Provider Notice issued 01/28/10

Illinois Health Connect Urgent Care Referral Policy for Phase I

In follow-up to the September 4, 2009, provider notice, regarding the Illinois Health Connect Referral System Implementation and Direct Access Service Billing Requirements, the Department of Healthcare and Family Services (HFS) and Illinois Health Connect (IHC) would like to clarify that, during Phase I of the referral system implementation, IHC PCPs may provide services to an IHC enrollee at an Urgent Care facility without obtaining a referral when:

• The IHC PCP is salaried/contracted by the Urgent Care Facility to provide medical services and;

• The Urgent Care Facility location is not the IHC PCPs enrolled location of service or affiliation under the IHC Program and;

• The IHC PCP is providing services outside of their regular practice hours for IHC enrollees who are not enrolled on their IHC panel.

Urgent Care is defined as a location, distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention.

IHC PCPs who meet the above criteria and provide services in an Urgent Care facility should submit claims to the department using Place of Service (POS) Code 20 – urgent care facility. This POS may be used on paper claims or in the 837P electronic format. The department does expect the PCP to educate the IHC enrollee on the importance of obtaining services from their medical home or refer the enrollee back to their medical home at the time of service. In addition it is requested that the enrollee’s IHC PCP be notified that the client sought services at the Urgent Care facility, including the date of the service, and the reason for the visit. 

Questions about this notice should be directed to the Illinois Health Connect Provider Help Desk at 1-877-912-1999.

Theresa A. Eagleson, Administrator

Division of Medical Program