Proposed Changes to Child & Family Connections Procedure Manual - July 2013

Helping Families. Supporting Communities. Empowering Individuals.

CHAPTER 10 PUBLIC AND PRIVATE INSURANCE USE DETERMINATION

10.1 Policy for Public Benefits

  • 10.1.1 All families shall be provided the Notice of System of Payments and Fees as well as the Family Participation Fees Program Fact Sheet at Intake and at each annual IFSP explaining EI's system of payment provisions and no cost protections.
  • 10.1.2 CFCs will not require any family to have an application for Public Benefits (AllKids) submitted on their behalf by the AllKids Application agent (CFC). But, families with no public benefits who may qualify for AllKids should be encouraged to apply for AllKids. If the family chooses to apply, the CFC must assist the family in applying for AllKids.

10.2 Procedures for Public Benefits

  • 10.2.1 During Intake and at each annual IFSP, the CFC will provide Notice of System of Payments and Fees as well as the Family Participation Fees Program Fact Sheet to all families. Ensure the families have all concerns answered.
  • 10.2.2 Based on the results at Intake and each Annual IFSP of the Screening Device for Determining Family Fees and Eligibility for All Kids & DSCC, determine if the family is currently enrolled in AllKids or is potentially eligible for AllKids. Explain to family that DSCC eligibility will require a family to cooperate with DSCC financial factors if DSCC is to fund any service/device for their child. Failure to cooperate with DSCC will result in a status of non-cooperation with EI which may cease EI service/device subject to Family Participation Fees.
  • 10.2.3 Provide the family the Notice to Use Public Benefits-AllKids Enrolled or Potentially Eligible for AllKids. Document the receipt of this notice. If the family is already enrolled in AllKids:
  • Obtain a copy of the current AllKids card or a screen print of the PA42 showing current eligibility.
  • 10.2.4 If the family is not currently enrolled in AllKids but the screening tool shows potential eligibility, advise the family that they are not required, but are encouraged, to submit an application for AllKids and offer any assistance for that process. Provide the family with the Notice to Use Public-AllKids Enrolled or Potentially Eligible for AllKids and document the receipt.
  • Ask the family for future outcome information on any application submitted to HFS. Check with the family periodically if they have indicated they did apply. PA42 should also be used to review eligibility status once an application is processed by HFS.
  • 10.2.5 If the family is not currently enrolled and does not show potentially eligible for AllKids, remind the family to also report any changes to income or household circumstances that may cause potential eligibility and offer to assist in the future if needed.

10.3 Benefits Verification Process for Public Benefits

  • 10.3.1 For families currently enrolled in or potentially eligible for AllKids, and no private insurance plan:
  • Ensure the family signed the Consent to Collect, Store & Utilize Personally Identifiable Information PII,
  • Indicate in the Cornerstone system using the Insurance Flag set to "No Private Insurance".
  • There is no need to complete a benefits' verification.
  • 10.3.2 For families enrolled in or potentially eligible for AllKids and also do have private health insurance:
  • Ensure the family signed the Notice to Assign Rights to Use Private Insurance and the Consent to Collect, Store & Utilize Personally Identifiable Information PII:
  • Submit the normal benefits verification outlined in Chapter 10.6 below.

10.4 Policy for Private Health Insurance Benefits

  • 10.4.1 During Intake and at each IFSP, the CFC will provide Notice of System of Payments and Fees as well as the Family Participation Fees Program Fact Sheet to all families. Ensure the families have all concerns answered. Families whose children are enrolled under private insurance plans must allow use of their benefits to assist in meeting the costs of covered EI services and AT devices.
  • 10.4.2 EI service providers are required to follow authorizations for services, including insurance usage, waivers, exemptions, etc and bill appropriately following policies and procedures. NOTE: The following services are the exception to insurance billing: Developmental Therapists, Translators/Interpreters, Deaf Mentors, and Physicians providing only medical diagnostics, Transportation providers and Parent Liaisons.

