Illinois Health Partners (IHP)
Provider Manual
Illinois Health Partners
Health Partner Management Committees
Midwest Physicians Administrative Services (MPAS)
IHP/MPAS Administrative Directory
IHP Contract Health Plan Listing
Member Eligibility
Eligibility Verification
PCP Selection / Member Assignment
IHP Plan Link
Copayments
Health Services
Utilization Management
Case Management
Pre-Certification Process
Office Referral Procedure
Referral Turnaround Times
Pre-Certification List
Hospitalist Program
Concurrent Review Process
Out-Of-Network Care
Out-Of-Area Care
Quality Improvement
Provider Reimbursement
Capitation
Sample PCP Capitation Detail Reports
Provider Office Access
Claims
Claims Submission
IHP Check Sample
IHP Explanation of Benefits (EOB) Sample
Coordination of Benefits (COB)
Credentialing
Initial Credentialing Process
Re-Credentialing Process
Medicare Advantage
Coding
Super Visit/Annual Health Assessment Process
CMS Compliance
IHP Fee for Service (FFS) Plans
Medicare/Medicaid Dual Eligible Plans
Blue Cross Blue Shield Community
Humana Gold Plus Integrated
Medicaid Humana Care Integrated
Accountable Care Organization Plans
Medicare
Blue Cross Blue Shield PPO
United Healthcare
Illinois Health Partners
Illinois Health Partners (IHP) is a network of more than 1,800 affiliated physicians throughout the
west, northwest and southwest suburbs of Chicago. This network jointly manages the health care
needs of HMO and Medicare Advantage patients in the Blue Cross Blue Shield and Humana networks.
IHP was formed in 2011 by DuPage Health Partners/DuPage Medical Group and Edward Health
Partners/Edward Health Services. In 2013, the Elmhurst Memorial Healthcare and Elmhurst Physician
Association joined IHP. The IHP network was further enhanced with the addition of Northwest
Community Health Partners in 2015. Edward Hospital, Linden Oaks, Elmhurst Hospital and
Northwest Community Hospital are IHP’s hospital partners.
Our Mission:
Delivering value through quality, access and efficiency.
Our Vision:
To be a regional provider network recognized for delivering highly efficient and coordinated care with
exceptional outcomes.
Our Physicians:
Illinois Health Partners offers a large panel of over 1,800 physicians. Included are primary care
physicians in the areas of family practice, internal medicine and pediatrics; specialists trained in 50
different areas of medicine; and three hospitals.
IHP’s Program:
IHP offers its members and providers the benefits of a multispecialty network including PCPs,
specialists and hospitals that provide state of the art, comprehensive and efficient healthcare to meet
patients’ medical needs.
IHP Structure:
IHP is dedicated to ensuring high quality and efficient care across the entire network and all its patient
populations. IHP negotiates and holds the managed care health plan contracts for the IHP network.
Under Illinois Health Partners there are currently three medical groups or “tower divisions” (DuPage
Health Partners, Edward Health Partners and Elmhurst Health Partners). In 2015, Northwest Health
Partners will be added as the fourth IHP Tower.
IHP Health Partner Management Committees
IHP strategic network decisions are made at the IHP Board and Finance/Contracting Committees.
Health Partner Management Committees have been formed to advise IHP leadership of system
activities, provide feedback on operations and make policy recommendations to IHP. The Health
Partner Management Committees meet bi-monthly to discuss IHP directives, initiatives and system
operations. Each Tower Committee has its own governance and charter that outlines the Committee
responsibilities and duties including:
UM/QI Performance oversight
Review of patient satisfaction scores
Financial report review
ACO and shared savings contract performance review of IHP providers
Review of prospective providers requesting to join the tower
Determination of bonus distribution methodology
Payout approval
Operating expense approval
Medical Director review and oversight
IHP has designated Midwest Physicians Administrative Services (MPAS) as the management
organization responsible for administering and managing the operations required to successfully
support its health plan contracts. Tower Management leadership also serves on the MPAS Operations
Committees (UM, QI, and subcommittees) to provide medical network insight, make recommendations
for administrative operations and communicate initiatives to IHP leadership, committees and network
providers.
Midwest Physicians Administrative Services
(MPAS)
Midwest Physicians Administrative Services (MPAS) is IHP’s management partner. MPAS provides
the administrative functions required to successfully deliver high quality and efficient care to the
Illinois Health Partner members and providers.
IHP has an agreement with MPAS to provide the following administrative services for IHP risk
contracts:
Eligibility
Claims Processing
Credentialing
Information Systems
Medical Management
Quality Improvement/Population Management
Actuarial and Financial Services
In collaboration with MPAS, this manual has been developed to provide your office with the resource
information necessary to operationalize health plan benefits and effectively coordinate care as
members obtain services throughout the IHP network.
