Provider Eligibility

To be eligible to bill for reimbursement, a provider must first have the correct certification by DHS/DASA and the correct corresponding enrollment with the Department of Healthcare and Family Services (HFS). The procedure for making application for certification is contained in DHS Rule, Part 2090. All completed enrollment applications must be sent to DHS/DASA.

In order to maintain eligibility, providers must deliver substance abuse services in accordance with DHS rules that specify:

  • The minimum standards necessary to deliver quality care (Part 2060);
  • The reimbursement limits as applicable for each level of care (Part 2090); and
  • The minimum standards designed for administration of funding (Part 2030) as well as any other specific contractual obligations, if applicable.

Violations may result in financial penalty.

Patient Eligibility

In order to receive services that are reimbursed by DASA Medicaid, the patient must meet eligibility requirements under Title XIX and Title XXI (Medicaid) for covered services through the Medical Benefits, All Kids and Family Care. The eligibility status of such patients changes frequently. In order to reduce the incidence of billing error and/or recoupments, the provider must make every effort to verify the patient's eligibility for the Medical Benefits, All Kids and Family Care PRIOR to service delivery. Learn the status of the patient's eligibility using the MEDI (Medical Electronic Data Interchange) system, REV (Recipient Eligibility Vendor) or through the AVRS (Automated Voice Response System) by calling 1-800-842-1461. HFS currently produces monthly identification cards, however, the se monthly cards will soon be replaced by semi-permanent durable medical cards. Therefore, it is imperative that all providers check the status of a client's eligibility through one of the above systems. Specific information relative to HMO coverage and Spend Down requirements should also be verified.

Managed Care Enrollees Served by Community Substance Abuse Agencies

There are two types of managed care programs serviced by Community Substance Abuse Agencies. The Integrated Care Program is a mandatory program for Medicaid only older adults and adults with disabilities who live in Suburban Cook (non 606 zip codes), Lake, Kane, DuPage, Will and Kankakee counties. There are currently two managed care organizations (MCOs) participating in this program. The names of the current Integrated Care Program MCOs can be found at: (http://www.hfs.illinois.gov/managedcare/).

When a person enrolled in the Integrated Care Program presents themselves for services, their eligibility status in the system will reflect in which MCO they are enrolled. The enrollee should also have an identification card from that MCO. If your agency is part of the MCO's provider network, you should provide services according to the MCO procedures, If your agency is not part of the MCO's provider network, you should contact the MCO prior to providing services.

The Voluntary Managed Care Program is a voluntary program for All Kids, Family Care and Moms & Babies participants who opt out of the Primary Care Case Management Program, Illinois Health Connect, and choose to enroll in an MCO. There are currently three MCOs participating in the voluntary MCO program. The names of the current voluntary MCOs can be found at: (http://www.hfs.illinois.gov/managedcare/).

The voluntary MCO program operates in Cook, Kane, McHenry, Lee, Henry, Rock Island, Mercer, Adams, Brown, Scott, Pike, Madison, St. Clair, Randolph, Perry, Jackson, Washington and Williamson counties and additional counties may be added. When a person enrolled in a voluntary MCO present themselves for services, their eligibility status in the system will reflect in which MCO they are enrolled. They should have an identification card from that MCO.

Below please find steps for community substance abuse providers to follow when patients enrolled in the voluntary MCO program present themselves for services. The determining factor for the provision of or the referral for treatment is the scope of services needed.

  1. Learn the status of the patient's eligibility using the patient's MediPlan card, the card issued by the patient's managed care organization, using one of the Department of Healthcare and Family Services' Recipient Eligibility Vendors (REV) or by contacting the Provider Eligibility Inquiry Hotline at 1-800-842-1461.
  2. Perform a clinical assessment to determine the scope of substance abuse services needed by the patient. This assessment should be in accordance with 77 Ill. Adm. Code 2060 Section 2060.417. Reimbursement will be made through the Division of Alcoholism and Substance Abuse in accordance with that rule.
  3. If the assessment indicates that the only services needed are those the managed care organization is required to cover, the community based health provider (CBHP) will refer the individual to the managed care organization. If the individual refuses a referral, the CBHP must inform the individual that if they want to receive services through the CBHP, they must disenroll from the managed care organization. The CBHP must document its attempts to refer the individual to the managed care organization in the medical record. The Department of Healthcare and Family Services has a process to disenroll individuals on a case-by-case basis. The number to call is 1-800-226-0768. Managed care organizations provide inpatient hospitalization, pharmaceutical, laboratory and physician services including outpatient services.
  4. If the assessment indicates that comprehensive behavioral health outpatient services, which may include physician/psychiatrist services are needed, the CBHP will treat the individual and be reimbursed through fee-for-service. The managed care organization will be responsible for payment of drugs prescribed by a licensed physician and laboratory services. The CBHP must inform the individual that prescriptions must be filled at a pharmacy in the managed care organization's network. Laboratory services must be coordinated by the CBHP with the managed care organization.
  5. Treatment of patients for substance abuse is confidential. Clinical information can only be shared with patient consent. This includes information to the patient's primary care physician, the managed care plan or the plan's behavioral health provider. The provider may utilize their standard forms and procedures for obtaining patient consent.
  6. Any service the community provider renders should be communicated with the patient's Managed Care provider or primary physician. This allows for continuity of care. Patient consent is required.

Medical Assistance Spend Down Information

A Medical Assistance Spend Down is much like an insurance deductible with three major exceptions:

  1. The participant's spend down is determined on a monthly basis.
  2. The amount of that monthly spend down is based upon the participant's income and assets.
  3. When spend down is met in the middle of the month, the decision as to which bills are the patient's responsibility and which are the Department's is made chronologically based on the date of the service.

Although enrolled in the Medical Assistance program, spend down participants do not automatically receive a MediPlan card each month. MediPlan cards are only issued for the month (or portion thereof) for which participants have demonstrated that incurred or paid medical expenses equal the spend down by presenting medical bills and receipts to the local DHS office. A patient must incur a specified amount of medical bills before they can receive Medical Benefits, All Kids and Family Care coverage for a designated month. Each month, thereafter, spend down must be continued to be met for coverage to remain in effect. The provider may also want to contact the Provider Eligibility Inquiry Hotline at 1-800-842-1461 to check eligibility.