10.5 Procedures for Private Health Insurance Benefits

  • 10.5.1 During Intake and at each annual IFSP, the CFC will provide Notice of System of Payments and Fees as well as the Family Participation Fees Program Fact Sheet to all families. Ensure the families have all concerns answered. Document receipt of the notices.
  • 10.5.2 The CFC will provide the family the Notice to Assign Rights and Use Private Insurance form for their review and signature.
  • 10.5.3 The family must also be fully informed of the ramifications of waivers, exemptions and Family Fees based on the results of the benefits verification process and provider choice options. A family must follow the policies and procedures of their private health insurance plan with regards to provider choice and the philosophy and principals of EI.

10.6 Benefits Verification Process for Private Health Insurance

  • 10.6.1 Submitting a Benefits Verification Request
  • Obtain a copy of the front and back of the private insurance card.
  • Indicate the proper insurance flag of "Bill Insurance First" in Cornerstone for each authorization billable to private insurance.
  • Submit a copy of the front and back of the insurance card, the signed Notice to Assign Rights and Use Private Insurance along with the CFC Fax Cover Sheet for Insurance Benefits Verification Requests/Updates form to the CBO for the benefits verification process.
    • Include a copy of the form to the CBO with the benefits verification process.
  • The CBO will verify the private health insurance benefits and provide a result to the CFC within 5 working days to assist the family and CFC in determining Provider Choice limits, if applicable.
  • The CBO will inform the CFC if the results indicate a need for a pre- billing waiver due to finding no enrolled EI providers or due to the private benefits plan indicating the EI services are not covered under the plan. The CBO will work with the CFC to automatically issue a pre-billing waiver to the service provider.
    • If the provider is not known yet, the CBO will issue a pre-billing waiver for the specific discipline.
    • The CFC must inform their CBO Insurance Processor when a payee/provider is located. The CBO will re-issue the pre-billing waiver in the individual payee/provider's name for the records.
    • The CFC must pass a copy of the pre-billing waiver to the rendering provider for their records. No provider should be asked to perform services without the waiver process being completed and a wavier in hand for their records.
  • The CBO will provide a pre-billing waiver automatically if the PCP referral is unobtainable due to the PCP not referring to an EI enrolled provider.
    • The CFC must inform their CBO Insurance Processor when a payee/provider is located. The CBO will re-issue the pre-billing waiver in the individual payee/provider's name for the records.
    • The CFC must provide a copy of the pre-billing waiver to the rendering provider for their records. No provider should be asked to perform services without the waiver process being completed and a wavier document provided for their records.
      • NOTE: The physician's prescription must still be obtained prior to direct service provision. A copy must be forwarded to the appropriate service provider and a copy maintained in the record for services provided by Audiologists, Speech Language Pathologists, Occupational Therapists and Physical Therapists.
  • The CBO benefits verification process is a high-level request and does not replace the more comprehensive and detailed benefits verification the rendering provider must perform with the insurance plan to ensure accuracy of billing/payment. Remind the providers that providers who fail to perform their own comprehensive benefits verification risk non-payment for services rendered.
  • Upon receipt of the results of the benefits verification from CBO, determine if the CBO benefits verification process results render the need for a pre-billing waiver or exemption of using the private insurance and submit the CFC Fax Cover Sheet for Insurance Benefits Verification Request/Update indicating the applicable waiver/exemption request.
  • 10.6.2 Waiver of Private Insurance Use
    • If the benefits verification limits the choice of EI providers and the CFC has contacted all the providers on the list with no success of locating a provider who can accept the referral within 15 days, the CFC must submit a pre-billing waiver request.
      • Provider Not Available: Complete the Waiver request section of the CFC Fax Cover Sheet for Insurance Benefits Verification Request/Update, the Pre-Billing Wavier Request form and submit, along with the appropriate case documentation (notes indicating the results of the contacts with the list of insurance mandated providers including the date of contact, phone number or e-mail address and, date services could begin by the insurance mandated provider), to the CBO.
      • Provider Not Enrolled: Complete the Waiver request section of the CFC Fax Cover Sheet for Insurance Benefits Verification Request/Update, the Pre-Billing Wavier Request form and submit, along with the appropriate case documentation (notes indicating the results of the any contacts providers including the date of contact, phone number or e-mail address), to the CBO. NOTE: If the CBO is aware that there are no insurance-enrolled, EI credentialed providers at the time of the benefits verification, a pre-billing waiver will be automatically issued.
      • Excessive Travel Time or Distance: If the insurance mandated provider must be a clinic-based provider based on the IFSP team's decision due to the needs of the child and the family would have to travel more than 15 miles or 30 minutes from their home, a pre-billing waver must be submitted. Complete the Waiver request section of the CFC Fax Cover Sheet for Insurance Benefits Verification Request/Update, the Pre-Billing Wavier Request form and submit, along with the appropriate case documentation (notes, address of clinic family will travel to), to the CBO.
      • If any information is incomplete or missing on the request, the CBO will have no choice but to deny the request and the CFC must resubmit a new request including all the above indicated required forms, documents or items.
      • The CBO will process and inform the CFC the results within 10 working days of receipt of the Waiver request.
      • Maintain all documentation and requests in the child's permanent record.
      • Based upon the type of private insurance plan, plan restrictions, waivers or exemptions, the CFC must assist the family in choosing the provider based on the allowances of the private benefits plan, the availability of EI providers and the plans coverage. If the insurance plan will not approve benefits to an out-of-network provider, the family will be required to accept services from an EI enrolled in-network provider following all other policies and procedures of accepting private insurance usage.
  • 10.6.3 Exemption of Insurance Use
    • If the family has chosen, or if the CFC becomes aware of a need for an exemption to using private insurance, the CFC should submit that request by indicating on the CFC Fax Cover Sheet for Insurance Benefits Verification Requests/Updates as early in the process as possible. The current Exemption request may be necessary based on: 1) an Individually Purchased/Non-Group Plan; 2) a plan that has a Lifetime cap (limits) that EI services may exceed or exhaust the amount if the plan is used for EI; and 3) the family has a Tax Savings Plan (such as a Health Savings Account or Health Reimbursement Account) that is automatically withdrawing funds when claims are submitted to the health plan.