IHP/MPAS Administrative Directory
MPAS Administrative Offices
1100 W. 31st St. Suite 400
Downers Grove, Illinois 60515
Main Phone: (630) 942-7950
MPAS TEAM
Department Contact Name Contact #
Utilization Management/Referrals
Case Management & Compliance
Melody Klaisner.-Manager
Kathy Davis- Supervisor
630) 547-8031
(630) 456-7905
Eligibility & Revenue Recovery Susan Brown – Manager (630) 967-2391
Eligibility & Revenue Recovery Tammy Hanc – Supervisor (630) 545-5007
Claim Operations Bonnie Mezzano – Manager (630) 545-3614
Claim Operations Kim Carlock – Supervisor (630) 547-5024
Customer Service & Communications Mark Schepperley - Supervisor (630) 324-2996
Quality Management Linda Meyers, R.N. – Director of (630) 545-3817
Quality Management
IHP PROVIDER RELATIONS TEAM
Contact Name Title Contact #
Derek Johnson
Sheri Kowalski
Account Mgr., Provider Relations
Illinois Health Partners/MPAS
Sr. Provider Relations Analyst
Edward-Elmhurst Healthcare
(630) 967-1601
(630) 646-3876
Kathy Rott Sr. Provider Relations Analyst (630) 646-3875
[email protected] Edward-Elmhurst Healthcare
IHP Health Plan Contracts
Capitated Health Plans - Managed by MPAS
Commercial: BCBS HMO Illinois, BCBS Blue Advantage, Humana HMO (including
employee plan)
Exchange: BCBS Blue Precision (HMO)
Medicare Advantage (MA): Blue Medicare Advantage, Humana Medicare Advantage
Non-Risk Plan - Managed by the Health Plan
MMAI Dual Eligibles: BC Community MMAI, Humana Gold Plus Integrated
Medicaid: Humana Care Integrated
Accountable Care Organizations
Medicare
Blue Cross Blue Shield of Illinois PPO
United Healthcare Medicare Advantage
BCBS MA PPO
Member Eligibility
All members have a Health Plan assigned ID card that provides member specific information, the name
of the medical group and/or Primary Care Physician that the member is assigned to, basic co-pay
information and health plan contact resources. Member ID card samples are located on the resource
section of this manual.
Verifying Eligibility
It is important that all providers verify member eligibility at every visit prior to providing or referring
services. If a member is unable to provide an ID card at the time of service, eligibility can be
confirmed electronically through the PlanLink system or by contacting MPAS telephonically (see
contact list).
Primary Care Physicians can also check member eligibility against their monthly capitation list.
Confirming member eligibility helps ensure that the patient is assigned to IHP and the practice and is
therefore eligible to receive services through Illinois Health Partners. It is recommended the office
make a copy of the member’s ID card at each visit to provide the most current information available.
Offices may also submit a system email inquiry at [email protected]. MPAS will
investigate member eligibility and respond back to the office within 24 hours (one business day).
Health Plan Eligibility
Each contracted risk health plan provides MPAS with a member eligibility list monthly via electronic
file. Files are loaded on the 16th
of the month and eligibility is provided to each PCP based on the
health plan list and PCP assignment.
Ineligible Members
If health care services are provided to an individual and it is later determined that the patient was not
an IHP member, services will not be eligible for payment by IHP. Depending on the situation, the
office may be instructed to either bill the patient directly or re-bill services to the appropriate entity for
processing. IHP does not forward ineligible member claims to the responsible payer.
If the patient is not currently enrolled in an IHP Medical Group and requests to join, the member must
contact their health plan’s member services department to transfer medical sites (the number is located
on their health plan card). Medical group transfers must be made by the health plan. Due to the lag
time in reporting eligibility changes, patients may not be immediately eligible for services when
electing a new medical group.
Primary Care Physician (PCP) Selection/Member Assignment
BCBS requires that upon enrollment, the member select a medical group site. BCBS does not pre-
assign member PCPs; they have delegated PCP assignment responsibility to MPAS. For BCBS
members:
MPAS receives a member eligibility list of members who have chosen one of the three IHP
medical groups as their medical site.
An IHP welcome packet is mailed to each new member. Welcome packets include IHP
instructions, orientation materials and a physician PCP listing. Each member is asked to notify
MPAS of their PCP choice.
If a member does not respond to this request within 45 days, they will be assigned a PCP by
MPAS. MPAS will advise them of their PCP assignment via mail.
Humana plans require that members choose a PCP affiliation at the time of enrollment or when
electing a medical group site transfer. Humana members must contact Humana directly to choose a
new medical group or to make a PCP change.
