Illinois Medicaid fee-for-service providers use this request to get prior approval for medical equipment and prosthetics, medical supplies, home health, podiatry, optical and physician services that need it. It is prepared by the provider who will furnish the item or service and names the physician whose order or prescription backs it. HFS mails its approval or denial notice to both the provider and the patient.
The provider who will furnish the service or item completes the form and signs item 23 in ink, naming the physician or other practitioner who signed the order or prescription in items 7, 9 and 11. Item 22 is signed only by the Department of Children and Family Services when it authorizes in-home shift nursing.
Enter the patient's nine-digit recipient identification number, name and birthdate. The form's built-in help notes that the ID number appears to the right of the patient's name on the back of the Medical Programs Card. All fields on the HFS 1409 are required unless the instructions say otherwise, so these three must be complete.
Items 4, 5, 6, 8 and 10 identify the provider who will furnish the service or item: provider number or NPI as shown on the Provider Information Sheet, office phone, name and address. HFS uses the phone number when it needs more information to act on the request. Items 7, 9 and 11 give the name and address of the physician or other practitioner who signed the order or prescription recommending the item or service.
Enter the ICD-9-CM or ICD-10 diagnosis code according to the date of service, any additional diagnosis codes, and the written description that corresponds to the item 12 code. Patient height and weight are required for durable medical equipment and supply requests and for gastric bypass procedures.
Give the five-digit HCPCS or CPT code and a brief description. Home health requests say whether services are intermittent visits or hourly in-home shift nursing, with the workweek for shift nursing; home health therapy adds frequency, duration and time frames. Quantity is the number of items for the approval period or times the service is performed. Category of service is 01 physician, 04 podiatric, 41 equipment or prosthetics, 45 optical, 48 supplies or 66 home health. For podiatry pairs, list the code, then 99199.
Enter the total amount to be charged for the item and leave Approved HFS Amt blank. Enter a begin date only if the item or service has already been dispensed; leave it blank when it waits on approval. Add an end date where applicable. DME providers mark F for repair, M for modification, P for purchase or R for rental; all other providers use P or R. Leave Mod blank.
Lines 17 to 20 hold up to four more procedure codes, completed the same way as item 16: code, description, quantity, category of service, provider charge, dates, purchase or rental and modifier, with the Approved HFS Amount left blank. A request is limited to five procedures in total; if more are needed, another HFS 1409 must be submitted.
Use this space for other medical information that supports the request. For optical requests, include a narrative explanation, the diagnosis and visual acuity both with and without glasses. Item-specific HFS questionnaires and certificates of medical necessity, such as those in the HFS 2305 and 3701 series, go with the request where they apply.
Item 22 is used only by the Department of Children and Family Services to authorize in-home shift nursing. Item 23 is signed in ink and dated by the individual who will provide the service, certifying that the information above is true, accurate and complete. The instructions ask providers to review the request for completeness and accuracy before sending it and allow a copy to be kept in the provider's records.
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Prior Approval Request
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Sources for this guide
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No. The HFS 1409 is for Illinois Medicaid fee-for-service. Patients enrolled in a HealthChoice Illinois managed care organization go through that plan's own prior authorization process. Drugs are handled differently: the uniform HFS 1409X pharmacy prior authorization form is accepted by fee-for-service Medicaid and by every HealthChoice Illinois plan.
The individual who will provide the service or item signs item 23 in ink and dates it, certifying that the information is true, accurate and complete. The ordering physician or other practitioner is named in item 7 as the person who signed the order or prescription. The Department of Children and Family Services signs item 22 only when it authorizes in-home shift nursing.
Item 12 takes the diagnosis code that matches the written description in item 14, and item 13 holds any additional codes. The instructions call for ICD-9-CM or ICD-10 codes according to the date of service. Item 21 holds other medical necessity details, and optical requests add a narrative plus visual acuity with and without glasses.
The HFS 1409i instructions list procedure codes G0156, G0299 or G0300 for in-home shift nursing. The description must say whether services are intermittent visits or hourly in-home shift nursing, and the provider's workweek must be shown. When the Department of Children and Family Services authorizes the nursing, its approving authority signs item 22.