NOTE: Effective 06/28/13, State law provides the following assurances regarding the use of private insurance to pay for Part C services: (1) cannot count toward or result in a loss of benefits due to annual or lifetime caps; (2) cannot negatively affect the availability of health insurance; (3) cannot be used to discontinue health insurance; and (4) cannot be used as a basis for increasing health insurance premiums.

    • If a family communicates that their private insurance plan is not consistent with these assurances, the CFC should contact their EI Specialist who will begin an investigation. DHS may exempt the family's private insurance from use based on the investigation. The EI Specialist may instruct the Service Coordinator to inform the family they have the right to complete a consumer complaint form with the Department of Insurance.
  • Complete the appropriate section and include all noted documentation necessary to complete the request.
    • For Tax Savings Plan exemptions, the CFC must also submit the completed CFC Tax Savings Account Information Sheet to let CBO know the contact information for the tax savings plan account. NOTE: Families may decline the exemption for tax savings plan as long as the family is well informed of the consequences of their decision. If the family does request EI to utilize the tax savings account to pay for EI services, have the family sign the Acknowledgement to Decline Exemption for Tax Savings Account form and submit to the CBO with the CFC Fax Cover Sheet for Insurance Benefits Verification Requests/Updates indicating "other" as the required attachments in Section 4.
    • CBO will process and inform the CFC the results within 10 working days of receipt of the Exemption request.
  • 10.6.4 Updating Insurance Information

When status of private insurance changes the CFC must act immediately to ensure continuance of services and reimbursement to providers.