PCP Transfer Requests
BCBS members, who are enrolled in Illinois Health Partners but are currently not assigned to a
particular PCP practice, can change their PCP affiliation by calling the MPAS customer service
department (see contact list). Humana members must arrange for PCP transfers through the Humana
member services line (the number is located on their Humana card).
PlanLink Access
PlanLink is a web based portal that enables Non-Epic users to connect to the IHP/MPAS system to:
Submit Referrals
Review Existing Referrals
Add Referral Notes
Check Patient’s Eligibility
View Patient’s Benefit Information
Check the Status of Claim
To request a PlanLink account
If your practice is not currently using PlanLink, complete a Provider Practice PlanLink Request Form
and e-mail the request to IHP provider relations. Once the practice and the requested users are loaded
into PlanLink, individual user passwords and training materials and will be provided for your
reference.
To add Plan Link users to an existing account
Adding new users to an existing PlanLink account requires that the practice complete and fax a
PlanLink User ID Request Form to the IT Department at (630) 348-3063. The request form is provided
by contacting IHP provider relations departments. Once a new user’s access information has been
established, passwords will be communicated back to the practice and the users will be able to access
the system.
Planlink Help desk # (855) 778-7688.
Epic, Epicare, PlanLink Contacts
If your practice is currently using Epic, EpicCare, or you are an Edward affiliated independent
practice, contact the Edward ISS help desk at (630) 527-3346 for system assistance. PlanLink access
or inquiries from Elmhurst affiliated providers should be directed to the PlanLink help desk at (855)
778-7688.
Copayments
Primary Care and Specialist physician offices are responsible for collecting service applicable
copayments ("copays") at the time of the member’s visit. Copays are determined by the benefit plan
coverage that is offered by the member’s employer or government program. Member copays differ
according to their health plan benefit. Depending on the benefit plan, copays for the Emergency
Room, Urgent Care, and Rehabilitation Therapy (Speech, Physical or Occupational), and Outpatient
Surgical Services may apply. The member’s ID card should be checked to determine if copays are
applicable to the services being rendered. The PCP capitation lists also provides office visit copay
amounts.
Offices cannot collect copays when providing wellness and preventive care services. In general,
copays are applicable when:
A member is seen by their physician for an office visit as defined by an Evaluation and
Management CPT code.
A non-physician provider is rendering services such as allergy injections, blood draws and
blood pressure checks.
Preventive and sick care services are provided and documented during the same visit.
Copays should always be verified and collected at the time services are rendered. If a member refuses
to pay their copay and the office has made and documented a reasonable effort to collect, MPAS
should be notified. Refusal to pay copayment amounts is a violation of the member’s health plan
agreement and may be grounds for disenrollment from the health plan.
To verify whether a copay can be collected at the time of service, providers can confirm copay
information by checking the member’s benefit information in PlanLink, calling the health plan directly
(number is located on the member card) or contacting the MPAS Eligibility Department at 630-942-
7950.
Health Services
Utilization Management
The purpose of the Utilization Program is to assure that high quality patient care is provided in
the most cost efficient manner. The MPAS staff works closely with health plans and network
providers to ensure that appropriate services are being provided to members at all levels of care
delivery. MPAS assists the network with efficient delivery of care through the following
processes:
Pre-certification and monitoring of referral requests for services noted on the IHP
pre-certification list
Initial review and determination of medical necessity and appropriateness of service
and site for inpatient services
Concurrent review of inpatient cases that require pre-certification or have exceeded
the expected stay length
Discharge planning
Retrospective review of out-of-network referrals
Pre-Certification Process
Members requiring medical services outside of the PCP office should be referred to IHP
network providers. Pre-certification is no longer required for cross-tower referrals unless the
services required are listed on the IHP/MPAS Pre-Certification List. If the required services
cannot be rendered within the IHP network, services must be pre-certified through MPAS.
Service pre-certification is necessary for various reasons including:
Health Plan liability (inpatient facility and outpatient surgeries)
Monitoring of benefit limitations (physical therapy)
Benefit Coverage (transplants and infertility treatments)
PCPs and Specialists are both able to enter referrals. Specialists should initiate referrals for
services related to the diagnosis for which the PCP referred. If a member referral is required
for services outside of the scope of the specialist, the PCP should be notified and is responsible
for entering required referral(s).
Referrals are generally approved for a 90 day period. If global treatment referrals are required,
contact the MPAS referral department to discuss extension options. Offices should refer to the
IHP pre-certification list to determine whether pre-authorization is required. For pre-
certification questions, contact the MPAS Utilization Management Department at 630-942-
7950 (Option #4).
In some cases, the Health Plan may require MPAS contact them for pre-approval, which could
delay the processing of the referral request for up to 14 days.
