnesses.

The Preferred Drug List is the list of drugs covered by YouthCare. This list includes prescriptions and over-the-counter drugs used for treatment. Most are covered without a referral or medical review.

Other drugs require prior authorization (PA) from your doctor. If needed, your provider will fill out a prior authorization request form for you.

Sometimes a drug on the PDL doesn’t work for you or makes you sick. Your provider can ask for a different drug via the prior authorization request form.

Visit Pharmacy Services for more information.

Once YouthCare receives the request:

• Clinical experts review the request using medical guidelines
• A decision is made based on medical necessity and your plan benefits
• You and your provider are notified of the decision within established timeframes

If more information is needed, YouthCare may ask your provider for additional details.

YouthCare follows Illinois Medicaid and state requirements for reviewing prior authorization requests. Decision timeframes depend on:

• The type of service requested
• Whether the request is urgent

For standard requests we will make a decision and notify you and your PCP, as well as any other providers involved in writing within 5 calendar days of receiving all required information. Your provider can tell you if a request is urgent and a decision will be made within 48 hours after receiving all required information.

If your prior authorization request is denied:

• You will receive an Adverse Benefit Determination letter explaining the decision
• The letter will explain your appeal rights
• You can ask your provider to help you file an appeal if you disagree with the decision

Visit Appeals and Grievances for more details.

Within thirty (30) calendar days after the date on the YouthCare appeal Decision Notice, you may choose to ask for a review by someone outside of YouthCare. This is called an external review.

The outside reviewer must meet the following requirements:

• Board-certified provider with the same or like specialty as your treating provider
• Currently practicing
• Have no financial interest in the decision
• Not know you and will not know your identity during the review

External review is not available for appeals related to services received through the Persons with Disabilities Waiver; Traumatic Brain Injury Waiver; HIV/Aids Waiver; or the Home Services Program.

You can ask for external review in these ways:

• Call 844-289-2264 (TTY: 711), Monday through Friday, 8 a.m. to 6 p.m. to speak with one of our representatives.
• You can write a letter asking for external review and mail it to:
  YouthCare
  Attn: Grievance & Appeals Department
  PO Box 733
  Elk Grove Village, IL 60009-0733

Need Help or Have Questions? Member Services can help you:

• Understand if a service needs prior authorization
• Answer questions about coverage
• Explain letters you receive about your care