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

Derek.johnson@mpasmd.com

Sheri Kowalski

SKowalski@edward.org

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

KRott@edward.org 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 PlanlinkSupport@mpasmd.com. 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.