Office Referral Procedure
When referring members for services, remember to:
Confirm the need for pre-certification using the IHP Pre-Certification List. If the services do not
appear on the Pre-Certification listing, the member should be referred to an IHP network provider.
Verify member eligibility prior to submitting the referral.
Use PlanLink to electronically enter referrals.
Referral Turnaround Times
Pre-certification required referral requests will be processed according to the following criteria:
Elective: Authorization will be returned to the office within five working days.
Urgent: Authorization will be returned to the office within 3 working days.
Emergent: Provide immediate care to the patient and contact MPAS within 24 hours or
the next business day.
On the occasion that a submitted referral is denied, the physicians will be notified verbally and
has the right to appeal the denial to a group of his peer specialists or a Medical Director.
Providers should contact the MPAS UM Dept. at (630) 942-7950 (Option #4) for assistance
with initiating the appeals process.
Case Management
Illinois Health Partners is delegated to provide Case Management services for all Blue Cross
Commercial and Medicare Advantage HMO members and Humana HMO Medicare Advantage
members.
Case management is a collaborative process of assessment, planning, facilitation, care
coordination, advocacy and evaluation. The case manager facilitates the integration of the
patient and provider with consideration of cost factors by providing strategies to manage a
patient’s comprehensive and holistic health issues with the goal of attaining quality outcomes
and enhancing the patient’s quality of life. These services are free of charge to members, and
members can self-refer or be recommended by providers for participation Case managers focus
on improving patient’s care through the following:
Optimizing the patient’s outcome of independence in self care
Planning and delivery of care through participation as members of multidisciplinary teams
Decreasing fragmentation of care
Promotion of cost effective resources in collaboration with the patient’s care team
Population management focused on individualized goal setting to impact health risks and
utilization of services; case management is focused on the promotion of the patient
attaining individualized outcomes. The case manager is responsible for the process; the
patient is supported with strategy to impact behavior changes to impact their quality of
life.
MPAS Case Management can be reached at 630-545-7790.
MPAS
IHP Pre-Certification List
2016 Inpatient Admissions
Acute Care Hospital
Behavioral Health Hospital (except Humana)
Acute Rehab / LTACH
Skilled Nursing Facility (SNF)
Alternative Levels of Care
Home Health
Hospice
Cardiac Rehab
Day Rehab
Mental Health IOP/PHP (except Humana)
Diagnostic Testing
Neuro Psych Testing
EGD
Colonoscopy / Endoscopy
Nuclear Medicine Studies
Out of Network / Out of Area Requests
Tertiary Care
Providers Not Listed on IHP Rosters
Non-Contracted Lab
Ambulatory Procedures / Surgery
Outpatient Hospital
Ambulatory Surgery Center
Lithotripsy
Cardiac Cath
Hyperbaric Treatment
Dialysis
Rehabilitation Therapy Services
PT/OT/ST
Applied Behavioral Analysis (ABA)-Call Case Management (630) 545-7790
Aural Rehabilitation
Chiropractor/Acupuncture
Oncology
Chemotherapy / Radiation Gamma Knife / Proton Beam / Cyber Knife
Durable Medical Equipment (DME) / Orthotics & Prosthetics (O&P) Family Planning
Infertility
Sterilization
Termination of Pregnancy
Genetic Testing Benefit Determinations
Cosmetic Procedures
Sclerotherapy
Bariatric Surgery Consults
Clinical Trials
Acne Surgery
Dental / Oral Surgery
Hearing Aids
Transplants Drugs
Synvisc Botox
Epogen, Procrit (J0085) Xolair (J2357)
Transplant, Bariatric (including consult), Urgent and Retro requests must be submitted telephonically. Prior authorization is not required for routine labs, radiology, physician consultation (unless specified above), office visits (excluding procedures) to IHP providers. For questions, contact the UM Dept. at (630) 942-7950, select option 4. Supporting clinical must be submitted with each referral request. IHP specialists’ offices should be entering referrals for services on diagnoses for which they were consulted.
Hospitalist Services
In the IHP network, hospitalists are used to assist the PCP in care coordination for inpatient stays at
Edward, Elmhurst, Central Dupage and Advocate Good Samaritan Hospitals. Objectives of the
hospitalist program are to reduce admit length of stay, re-admissions, avoidable days, inappropriate
emergency room admissions and change one-two day stay status to observations.
Hospitalists coordinate care for all admission categories except NICU, Psychiatric, OB/GYN and
Pediatrics. During an inpatient stay, hospitalists are responsible for:
Admission of patients
Communication with the PCP to maintain continuity and quality of patient care
Providing continuous care, coordination and interpretation of test results and specialty
consultations
Conducting discharge planning and patient discharge
At least one daily visit to hospitalized patients, including medical record documentation of
the visit
Hospitalists concurrently review inpatient stays and communicate with the patient, PCP, Specialists,
health plan, staff, and patient families to ensure that care is coordinated and discharge services are
timely.