    • Check monthly with the family to ensure all coverage is the same. Being especially mindful of major plan year changes such as end of calendar year or fiscal years (each plan is different). Ask specific questions to families to ensure the most current accurate information is known. It might be the provider who discovered the update first. If so, take appropriate actions immediately when informed by provider or family.
    • Use the CFC Fax Cover Sheet for Insurance Benefits Verification Requests/Updates and complete the Change/Update section on an active child with an IFSP.
    • Families obtaining insurance for the first time will receive a 45-day exception to insurance billing for providers, beginning the day the CBO receives the request from the CFC. This 45-day exception allows the services to continue and the provider to bill the CBO directly for a period of time while the CBO, the CFC and the provider all process the benefits verification information to determine benefits coverage. As soon as the results of the benefits verification are received by the CFC, or once the 45-days are over, the services must be delivered in the manner matching the benefits verification results, including any need for a waiver or exemption. NOTE: The CFC must ensure the insurance flag is correctly set to Bill Insurance First.
  • Families changing private benefits plans (including new plan within same insurance company/carrier) will also receive a 45-day exception to insurance billing, beginning the day the CBO receives the request, while the CBO, the CFC and the provider all process the benefits verification information to determine benefits coverage and start date of services. NOTE: The CFC must ensure the insurance flag is correctly set to Bill Insurance First.
  • If the family does not have the new insurance plan card or identification yet, the CFC must complete the CFC Change of Insurance Notification form along with the CFC Fax Cover Sheet for Insurance Benefits Verification Requests/Updates to assist the CBO in processing the benefits verification request.
  • Families changing from having private benefits to having no private benefits will have all services billed directly to EI which will impact the Family Fee if the family participates in Family Fees. Again, submit the update request to the CBO and adjust Cornerstone only when the CFC receives the results from the CBO confirming the date of the lapse in private benefits coverage. After the CFC receives the confirmation of Lapse Date of private benefits, the CFC must adjust the insurance flag in Cornerstone to No Private Insurance and must re-write all direct service authorizations to correctly reflect the insurance status to providers. Immediately inform providers of changes to insurance status.
  • The CFC should recommend families who lack private benefits to research options such as AllKids. Answer any questions as needed for families.

(Below is text only from the DRAFT Child and Family Connections Manual entitled "Notice of System of Payments and Fee".  Once finalized, this notice will be provided to families entering the Early Intervention Program.)

CHILD AND FAMILY CONNECTIONS-NOTICE OF SYSTEM OF PAYMENTS AND FEES


The Illinois Early Intervention (EI) Program is funded through various sources and every attempt is made to maximize these sources. Some of the sources involve the family. Family sources for funding EI may include any combination of private insurance, AllKids and Family Participation Fees.

Private Insurance

  1. Families whose children are enrolled under private insurance plans must allow use of their benefits to assist in meeting the costs of covered EI services and AT devices. State law provides that the use of private health insurance to pay for Part C services: (1) cannot count towards or result in loss of benefits due to annual or lifetime caps; (2) cannot negatively affect the availability of health insurance; (3) cannot be used to discontinue health insurance; and (4) can't be used as a basis for increasing health insurance premiums. If I believe my insurance company is not following State law assurances, I will immediately contact my Service Coordinator. I also have the right to request the Illinois Department of Insurance (DOI) to investigate my complaint by filing a consumer complaint with the DOI, either electronically or in hard copy.
  2. EI will process insurance claims for Providers to cover the cost of covered EI services. If a private insurance Explanation of Benefits (EOBs) indicates no payment or reduced payment due to deductibles or established insurance reimbursement rates lower than EI rates, the Bureau will make necessary payments to the provider. If I participate in Family Participation Fees AND EI pays for services due to those or similar examples, this may impact the amount of Family Participation Fees I owe. I understand I am not required to pay more than the maximum out of pocket calculated based on my ability to pay. I agree to check with my own private health insurance to determine coverage and share any concerns with my EI Service Coordinator.
  3. If private health insurance is used and the family is subject to Family Participation Fees (see below), the use of private insurance can reduce the amount EI pays which can reduce the amount of Family Fees paid.
  4. Families with public insurance or benefits or private health insurance will not be charged disproportionately more than families who do not have public insurance or benefits or private health insurance.

