Date: March 9, 2015
To: All Medical Providers
Re: Care Coordination Health Plan Identification and Billing Procedures Depending on Health Plan Enrollment
This Informational Notice provides guidance to providers on how to identify Care Coordination Health Plans in the Medical Electronic Data Interchange (MEDI) system and how to properly bill for services depending on the Medicaid client's health plan enrollment.
As the Department of Healthcare and Family Services (HFS) finalizes the roll-out of Medicaid managed care in five mandatory regions of the state (pdf), it is critical that providers understand that you bill differently depending on the type of managed care entity in which a Medicaid client is enrolled. The four types of managed care entities operating in the five mandatory managed care regions are: 1) Accountable Care Entities (ACEs); 2) Care Coordination Entities (CCEs); 3) Managed Care Community Networks (MCCNs); and 4) Managed Care Organizations (MCOs).
Accountable Care Entities (ACEs) & Care Coordination Entities (CCEs)
- If a Medicaid client is enrolled in an ACE or a CCE, medical providers bill HFS directly on a fee-for-service basis, using the client's Recipient Identification Number (RIN) as you have always done. In addition, the process for obtaining prior approval from HFS remains unchanged. Please refer to the Medicaid Provider Handbook for guidance on prior approval and billing HFS.
- Dental Providers do not bill HFS directly for any ACE or CCE Medicaid client; all claims should be submitted to DentaQuest using the client's RIN. Please refer to the Dental Office Reference Manual (pdf) for guidance on prior approval and billing for Dental services.
- ACEs and CCEs will receive a monthly fee to coordinate their enrollees' care. ACEs and CCEs are not required to issue health plan-specific member cards but most do. If they do, the health plan card will contain the client's HFS RIN.
- Providers must verify coverage and health plan enrollment through one of the HFS automated systems (MEDI, REV, and AVRS) using the client's Social Security Number or the client's RIN found on either the HFS Medical Card or the health plan member card. Members are not required to show a health plan card or HFS medical card to receive services.
- The Illinois Health Connect (IHC) Medical Home Program will continue for PCPs enrolled in an ACE or CCE health plan. PCPs seeing ACE or CCE patients who are not enrolled on their panel, or on an affiliated PCP's panel within the health plan, on the date of service, must obtain a referral from the patient's PCP in order to be reimbursed by HFS for services provided. PCPs are able to submit referrals for their patients to see other enrolled PCPs:
- Through the IHC Provider Portal via the secure HFS MEDI system;
- Directly with IHC via fax using a Provider referral Fax Form from the IHC website (select Providers, then IHC Provider Forms under Provider Resources tab); or
- By calling the IHC Provider Helpline at 1-877-912-1999, option #3.
- Specialists and non-Illinois Health Connect PCPs do not require a referral under the IHC medical home program.
- Since ACE and CCE entities are responsible for providing support to their health plan providers, all provider questions, including billing questions, should be directed to the ACE or CCE health plans (see contact list below). If a Dental Provider has a billing question, contact DentaQuest by e-mail or by calling 1-888-281-2076 or faxing 1-262-241-7379.
Managed Care Organizations (MCOs) & Managed Care Community Networks (MCCNs)
- If a Medicaid client is enrolled in an MCO or an MCCN, providers bill the health plan directly. All Medicaid clients enrolled now receive their dental services through the MCOs and MCCNs and the dental provider needs to bill the appropriate health plan dental administrator (see contact list below). Every MCO and MCCN member card contains the client's HFS RIN. Providers MUST verify coverage and health plan enrollment through one of the HFS automated systems using the client's Social Security Number or the client's RIN found on either the HFS Medical Card or health plan member card. Members are not required to show a health plan card or HFS medical card to receive services.
- HFS pays these managed care entities on a full-risk capitated basis to cover the cost of Medicaid services and care coordination. Providers must provide services in accordance with each MCO and MCCN's utilization policies and procedures, including procedures for prior authorization and billing. All questions, including billing questions, should be directed to the MCO or MCCN health plans (see contact list below).
Illinois Health Connect (IHC)
- IHC will no longer be a health plan choice for clients in these mandatory managed care regions but will be a choice for most individuals enrolled in an HFS medical program outside the five mandatory managed care regions. In some of these counties, voluntary managed care is also available.
- IHC does not issue member cards.
- See the care coordination regions of the state map (pdf) for the exact counties affected and care coordination plans operating in those voluntary counties.
- If a Medicaid client is enrolled in IHC, providers bill HFS directly using the client's Recipient Identification Number (RIN) as you have always done. The process for obtaining prior approval from HFS remains unchanged. Please refer to the Medicaid Provider Handbook for guidance on prior approval and billing HFS.
- Some clients are excluded from mandatory participation in IHC or any MCO, MCCN, ACE, or CCE, like those with TPL insurance, eligible through spenddown, with temporary coverage or enrolled in the Breast and Cervical Cancer program. In those instances, no health plan or PCP will be listed for the client and the provider will need to bill HFS in accordance with the reimbursement policies as you do today. Please refer to the Medicaid Provider Handbook for guidance on prior approval and billing HFS.