Concurrent Review Process
MPAS UM Nurses work with the hospitalists and providers to provide concurrent review
services for the BCBS HMO and the BCBS and Humana Medicare Advantage members.
Concurrent review assesses the medical necessity and appropriateness of care at the acute level.
The UM Nurses telephonically obtains relevant clinical information and/or consult with the
attending hospitalist and physicians as necessary. Concurrent reviews are performed on pre-
certification cases and cases that exceed their assigned length of stay.
UM Nurses document potential discharge needs upon admission and monitor discharge plans
throughout the patient’s stay and arrange for any required services. In addition, MPAS case
managers assist with out-of-network hospitalization reviews and communication with the
hospitalist or PCP to arrange in-network transfer as soon as medically appropriate.
Humana HMO members admitted to Edward or Elmhurst hospital are monitored by the
hospital case management RNs. The hospital case managers notify Humana upon initial
admission and provide clinical updates during the inpatient stay. Humana members that are
admitted out of network are managed by MPAS UM Nurses until such time that the member is
transferred in network or discharged from the hospital. Physicians should contact the MPAS
UM Department with any questions related to acute care.
Out-Of-Network Care
IHP providers are required to refer members to specialty physicians within the IHP network whenever
possible. Occasionally, there may be a service or treatment which cannot be provided by a physician
or contracted ancillary provider within the IHP network. In these cases, the provider is required to
obtain pre-certification. If a provider requires clarification on whether services required can be
performed by an IHP network participant, contact MPAS for assistance in identifying provider options.
The Primary Care Physician is still responsible for the management of care when a member is referred
outside the network and is expected to maintain communication with the out-of-network provider
throughout the course of treatment. After the referred treatment, the member should be brought back
into network as soon as medically possible. It is the PCP’s duty to ensure that he/she receives
consultation notes from these out-of-network providers and keeps them as a part of the patient’s
permanent medical record. The out-of-network providers should only provide those services which
were pre-certified and should not refer the patients for additional care (i.e., MRI, laboratory studies,
etc.) without first consulting an IHP PCP or specialist.
Out-Of-Area Care
If a member is out-of-area, or away from the service area, and requires urgent or emergent care:
Direct the member to contact their health plan directly for authorization of service
or treatment (health plan number is listed on the member’s insurance card).
The PCP should act in an advisory capacity with the out-of-area provider in order to stay
informed of the treatment decisions and medical care rendered to the member. In this manner,
the PCP will be in a better position to accept transfer of the patient and to coordinate care of
the patient upon return to the service area.
Most insurance carriers will only cover out-of-area emergency treatment and will not cover
any routine care out-of-area.
The out-of-area scope varies for each health plan. For some plans, there is a mileag
determination (i.e., 30 miles from PCP, 50 miles from PCP, etc.) and for other plans this
scope will involve specific counties surrounding the member’s PCP office.
Quality Improvement
IHP, through its MPAS relationship, has developed an extensive and detailed Quality Improvement
(QI) program designed to improve member healthcare and comply with health plan mandated
programs. To more efficiently coordinate all of the health plan’s programs and initiatives, IHP is
moving to a population health management philosophy. Population health management focuses on the
development of tools to assist office staff and providers with documentation requirements that will
facilitate optimal reporting of healthcare services across the entire IHP patient population.
MPAS works with providers, health plans, government agencies and health care associations to
identify guidelines for defining and achieving quality in the patient care setting. To ensure that all IHP
patients receive outstanding care, IHP tracks, measures and implements programs that assist providers
in continuously improving levels of care. Key components of the quality program include:
Identification of standards of care using evidence based medicine.
Ensuring compliance with health plans and regulatory agency standards through
monitoring provider outcomes.
Collection, analysis and reporting of outcome data.
Working collaboratively with health plans, IHP leadership and providers to develop
meaningful programs to assure patient quality at all levels of the patient care experience.
Continuous assessment of performance, identification of issues and barriers and
development of initiatives to improve care delivery programs.
The MPAS Quality Improvement department works with IHP leadership through the IHP QM/UM
committee to monitor outcomes, set network care goals and design/implement programs to improve
member health care. IHP provider participation in the quality program is key to the success of the IHP
organization. Physician and staff communication is the most important factor in improving patient
activation, outcomes and experience.
Each office is asked to identify a dedicated staff member to serve as the Quality Liaison for the
purpose of facilitating communication and implementation of the quality initiatives at the practice
level. MPAS Quality Specialists work directly with provider offices providing expertise, education
and information resources. Physicians and office staff are encouraged to contact the MPAS Quality
Department to discuss office metrics and available resources.