AllKids

  1. AllKids is the state public benefits program. For certain AllKids eligible families, EI receives funds from AllKids to pay for EI services. EI must obtain your consent to disclose personally identifiable information (PII) for billing purposes to the Illinois Department of Healthcare and Family Services (HFS), the state public agency responsible for administration of AllKids.
  2. The use of AllKids to reimburse EI for a portion of the cost for an eligible child's services will not: (1) decrease available lifetime coverage or any other insured benefit for your child under AllKids; (2) result in fees for services that would otherwise be covered by AllKids; (3) result in any increase in premiums or discontinuation of AllKids for you or your child; or (4) risk loss of eligibility for you or your child for home and community based waivers based on aggregate health related expenditures.
  3. EI services, as specified in your child's Individualized Family Service Plan (IFSP), and to which you have consented, cannot be denied due to your refusal to disclose your child's personally identifiable information (PII) to HFS and you have the right to withdraw your consent to disclose your child's PII at any time without affecting the EI services your child is receiving as specified in the IFSP. If you would like to withdraw your consent, notify your EI Service Coordinator.
  4. If you have private insurance in addition to AllKids, AllKids will require the use of private insurance as the primary insurance. You will be provided a copy of the Notice to Assign Rights and Use Private Insurance to explain those no-cost protections.
  5. You may contact your EI Service Coordinator if you are interested in more information about AllKids eligibility.
  6. Families with public insurance or benefits or private health insurance will not be charged disproportionately more than families who do not have public insurance or benefits or private health insurance.

Family Participation Fees

  1. EI requires that families help pay for EI services when financially able.
  2. The fee assessment calculates how much your family is able to pay (see Family Participation Fees Program Fact Sheet) and is recalculated annually.
  3. Fees will not be charged for the services that a child is otherwise entitled to receive at no cost.
  4. Families will not be charged any more than the actual cost of the EI services subject to fees (factoring in any amount received from other sources for payment such as private health insurance). For families subject to Family Participation Fees, the family will not be charged more than the actual cost of EI services subject to fees OR the maximum out-of-pocket calculated for their Family Participation Fees - WHICHEVER IS LESS. This means if the Family Participation Fee is calculated to be more than the actual cost EI pays for services, then EI will only charge the amount EI paid out for services and not the full Family Participation Fee that was calculated.
  5. The family may decline to provide the requisite income information and documentation. Any family who declines to provide the required income information and documentation will be charged the highest amount on the fee scale.
  6. To determine ability to pay, EI compares household size and taxable reported income to the Federal Poverty Level on a sliding scale and considers out of pocket medical/disaster expenses. A family meets the definition of ability to pay if the family falls within the scale and does not have proven out-of-pocket medical (allowable as IRS deductions) or disaster (fire, flood or act of nature) expenses in excess of 15% of the reported income.
  7. Inability to pay is defined as a family whose household size and taxable reported income does not fall within the sliding scale and/or has proven out-of-pocket medical (allowable as IRS deductions) or disaster (fire, flood or act of nature) expenses in excess of 15% of reported income. These families must be provided all EI IFSP approved and consented services at no cost.
  8. A family will not experience a delay or denial of services for an inability to pay if the family meets the State's definition of inability to pay.

