Private Insurance Use

Utilization of private insurance benefits is mandatory. Providers are required to accept insurance and/or EI-EI-CBO payment as payment in full for services and agree not to bill the family for further payment. To ensure that the EI-CBO is aware of the appropriate payer, providers must notify the CFC immediately of any changes of insurance coverage that they become aware of for the families they are serving.

Providers should not bill the family directly for any EI services unless the insurance payment was paid to the family versus the provider. EI-CBO pays patient co-pays and deductible charges, up to the maximum allowed per service. An EOB from the insurance company must be attached to all claims billed to insurance regardless of the payment level of the insurance company, even if insurance has paid the claim in full.

Technical assistance with issues related to private insurance use is available from the EI-CBO by calling (800) 634-8540 or http://www.eicbo.info under support and click on "Create Help Ticket" to send your questions via e-mail. Visit the DHS and EI-CBO web sites will contain the latest updates to insurance billing requirements and/or procedures.

RESPONSIBILITIES

Child and Family Connections

  • Assist family in completing Insurance, Affidavit, Assignment and Release form
  • Provide copies of the family's insurance card to the provider and EI-CBO
  • Request approval of pre-billing waivers and exemptions from the EI-CBO
  • Update EI-CBO and provider of changes in insurance policy and benefits

Provider

  • Verify insurance benefits with all insurance companies covering the family
  • Verify that insurance coverage had not changed before each service is performed. The provider must be aware of who their payer will be and their requirements for each service provided
  • Bill the insurance company and EI-CBO appropriately
  • Update CFC and EI-CBO of changes in insurance policy and benefits
  • Follow up with insurance company per EI-CBO instructions

Family

  • Assist the CFC and provider in determining insurance benefits and obtaining required documentation, if necessary
  • Provide timely notification of changes in insurance policy/benefits to CFC, EI-CBO, and/or provider
  • Turn over recouped payments to the provider as appropriate

EI-CBO

  • Benefit verificationForward insurance data to CFC
  • Approval/denial of pre-billing waiver and exemption requests
  • Provide technical assistance to provider to help maximize insurance benefits

WAIVERS AND EXEMPTIONS

Child and Family Connections offices will determine if pre-billing waivers or exemptions are appropriate for children they are serving. Requests are submitted by the CFC to the Central Billing Office for approval or denial. If approved, direct service providers bill the CBO for all dates of service. If denied, claims must be submitted to the private insurance carrier for payment before billing the CBO. Notice of the approval/denial will be forwarded in writing to the CFC, provider, and family.

Pre-Billing Insurance Waivers

  • Pre-billing waivers will only be issued for the following situations:
    • An insurance required provider is not available to receive the referral and begin services
    • No insurance required providers are credentialed in Early Intervention
    • Travel to the insurance required center based provider would be a hardship to the family
  • Become void if the family's insurance coverage changes or if provider receives payment from the insurance company
  • Are effective for the IFSP period during which they are approved

Insurance Exemptions

  • Exemptions will only be issued for the following situations:
    • Privately Purchased/Non-Group Plan
    • Lifetime Cap (overall policy or service specific)
  • Approval/denial will be forwarded to the family, CFC, and the provider, as appropriate
  • Become void if the family's insurance coverage changes

Post-Billing Insurance Waivers

  • Will be issued by the CBO based on the denial reason listed on the insurance company EOB
    • This means the provider will not need to bill for this particular service until the beginning of the next benefit year
  • Expire at the end of the insurance plan's benefit year (NOT IFSP PERIOD) when the provider will be required to bill insurance company according to program requirements
  • If the family's insurance coverage changes, all waivers become void and the provider must bill the new insurance company

PROVIDER SAFETY NET

The Early Intervention program requires an explanation of benefits from the insurance company when a child is covered by private insurance. In some situations, the provider may experience difficulty in obtaining the required documentation from the insurance company. In these situations, the following process should be followed in order to facilitate a payment decision from the insurance company:

  • If no response is received within 30 days from the date of the original claim submission, follow up to inquire about the status of the claim with the insurance company and document the second method of contact.
  • Comply with all requests for any additional information and document the submission of the information.
  • After 60 days from the date of the original claim submission, if the insurance company still has not responded, the provider should submit a complaint form to the Illinois Department of Financial & Professional Regulation's (IDFPR) Division of Insurance. They can be reached at (877) 527-9431 or http://www.ins.state.il.us.
  • IDFPR will investigate the reason for the insurance company's failure to adjudicate the claim and will notify the provider of the outcome in writing.
  • If the insurance company agrees to pay after the investigation, the provider submits the claim along with the insurance company EOB to the CBO.
  • If the insurance company denies the claim, the provider submits the claim and denial within 90 days to the CBO
  • CBO will review based upon normal program requirements.