Using REV and MEDI to Determine a Client's Health Plan
It is critical that providers check Department electronic eligibility systems regularly to determine client's enrollment in a health plan. The three options are: 1) Recipient Eligibility Verification Program (REV); 2) the Medical Electronic Data Interchange (MEDI) system; or 3) The Automated Voice Response System (AVRS) at 1-800-842-1461.
- Recipient Eligibility Verification (REV) programs and MEDI identify the type of health plan and name of the health plan for Medicaid clients enrolled in a health plan. The type of health plan is either a Managed Care Organization (MCO or MCCN) or a Care Coordination Entity (ACE or CCE). Providers will bill the health plan for individuals enrolled in an MCO or MCCN. Providers will continue to bill HFS for services provided to individuals enrolled in an ACE or CCE on a fee-for-service basis.
- In REV and MEDI, enter the client's RIN or name and social security number.
- The display for an ACE or CCE member will have a section on coverage details and then the member's primary care provider followed by health plan information: example of section on coverage details (doc)
- The display for an MCO or MCCN member will have a section on coverage details followed by health plan information: example of section on coverage details (doc). Note there is no PCP information for MCO or MCCN members.
- The display for Medicaid clients enrolled with IHC will not show any health plan information just PCP.
- The display for clients not enrolled in any health plan or IHC will only show coverage details, no PCP information or health plan information.
Using the AVRS to Determine a Client's Health Plan
Providers can get participant eligibility information by calling 1-800-842-1461, the Automated Voice Response System (AVRS). To check eligibility on AVRS, providers will need the:
- 9-, 10- or 12-digit Medicaid provider number;
- 9-digit Recipient Identification Number (RIN); and
- Date for which eligibility information is being sought.
The AVRS will provide all information relating to a participant's eligibility, including health plan enrollment, and will permit up to 6 eligibility inquiries during each telephone call.
- Currently, the automated response for an ACE and CCE member refers to them as having a "case manager:"
The recipient is eligible for Medicaid services until [DATE]; however other eligibility conditions for this recipient may change before that date. It is recommended that eligibility be verified on each date of service. The recipient has a case manager. You may contact [phone number of ACE or CCE].
- Currently, the automated response for an MCO and MCCN member is:
The recipient is eligible for Medicaid services until [DATE]; however other eligibility conditions for this recipient may change before that date. It is recommended that eligibility be verified on each date of service. The recipient is enrolled in a managed care plan; you may contact [name of managed care plan] at [phone number of managed care plan].
- Currently, the automated response for an IHC member is:
The recipient is eligible for Medicaid services until [DATE]; however other eligibility conditions for this recipient may change before that date. It is recommended that eligibility be verified on each date of service. The recipient is under the care of a Primary Care Physician. For more information regarding the PCP you will need to speak to a Hotline representative.
- Currently, the automated response for a Medicaid client not participating in any MCO, MCCN, ACE, CCE or IHC is:
The recipient is eligible for Medicaid services until [DATE]; however other eligibility conditions for this recipient may change before that date. It is recommended that eligibility be verified on each date of service.
If the provider has a question that cannot be answered by the AVRS or needs the participant's RIN, the provider can select the option of speaking to the next available Provider Eligibility Inquiry Hotline representative. Hotline representatives are available from 8:30 a.m. to 4:45 p.m. each work day.
Provider Participation in Health Plans
- Medicaid providers (including specialists), other than PCPs, are not required to become part of an ACE or CCE in order to serve members enrolled in those plans at this time. However, all ACE and some CCE plans are working toward becoming full-risk capitated plans. Once they become full-risk capitated health plans, providers will be required to be part of the health plan network to continue to serve their members. Medicaid providers who have not done so are encouraged to contact one or more health plans to become part of their networks.
- Medicaid providers must be part of the MCO or MCCN's network, or have an arrangement with a MCO or MCCN, in order to provide services for a member in an MCO or MCCN plan and receive reimbursement for those services.
Contact Information for Health Plans
- Below is provider contact information for the managed care entities in Illinois. We hope that Medicaid providers will do your best to assist patients in navigating the Medicaid program as we transition to a care coordination system.
James M. Parker, Acting Administrator
Division of Medical Programs
ACE and CCE Provider Contact Information
MCO and MCCN Provider Contact Information
Managed Care Organizations
(MCOs)/ Managed Care Community Networks (MCCN)
|Provider Services Contact Information
|Aetna Better Health
||(866) 212-2851, press 2
|Blue Cross/Blue Shield IL
||(888) 657-1211, press 1
|| (866) 487-4331, press language choice, then 3
|Community Care Alliance of Illinois
||(866) 871-2305, press 3
| CountyCare (MCCN in Cook County only)
|| (312) 864-8200, press 3
|Family Health Network (MCCN)
||(888) 346-4968, press 3
|Harmony Health Plan
||(800) 608-8158, press 4
|Health Alliance Connect
||(800) 851-3379, press 3
|Humana Health Plan
||(800) 626-2741 (direct to provider relations)
|IlliniCare Health Plan
||(866) 329-4701, say "provider"
| Meridian Health Plan
|| (888) 773-2647, press 2
|Molina Healthcare of Illinois
||(855) 866-5462 (direct to provider services)
MCO and MCCN Dental Administrator Provider Contact Information
||Dental Contact #
|Community Care Alliance of Illinois
|Family Health Network
For additional information contact Brenda.Cunningham@illinois.gov