EI Services Provided at No Cost

  • Evaluations
  • Assessments
  • Service Coordination Services (including but not limited to Transition, IFSP Meetings, etc.)
  • IFSP Development and IFSP Meetings for Direct Service Providers
  • Developmental Screenings
  • Medical Diagnostic Services
  • Interpretation
  • Translation Services

EI Services Subject to Family Participation Fees, Insurance Billing and AllKids Reimbursement

  • Assistive Technology (Durable Medical Equipment and Supplies)
  • Audiology
  • Aural Rehabilitation and Other Related Services
  • Developmental Therapy
  • Health Consultation
  • Nursing Services
  • Nutrition Services
  • Occupational Therapy
  • Physical Therapy
  • Psychological and/or Other Counseling Services
  • Social Work and Counseling Services
  • Speech Language Therapy
  • Transportation
  • Vision Services

Under the provisions of the Illinois Mental Health and Developmental Disabilities Confidentiality Act, the Family Educational Rights and Privacy Act, 20 USC 1232g, and the Health Insurance Portability and Accountability Act of 1996, information collected hereunder may not be redisclosed unless the person who consented to this disclosure specifically consents to such redisclosure or the redisclosure is allowed by law.


(Below is text only from the DRAFT Child and Family Connections Manual entitled "Notice To Use Public Benefits-Allkids Enrolled Or Potentially Eligible For AllKids".  Once finalized, this notice will be provided to families entering the Early Intervention Program.)

CHILD AND FAMILY CONNECTIONS-NOTICE TO USE PUBLIC BENEFITS-ALLKIDS ENROLLED OR POTENTIALLY ELIGIBLE FOR ALLKIDS

NOTE: This form lists, the Child's Last Name, First Name & Middle Initial, Child's Date of Birth, and CBO/EI Number

NOTICE TO USE PUBLIC BENEFITS

The Illinois Early Intervention (EI) Services System is required to notify you of the following facts regarding the use of AllKids to pay for EI services:

  1. Families whose children are enrolled under private insurance plans must allow use of their benefits to assist in meeting the costs of covered EI services and AT devices. State law provides that the use of private health insurance to pay for Part C services: (1) cannot count towards or result in loss of benefits due to annual or lifetime caps; (2) cannot negatively affect the availability of health insurance; (3) cannot be used to discontinue health insurance; and (4) can't be used as a basis for increasing health insurance premiums. If I believe my insurance company is not following State law assurances, I will immediately contact my Service Coordinator. I also have the right to request an investigation by the Illinois Department of Insurance (DOI) by filing a consumer complaint with the DOI.
  2. EI will use my private insurance and the costs of co-payments and deductibles will be processed through EI and will be subject to Family Participation Fees if I participate. I will still incur my premiums.
  3. EI will process insurance claims for Providers for the cost of EI services. Not all services are covered by insurance. If a private insurance plan does not cover or an Explanation of Benefits (EOBs) indicates no payment or reduced payment due to deductibles or established insurance reimbursement rates lower than EI rates, the Bureau will make necessary payments to the provider. If I participate in Family Participation Fees AND EI pays for services under these circumstances, this may impact the amount of Family Participation Fees I owe. I understand I am not required to pay more than the maximum out of pocket calculated based on my ability to pay. I agree to check with my own private health insurance to determine coverage and share any concerns with my EI Service Coordinator.
  4. If private health insurance is used and the family is subject to Family Participation Fees (see below), the use of private insurance can reduce the amount EI pays which can reduce the amount of Family Fees paid.
  5. Families with public insurance or benefits or private health insurance will not be charged disproportionately more than families who do not have public insurance or benefits or private health insurance.

Under the provisions of the Illinois Mental Health and Developmental Disabilities Confidentiality Act, the Family Educational Rights and Privacy Act, 20 USC 1232g, and the Health Insurance Portability and Accountability Act of 1996, information collected hereunder may not be redisclosed unless the person who consented to this disclosure specifically consents to such redisclosure or the redisclosure is allowed by law.