Capitation
Capitation (“cap”) is a prepaid method of payment for health services. Capitation is paid on a Per-
Member Per-Month (PMPM) basis and is calculated for the members assigned to each Primary Care
Physician (PCP) for that current month. Monthly cap payments reimburse the PCP for all services
provided by the PCP during that month, regardless of the number or nature of the services provided.
Each health plan provides IHP with a monthly list of effective members. Some health plans assign
members to a PCP (Humana), while others ask the member to contact the medical group and identify
their PCP choice (BCBS). PCP capitation payments vary each month according to benefit plan
copayments, age and sex of each assigned member. IHP has established a cap rate for each category of
member and provides each PCP with a monthly capitation/eligibility list indicating the rate paid for
each assigned member.
To calculate the total monthly capitation payment for each PCP, IHP calculates the average member
payment and pays each PCP the average payment multiplied by the total number of PCP patients
assigned.
Capitated physicians are paid each month based upon the established capitation rate and number of
eligible members assigned to the PCP on the 16th day of the month. Cap payments are calculated
following the eligibility receipt, and checks are mailed by the end of each month.
IHP provides each PCP with a monthly capitation report that identifies the cap rate for all members
assigned to the PCP during the current month. The total capitation paid to each PCP is based on the
average member payment times the number of members assigned for that month to the PCP. Attached
is a sample PCP cap report.
Sample Capitation-Eligibility List
PROV NAME PAT NAME BIRTH
DATE
GENDER BENEFIT PLAN NAME PCP
COPAY
MEM
NUMBER
Physician, IHP Member A 4/22/2012 F JWG20 BA 20 888888888
Physician, IHP Member B 5/9/2011 M 092/688 ELM/EDW EMPLOYEES 45 H11111111
Physician, IHP Member C 2/16/2013 F 092/688 ELM/EDW EMPLOYEES 45 H43214321
Physician, IHP Member D 10/8/2007 F 092/688 ELM/EDW EMPLOYEES 45 H12341234
Physician, IHP Member E 5/4/2011 F QNH20 BA 20 999999999
Physician, IHP Member F 6/6/2010 F QNH20 BA 20 123412341
Physician, IHP Member G 11/29/2011 F QNH20 BA 20 432143214
Physician, IHP Member H 5/19/2010 M WRQ40 BA 40 222222222
Physician, IHP Member I 9/10/2009 F QMH30 BA 30 333333333
Physician, IHP Member J 11/19/2011 F QMH30 BA 30 555555555
Sample Eligibility-Capitation List
Illinois Health Partners, LLC
Capitation for June 2014
BUSINESS NAME PHYSICIAN Members Amount Avg/Me
mber
Members Amount Avg/Me
mber
IHP Medical Group, M.D. Physician, IHP 10 $207.57 $20.76 - -
Total 10 $207.57 $20.76 - -
Check Total 10 $207.57 $20.76
CAP - Commercial CAP-MA
Provider Office Access Responsibilities
Primary Care and Specialist Physician Offices
Access to care is one of the keys to managing patient care and satisfaction. As part of the IHP
contract, offices are expected to participate in the IHP programs and are required to provide member
care and follow-up according to the following guidelines:
Appointment for Preventive Care within four (4) weeks of request
Appointment for Routine Care within ten (10) business days or two (2) weeks of request,
whichever is sooner
Appointment for Immediate Care within twenty-four (24) hours of request
Response by IPA Physician within thirty (30) minutes of an Emergency call
Notification to the member when the anticipated office wait time for a scheduled appointment
may exceed thirty (30) minutes
Behavioral Health Care practitioners must provide access to care for non-life threatening
emergencies within six (6) hours
In addition, providing members access to services outside of the traditional office hours of 9 a.m. to 5
p.m. is an important factor in:
Reducing unnecessary emergency room use
Increasing member satisfaction
Complying with the BCBS access to care hour standards for all Primary Care Physicians
BCBS requires primary care physicians to offer appointments to members 2 hours a week outside the
hours of 9am-6pm Monday-Friday not including Saturday hours.
IHP providers are encouraged to review their office hours and if feasible, consider providing care in
the early morning or evening and on select weekends. As a reminder, IHP members are allowed to
utilize the IHP network urgent care centers facilities for urgent, immediate and routine care outside of
the established PCP office hours without pre-authorization or PCP approval. Once informed of a
member visit for ER or urgent care services, it is recommended that the PCP or specialist (depending
on the circumstances) follow up with the member to encourage them to come into the office for ER
follow-up or non-urgent care.
Claims Submission & Payment
Provider claim submission depends on the member’s health plan.
