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Elizabeth M. Whitehorn, Director

Provider Notice issued 09/04/09

Illinois Health Connect Referral System Implementation and Direct Access Service Billing Requirements

To:​ Participating Federally Qualified Health Centers (FQHC)​
Date:​ September 4, 2009​
Re:​ Illinois Health Connect Referral System Implementation and Direct Access Service Billing Requirements​

The Illinois Department of Healthcare and Family Services (HFS) and Illinois Health Connect (IHC) are implementing Phase I of the Illinois Health Connect Referral System by Region, on the dates provided below:

 

  • Northwest Counties - October 1, 2009

  • Collar Counties – December 1, 2009

  • Cook County – February 1, 2010

  • Central Counties – April 1, 2010

  • Southern Counties – April 1, 2010

For a listing of the counties in each region, refer to the August 3, 2009, Informational Notice regarding Illinois Health Connect Referral System Implementation – Phase I at <http://www.hfs.illinois.gov/all/>. Phase I of the Illinois Health Connect Referral System is being implemented to continue the ongoing efforts to connect Illinois Health Connect patients with their medical homes.

 

Effective with dates of service beginning on October 1, 2009, in the Northwest Counties, and after as identified by Region above, IHC participants must be seen by their own PCP or a physician or clinic affiliated with their PCP. PCPs seeing IHC participants not enrolled on their panel, or on an affiliated PCP’s panel on the date of service, must obtain a referral from the participant’s PCP in order to be reimbursed by HFS for services provided. Claims that require a referral from the participant’s PCP, but no referral is on file, will be rejected with error message G11– IHC PCP Referral Required. Care provided by specialists or other non-IHC providers does NOT require a referral in Phase I.

 

Under Phase I of the Illinois Health Connect Referral System, PCPs who provide direct access services, as outlined on the attached chart, will not need a referral from a participants PCP in order to be reimbursed for services provided at this time.

 

In addition, HFS will begin requiring PCPs who provide obstetrical or gynecological services to begin using a state defined modifier to identify these services. Modifier U5 (OB/GYN Service) will be required on any obstetrical or gynecological services provided by a PCP with the exception of abortions, Gardasil, or procedures that render a participant sterile but are not performed for sterilization purposes. The excepted procedures must continue to be billed with the appropriate modifier following current HFS policy. In addition to billing for obstetrical or gynecological services using the U5 modifier, the following CPT Codes for prenatal and postpartum visits are direct access: 0500F, 0502F, 0503F and 59430.

 

The chart provided with this notice identifies the direct access services that will not require a referral from a participant’s PCP in order to be reimbursed for services provided, and the proper billing procedures for each service.

 

Questions regarding this notice may be directed to the Bureau of Comprehensive Health Services at 1-877-782-5565.

Theresa A. Eagleson, Administrator
Division of Medical Programs

 

Direct Access Services Available Without A Referral
For Federally Qualified Health Centers (FQHC), Provider Type 040
The direct access service must meet the criteria of an encounter as defined in the Handbook for Providers of Encounter Clinic Services, Topic D-210
(As of 09-04-09)

 

Direct Access Service For direct access services to be paid without a referral, a claim must be submitted as follows:
Services to participants under 92 days old Bill medical encounter with HCPCS Code T1015. The appropriate E/M CPT Code must be reported in the detail billing.
Behavioral Health Services Bill behavioral health encounter with HCPCS Code T1015 with Modifier AH, AJ or HO.
Psychiatric Services Bill medical encounter with HCPCS Code T1015.  Services rendered by a psychiatrist or advanced practice nurse should be billed with the appropriate CPT Code 90801-90899 in the detail billing.  
Family Planning/Treatment of STD Bill medical encounter with HCPCS Code T1015. The appropriate E/M CPT Code in conjunction with Modifier FP must be reported in the detail billing.
Obstetrical/gynecological services Bill medical encounter with HCPCS Code T1015. The appropriate CPT Code in conjunction with Modifier U5 or the following codes for prenatal and postpartum visits – 0500F, 0502F, 0503F and 59430 must be reported in the detail billing.
Immunization When service is rendered as part of an eligible encounter, the appropriate CPT Code must be reported in the detail billing. 
Lead screening/epidemiological When service is rendered as part of an eligible encounter, the appropriate CPT Code must be reported in the detail billing. 
Pathology/lab services When service is rendered as part of an eligible encounter, the appropriate CPT Code must be reported in the detail billing. 
Radiology services When service is rendered as part of an eligible encounter, the appropriate CPT Code must be reported in the detail billing. 
EKG services When service is rendered as part of an eligible encounter, the appropriate CPT Code must be reported in the detail billing. 
Tuberculosis Treatment When service is rendered as part of an eligible encounter, the appropriate CPT Code must be reported in the detail billing and a tuberculosis diagnosis must be reported. 
Services to school children under 21 years of age Services provided at a school based or school linked facility must be billed with Place of Service 03 (school).
Mobile Unit Provider site approved by HFS as direct access mobile unit must submit claims with Place of Service 15 (mobile unit). 
Services to homeless Provider site approved by HFS as direct access homeless provider. Bill using homeless site NPI. 
Services to migrant workers Provider site approved by HFS as direct access migrant provider. Bill using migrant worker site NPI.