(Below is text only from the DRAFT Child and Family Connections Manual entitled "Notice To Assign Rights And Use Private Insurance".  Once finalized, this notice will be provided to families entering the Early Intervention Program.)

CHILD AND FAMILY CONNECTIONS-NOTICE TO ASSIGN RIGHTS AND USE PRIVATE INSURANCE

NOTE: This form lists, the Child's Last Name, First Name & Middle Initial, Child's Date of Birth, and CBO/EI Number

NOTICE TO USE PRIVATE INSURANCE:

  1. Families whose children are enrolled under private insurance plans must allow use of their benefits to assist in meeting the costs of covered EI services and AT devices. State law provides that the use of private health insurance to pay for Part C services: (1) cannot count towards or result in loss of benefits due to annual or lifetime caps; (2) cannot negatively affect the availability of health insurance; (3) cannot be used to discontinue health insurance; and (4) can't be used as a basis for increasing health insurance premiums. If I believe my insurance company is not following State law assurances, I will immediately contact my Service Coordinator. I also have the right to request an investigation by the Illinois Department of Insurance (DOI) by filing a consumer complaint with the DOI.
  2. EI will use my private insurance and the costs of co-payments and deductibles will be processed through EI and will be subject to Family Participation Fees if I participate. I will still incur my premiums.
  3. EI will process insurance claims for Providers to cover the cost of covered EI services. If a private insurance Explanation of Benefits (EOBs) indicates no payment or reduced payment due to deductibles or established insurance reimbursement rates lower than EI rates, the Bureau will make necessary payments to the provider. If I participate in Family Participation Fees AND EI pays for services due to those or similar examples, this may impact the amount of Family Participation Fees I owe. I understand I am not required to pay more than the maximum out of pocket calculated based on my ability to pay.
  4. I understand that even if Early Intervention submits claims to my private health insurance company, those services may not be covered by my plan. If the service is not covered by my plan, Early Intervention may waive or exempt the procedure for the Early Intervention provider to submit claims to my private health insurance. This will allow the Early Intervention provider to submit claims directly to Early Intervention for payment. If I participate in Family Participation Fees AND Early Intervention pays for any services due to waivers or exemptions, this may impact the amount of Family Participation Fees I owe. I understand I am not required to pay more than the maximum out of pocket calculated based on my ability to pay.
  5. I agree to check with my own private health insurance to determine coverage and share any concerns with my EI Service Coordinator.
  6. If I possess/utilize a Tax Savings Plan such as a Health Savings Account or Health Reimbursement Account or any account utilizing pre-tax dollars for payment of medical services not otherwise paid by insurance, I understand I am required to provide my Service Coordinator with current information regarding any such account. Failure to disclose this information could result in lost funds from the accounts, which are not reimbursable by Early Intervention.
  7. If I have federally funded AllKids and private insurance, I understand AllKids requires the use of private insurance as the primary insurance.
  8. I understand I must provide current, up-to-date insurance coverage and benefit information to Child and Family Connections (CFC) staff and EI providers for the child listed above.
  9. I understand I am responsible for providing assistance as needed in the prompt processing of any insurance claims including notification to providers if any claims are rejected by insurance.

ASSIGNMENT OF RIGHTS OF INSURANCE:

By signature below, I hereby assign the benefits from all non-exempted private health insurance for this child to my child's authorized EI provider(s) and consent to the release of information regarding benefit determinations, payee information and claims to the Department of Human Services or its designee, CFC staff and my child's authorized EI provider(s).

NOTE:  This form has the parent/guardian printed name and signature.  It also has a place for a witness signature, which is usually the family's service coordinator.

Under the provisions of the Illinois Mental Health and Developmental Disabilities Confidentiality Act, the Family Educational Rights and Privacy Act, 20 USC 1232g, and the Health Insurance Portability and Accountability Act of 1996, information collected hereunder may not be redisclosed unless the person who consented to this disclosure specifically consents to such redisclosure or the redisclosure is allowed by law.