All Humana HMO and Humana Medicare Advantage member claims should be submitted
directly toHumana for processing and payment.
Blue Cross Blue Shield (BCBS) HMO, Blue Precision and Medicare Advantage member
claims are submitted directed to IHP.
Claims Submission
Claims must be submitted within 90 days of the date of service. Claims may be submitted
electronically to IHP through the clearinghouse Availity, using the IHP Payer ID, 66727 or through the
clearinghouse Emdeon, using the IHP ID TH088.
Humana HMO and MA claims should be mailed to:
Humana Claims
P.O. Box 14601
Lexington, KY 40512-4601
All payments and co-payments are subject to the benefit information as defined by the member’s
Health Benefit Plan. Claim payment is always dependent on member eligibility status on the date of
service.
Billing and Payment Criteria
Hospital and Facility vendors are required to bill on a UB04 claim form. Professional providers are
required to bill on a CMS 1500 form. Electronic claims are accepted via the HIPAA standard format.
Claims must be submitted using the appropriate codes as published in the AMA’s CPT Level I,
HCPCS Levels II and III, ICD-9-CM and revenue codes. Code all claims completely and to the
most specific detail on all diagnosis and CPT codes to ensure that all services rendered
accurately depict the details and level of care provided.
IHP processes claims according to current year Medicare guidelines. The Correct Coding Initiative
(CCI) guidelines and audits for claims payments and use of modifiers are utilized when adjudicating
claims.
CPT defines the standard, acceptable modifiers to be used for professional claims.
HCPCS also includes acceptable modifiers for services not defined by CPT.
All modifiers published by CPT and HCPCS are acceptable for billing use.
Billing of unlisted procedure codes will require submission of documentation support for
review.
BCBS Precision Exchange Member Claims
IHP is contracted with BCBS for the Blue Precision Health Insurance Exchange Plan. Blue Precision
members are extended a premium grace period if they do not pay their premiums during the first three
months of eligibility.
Upon notification from the health plan that the member did not pay paid the premium, IHP will pend
any received claims with an EOB pend status stating: Exchange member: Claim pending during the
premium grace period. Providers cannot bill members for rendered services that have been pended by
IHP during the grace period (first three months of eligibility).
When the member has either exhausted their grace periods or paid their premiums, the health plan will
notify MPAS, who will process pended claims within 10 days of notification from the health plan. If a
member did not pay their premiums, submitted claims will be denied and providers are allowed to bill
the patient directly. When members do pay their premiums, providers will be paid for services
rendered according to their contract. Interest will be calculated from the original date received and
paid on qualifying claims.
Claims Inquiry and Appeals
Providers may check the status of a claim electronically by using PlanLink or telephonically by
contacting the MPAS Customer Service unit at 630-942-7950.
Providers may not always agree with claims payment decisions. Therefore, provider offices have the
right to appeal claim denials within 45 days from receipt of EOB. To appeal, providers should submit
the following information with documentation to support the denial appeal:
Submit appeal in writing.
Provide a copy of the EOB.
Attach any appropriate or missing information, i.e., copy of referral form, authorization
number, medical records, etc.
Forward claims appeals and corresponding information to:
MPAS
P.O. Box 3358
Glen Ellyn, IL 60138
MPAS will review the appeal and provide a written response to the request within 30 days from date of
appeal receipt. Per contractual requirements, balance billing of Illinois Health Partners patients is
prohibited in most instances.
Subrogation
Subrogation is the coordination of benefits between a health insurer and a third party insurer (i.e.,
property and casualty insurer, automobile insurer, or worker’s compensation insurer), not two health
insurers. The process to follow for subrogation is:
Provider identifies third party liability insurance or other health insurance coverage information.
Provider submits the claim to MPAS with any information regarding the third party
carrier (i.e., automobile insurance name, lawyer’s name, etc.).
All claims will be processed per the usual claims procedures.
Explanation of Benefits (EOB)
IHP adjudicates clean claims within 30 days of receipt. Once adjudicated, an EOB will be provided as
an explanation of how the claim was processed. A sample reimbursement check and EOB follow for
review. An EOB adjudication code crosswalk is located in the manual’s resource information section.
Illinois Health Partners Sample Check
Illinois Health Partners Sample EOB
Coordination of Benefits
Coordination of benefits (COB) is the mechanism used to identify which health insurance is
responsible for primary payment of health care services when a member is covered under two or more
health plans.
Identifying Primary Coverage
The insured is always primary on their own insurance. The spouse’s plan is secondary coverage
(if member is covered).
The “Birthday Rule” as defined by the Illinois Department of Insurance is the guideline used
for determining primary coverage for dependents. This guideline states that the patient whose
birthday falls first during the calendar year is the primary carrier. All legal agreements (i.e.,
divorce decrees) supersede this rule. Physician offices are to check with both carriers to
determine primary coverage for dependents.
COB guidelines
IHP’s claims department will pay up to the coinsurance/deductible of the primary carrier,
but not more than the contracted rate IHP has with the vendor.
The lesser of two copays will be assessed when the primary and secondary payers are
both managed care plans.
The patient liability will be determined up to, but not to exceed, the patient’s HMO
co-pay when Medicare is primary.
An explanation of benefits from the primary carrier must be submitted with the
secondary submission to the Group.
Secondary claims will not be denied for lack of referral or authorization.
Providers should always ask the member if they are covered under other health insurance plans at the
time of service and document health plan specifics for possible claims submission.
Physician Credentialing
Provider credentialing is a complex, ongoing process of gathering and documenting provider
information. The credentialing process verifies that a provider meets the educational, licensing, and
training standards required by the State, IHP and the health plans to provide care to IHP members.
MPAS is delegated to conduct the credentialing functions on behalf of its contracted health plans and
will work with network providers to ensure timely and accurate completion of the process.
Initial Credentialing Process
The initial credentialing process is conducted as part of the IHP application process and follows the
National Committee for Quality Assurance (NCQA) standards. IHP requires completion of the State of
Illinois Health Care Professional Credentialing and Business Data Gathering Form and submission of
all corresponding documentation. Once the required documentation is received, the IHP Credentialing
Committee will review and evaluate the participation application. Upon Board approval of the
application, notification of participation approval and all required documentation will be forwarded to
the contracted health plans for provider inclusion in the IHP network.
Re-Credentialing Process
MPAS follows the State of Illinois single cycle schedule for re-credentialing, re-credentialing all
providers every three years (based on the last digit of the provider social security number). When a
provider is up for re-credentialing, MPAS will provide a re-credentialing packet outlining the required
documents for submission. Once the completed information is received, the provider’s file will be
reviewed by the IHP Credentialing Committee for continued participation.
To meet all mandated credentialing deadlines, it is important that all providers submit requested
complete and accurate documents in a timely manner. Failure to submit all required information by
the established deadlines will likely delay a provider’s ability to see IHP patients.
Medicare Advantage Plan
Coding Importance
The health plans and ultimately our medical group are reimbursed by CMS based on documentation of
the member’s medical condition. Medicare revises member payment levels annually based on coding
submitted to CMS. The ICD-9 codes that are part of the documentation submitted on claims and
encounter data are assigned to Medicare’s Hierarchical Condition Codes. These Hierarchical
Condition Codes are used to develop a patient’s Risk Adjustment Score (RAF) which determines how
Medicare reimburses for the care provided. The higher the RAF score, the higher the Medicare
payment.
Diagnosis coding drives reimbursement in the MA Model
The MA coding model defines a numerical score for each disease
Aggregate scores for each member’s disease
Incorporate factors for age, gender, Medicaid status, and previously disabled status
The risk score is a sum of the scores
Every member has their own risk score
Member risk scores impacts premium
To ensure our compensation is appropriate for the level of care our members require, it is necessary to
document the member’s conditions by coding all diagnosis codes to the most specific level on all
claims and the health assessment form.
Annual Health Assessment Process
Health assessment forms (see resource section) must to be submitted for every Medicare Advantage
member annually. As required by the Medicare Advantage programs, Illinois Health Partners (IHP)
will process and submit health assessment information to the health plans on behalf of your members.
The health assessment form submission process is as follows:
Complete the health assessment form during the face to face Medicare Advantage member
super visit. Be sure to document to the most specific level, completing the member’s medical
history, current conditions, medications, life style assessment and treatment plan.
Fax the completed form to the coders at 630 942-7991.
A coder will review the document within 48 hours and if the form is incomplete, corrections
will be faxed to your office. Please add the missing information and re-submit by faxing to the
above number within three business days.
When submitting your HCFA 1500 for the super visit, services should be billed as CPT code
99420 (Administration and interpretation of health risk assessment instrument).
Place the original completed assessment form in the patient’s medical record Provider credentialing is
a complex, ongoing process of gathering and documenting provider information.
IHP and CMS Compliance Requirements
All providers who participate in the Medicare Advantage program are required to accept Medicare
assignment. To accept assignment and maintain an NPI number, each provider and office is required to
meet the CMS guidelines including the development and implementation of policies and procedures
and subsequent training of their staff on the CMS mandated compliance.
The IHP compliance program includes:
Physician and office staff training sessions
Reference materials for providers and office staff
Required attestations that provider and office staff training has been completed
Submission of required documentation to the health plans
IHP has developed a program to assist providers with Compliance and it is required that all health care
providers participate and complete the required program.