MedicaidPrior AuthHigh impact
Inpatient Utilization Review Change Mandated by P.A. 097-0689, the Save Medicaid Access and Resources Together (SMART) Act
Illinois Medicaid - HFS·IL · OB-GYN·Provider Notice
Effective date
Sep 1, 2012
We identified it
Jun 20, 2026
Summary
Illinois Medicaid will now subject cesarean sections to pre-payment utilization review starting September 1, 2012, and will only pay the normal vaginal delivery rate unless the cesarean was medically necessary. This is part of an effort to reduce elective deliveries before 39 weeks gestation.
Action Required
By September 1, 2012: Billing team must ensure all cesarean section claims for DRG 370 and 371 have proper medical necessity documentation before submission to Illinois Medicaid. Update billing workflows to flag these DRGs for pre-payment review by eQHealth Solutions. Providers must document medical necessity for all cesarean sections to avoid payment at the lower vaginal delivery rate.