Attachment 7: EI Public & Private Insurance Use Determination (pdf)

Early Intervention Public and Private Insurance Use Determination

Please monitor the EI website for changes to Early Intervention Insurance Use Determination procedures.

POLICY

  1. Families whose children are enrolled under private insurance plans are required to use their child's benefits to assist in meeting the costs of covered Early Intervention services and devices unless an insurance exemption has been approved.
  2. The family, in conjunction with the CFC, and in cooperation with their insurance company and the service provider, will determine insurance benefits. The provider shall contact the insurance carrier for verification of benefits and should send the verification in the form of a denied claim or statement of non-coverage under the insurance plan to the CBO as part of the billing process. One or more of the following items must be obtained by the CFC as documentation if the service is not covered:
    • Applicable pages from the plan that clearly state that the service is not covered;
    • Notes from conversation(s), with the name(s) of the insurance company contact, phone number(s) and date(s) of contact, by CFC Manager and/or service coordinator confirming denial of the service; and/or
    • Written response or denial from insurance company
  3. All Early Intervention service providers are required to bill private insurance prior to billing the CBO unless an exemption has been approved. The only exceptions are Developmental Therapists, Interpreters, Deaf Mentors, and Physicians providing only medical diagnostics, Transporters, and Parent Liaisons.
  4. Families may request exemption from private insurance for one or more services if such use would put the family at material risk of losing their coverage as specified on the Insurance Exemption Request form.
    1. Private insurance plan/policy covering the child was purchased individually by a head of household not eligible for group medical insurance.
    2. Child's private insurance plan/policy has lifetime cap for one or more types of early intervention services which could be exhausted during the IFSP period based on the estimated cost of the Early Intervention services.
  5. Service coordinators are required to enter private insurance information on Cornerstone for covered EI eligible children.
  6. Service coordinators are required to enter Medicaid or KidCare (State Child Health Insurance Program or other public insurance plan) recipient identification numbers on Cornerstone for covered EI eligible children.
  7. Regional intake entities are required to apply to the Illinois Department of Public Aid to become KidCare Applicant agents.
  8. Families determined eligible through use of the Screening Device are required to apply for benefits through Medicaid/KidCare in order to enroll and remain eligible for Early Intervention services.
  9. As payer of last resort, all other resources must be maximized to cover the costs of Early Intervention services prior to utilizing state and federal appropriations for Early Intervention services.

PROCEDURES

Determining Other Eligibility

  1. 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

  1. 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

  1. 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: