Determining Other Eligibility

1.0.  Complete the Screening Device to determine eligibility for KidCare/Medicaid and University of Illinois Division of Specialized Care for Children (DSCC) services. If indicated, complete and submit a KidCare application and/or make a referral to DSCC. As part of the referral to DSCC and with proper authorization (documented with the Consent for Release of Information form), send to the DSCC local office a copy of the completed Screening Device and the following Cornerstone screens/reports: Participant Enrollment Information, Assessment History, and Insurance. File the completed, signed screening form in the child's file.

Documenting Insurance Coverage

2.0.  Assist family in completion of the Insurance Affidavit, Assignment and Release form.

  1. If the child has private health insurance enter insurance information on Cornerstone.
  2. If the child has insurance coverage through Medicaid/KidCare or the Medicaid managed care program, enter the correct code into Cornerstone (refer to the Cornerstone Manual if necessary).
  3. If the child has public insurance through Medicaid/KidCare, and private health insurance or insurance through the Medicaid managed care program enter the correct code into Cornerstone (refer to the Cornerstone Manual if necessary).
  4. If the child does not have private or public insurance, enter correct code into Cornerstone (refer to the Cornerstone Manual if necessary).

Determining if Insurance will be Billed

3.0.  Determine if insurance may be used to pay for Early Intervention services and equipment or if any Statutory Waivers or Exemptions apply for that particular child. All information obtained on the family's policy must be forwarded to the service provider.

  1. Insurance use is NOT required if any of the following are true:
    1. Insurance provider is not available to receive the referral and begin services immediately (within 15 business days).
    2. Insurance provider is not enrolled and fully credentialed as a provider in the Early Intervention system.
    3. Insurance company will not cover the services in the manner required in the IFSP.
    4. Family would have to travel more than an additional 15 miles or an additional 30 minutes to the insurance provider as compared to travel to a different enrolled and credentialed provider.
    5. The family's insurance carrier has no approved providers that are enrolled and credentialed in the Early Intervention system or they allow for billing (even at a reduced rate) for Early Intervention services by non-insurance providers.
  2. Statutory Insurance Waiver Certification
    During service coordination activities, it may be determined that one of the situations in section 3.1 does exist and that issuing an insurance waiver may be appropriate. The service coordinator should:
    1. Determine which waiver type applies.
    2. Obtain written verification of the waiver type from the insurance company.
      1. If written verification is not attainable, obtain verbal verification and document the verification according to the guidelines of the At-A-Glance policy grid.*
      2. *Note: Insurance waivers ONLY, may be documented verbally if NO written documentation is attainable.
    3. Complete an insurance waiver.
    4. Immediately forward a copy of the completed waiver form to the CBO.
    5. Immediately forward a copy of the completed waiver form to the provider.
    6. Attach all documentation to the original waiver and maintain in the child's file.
  3. To apply for an Insurance Use Exemption, provide the family with a copy of the Insurance Exemption Request form and explain the two types of exemption that can be requested:
    1. Private/Non-Group Plan;
    2. Lifetime Cap on some or all IFSP services
  4. *These exemption requests require the signature of the CFC manager to confirm the appropriateness of the request and thoroughness of the submitted documentation and are the only type that should be sent directly to the Bureau of Early Intervention.
    1. Upon request of the family, assist them in completing the form and submit it and all attachments and documentation to the Insurance Exemption Request Coordinator at DHS. DHS will make a decision within 10 business days of receiving all required information.
    2. Update SV 07 Insurance field to indicate "Pending Exempt" for the authorized services for which an Insurance Use Exemption is be applied for on the same day the request is submitted to DHS. Do not use this code until the exemption request has been sent to DHS.
    3. Upon receipt of a decision from DHS, update the SV 07 Insurance field immediately.
    4. If the private insurance plan/policy covering the child is not part of a group medical insurance plan, and an exemption has been approved enter the code for "Insurance Exempt/Individual Plan".
    5. If an exemption has been approved for all IFSP services because a child's private insurance plan/policy has an overall lifetime cap which could be exhausted during the IFSP period due to the billing of early intervention services, enter the code for "Insurance Exempt/Cap on All".
    6. If an exemption has been approved for one or more IFSP services because a child's private insurance plan/policy has a lifetime cap for one or more types of early intervention services which could be exhausted during the IFSP period due to the billing of early intervention services, enter the code "Insurance Exempt/Cap on Some" on the SV 07 screen related to the authorizations for those services.
    7. If the Insurance Use Exemption has been denied, update the SV 07 Insurance field to reflect, "Bill Insurance First" and notify all service providers of the new insurance billing status. Claims submitted to the Central Billing Office more than 7 (seven)-calendar days after the date of the denial will be placed in a pending status if they do not have an insurance Explanation of Benefits attached.

Determining the Appropriate Insurance Billing Indicator in Cornerstone

4.0.  There is an insurance billing indicator (commonly referred to as the "Insurance Flag") for each Cornerstone generated authorization. The person generating the authorization must check the appropriate insurance billing procedure for the provider performing each service. The insurance billing indicator will print on the authorization that is shared with the authorized provider.

  1. The PA 35 screen will display a general billing indicator that may be different than the specific per service indicator. The general indicator should not be confused with the specific per authorization indicators generated per authorization.

Determining the Provider

5.0. Give the family a list of credentialed, enrolled Early Intervention providers in the geographic area. The list should include which insurance networks each provider participates in. If the providers that are approved by the family's insurance network are not known to the CFC or the family, the CFC will assist the family in obtaining a list of approved providers from the insurance carrier and verifying if any of those providers are credentialed and enrolled in the Early Intervention system.

  1. If HMO: The service coordinator will provide the family a list of approved providers, specifically identifying those providers who are approved by that family's HMO and are enrolled in the Early Intervention system. The family should be informed that, under certain circumstances, an HMO may make payments to a provider not in its HMO network. Determination of benefits is established in cooperation between the family, insurance company, and the provider. A determination of payment to a provider not in the HMO network is made with the same parties. If an HMO will not approve payment to an out-of-network provider, the family will be required to accept services from an HMO provider in accordance with all applicable Early Intervention rules and statutes.
  2. If PPO or POS: The service coordinator will provide the family a list of approved providers, specifically identifying those providers who are approved by that family's PPO and are enrolled in the Early Intervention system. The Service Coordinator will also advise the family that any of those listed enrolled Early Intervention providers would most likely be able to access the insurance but an actual determination of benefits would be established in cooperation between the family, insurance company and the provider.

6.0.  Print and attach the following and distribute to IFSP team members and family as part of the IFSP:

  • Cornerstone Insurance Report,
  • Family's insurance card, if applicable,
  • Insurance Affidavit, Assignment, and Release form.
  • Insurance Use Exemption Request form, if applicable

Service providers are not to bill private insurance until they have received this information from the CFC and not before the effective date shown on the Cornerstone Insurance Report. If private insurance exemption is approved for some or all services, attach a copy of the DHS exemption approval letter to the Cornerstone Insurance Report before distributing to providers and families.

7.0.  Tell families and providers that they must inform their service coordinator immediately if the child's Medicaid/KidCare or private insurance coverage changes. Failure to do so may result in the provider's inability to receive payment form the insurance company or the CBO and may create a liability on the part of the family.