SPECIALCARE OF ILLINOIS PROVIDER MANUAL

HOW TO USE THIS MANUAL
SpecialCare of Illinois is committed to working with our provider community and members to provide a high level of satisfaction in delivering quality health care benefits. We are committed to providing comprehensive information through this Provider Manual relating to SpecialCare of Illinois operations, benefits, policies and provider procedures. Please call the Provider Services department (“Provider Services”) at 1-866-486-6065 if you need further explanation on any topics discussed in the manual. You may also access this manual through our website at www.specialcareil.com.



General Content

The following chart includes several important phone and fax numbers available to your office. When calling SpecialCare of Illinois, please have the following information available:

  • NPI (National Provider Identifier) number
  • Tax ID Number (“TIN”) number
  • Member’s ID number or Medicaid ID number
DepartmentPhone Number
Fax Number

Provider Services 1(866)486-6065 1(888)682-9940
Care Senior Associate 1(866)487-3002 (opt. 4) 1(888)879-1740
Utilization Management 1(866)487-3002 (opt. 6) 1(888)682-9940
Authorization Request Discharge
Planning Case Management
1(800)511-6932
1(866)487-3002 (opt. 4)

Inpatient Admissions 1(866)487-3002 (opt. 6) 1(847)993-1995
24-Hour Nurse Line 1(866)576-8773 N/A
Illinois Department of Healthcare
and Family Services
201 South Grand Ave. East
Springfield, IL 62763-0001
1(217)782-1200
1(800)526-5812 TDD/TYY
www.hfs.illinois.gov
N/A
First Submission of Medical Claims,
Requests for Reconsideration and
Corrected Claims
Medical Claims Dispute-
1(866)486-6065 (providers)
1(866)487-4331 (members)
Medical appeals
1(855)320-4409
Paper Claims:
Cigna-HealthSpring
Attn: Claims
P O Box 981804
El Paso, Texas 79998
Claims Reconsiderations:
Cigna-HealthSpring
3601 O’Donnell Street
Baltimore, Maryland 21224

Attn: Appeals Unit
PO Box 24087
Nashville, TN 37202-4087
Pharmacy appeals 1(866)845-6962
Pharmacy Claims:
Address, Phone and Fax
Cigna-HealthSpring
SpecialCare of Illinois
PO Box 20002
Nashville, TN 37202
1(866)486-6065 1(888)766-6341
Electronic claims submission:
Clearinghouse Vendor (Emdeon), Payor ID - 52192
 

All SpecialCare of Illinois members receive a SpecialCare of Illinois member ID card (see sample). Members should present their ID at the time of service, but an ID card in and of itself is not a guarantee of eligibility; therefore, providers must verify a member’s eligibility on each date of service.

The card includes information such as:

  • Member ID number
  • Effective date24-hour phone number for health plan
  • PCP information

A new card is issued only when:

  • The information on the card changes
  • A member loses a card
  • A member requests an additional card


If you are not familiar with the person seeking care, please ask to see photo identification. If you suspect fraud, please contact Provider Services at 1-866-486-6065 immediately.

To verify member eligibility, please use one of the following methods:

  • Call our automated member eligibility interactive voice response (IVR) system. Call 1-866-467-3126 from any touch tone phone and follow the appropriate menu options to reach our automated member eligibility-verification system 24-hours a day
  • Call SpecialCare of Illinois provider Services. Call our toll-free number at 1-866-486-6065. Follow the menu prompts to speak to a provider Services representative to verify eligibility before rendering services

Our FREE IVR system is easy to use! The IVR system gives you greater access to information 24-hours a day, seven days a week, 365 days a year. Through the IVR system you can:

  • Check member eligibility
  • Check claims status

SpecialCare of Illinois’s website can significantly reduce the number of telephone calls providers need to make to the health plan which enables SpecialCare of Illinois staff to effectively and efficiently perform daily tasks.SpecialCare of Illinois’s website is located at www.specialcareil.com. Providers can find the following information on the website:

  • Member benefits
  • Clinical guidelines
  • Provider Manual and forms
  • Provider newsletters
  • Provider directories
  • Important contact information
  • Prior authorization requirements

The PCP is the cornerstone of SpecialCare of Illinois’s service delivery model. The PCP serves as the “patient-centered medical home” for the member. The “patient-centered medical home” helps:

  • Establish a member-provider relationship
  • Support continuity of care
  • Eliminate redundant services
  • Improve outcomes in a more cost effective way

SpecialCare of Illinois offers a robust network of PCPs to ensure every member has access to a PCP within reasonable travel distance standards. Physicians who may serve as PCPs include:

  • Internists
  • Pediatricians
  • Obstetrician/gynecologists
  • Family and general practitioners


Non-physicians who may serve as PCPs include:

  • Physician assistants and
  • Nurse practitioners


In an FQHC, RHC or Health department
setting, the following may also serve as PCPs:

  • Physicians
  • Physician assistants
  • Nurse practitioners


SpecialCare of Illinois offers pregnant Enrollees or Enrollees with chronic illnesses, disabilities or special health care needs the option of selecting a specialist as their PCP. An Enrollee, family member, caregiver or provider may request a specialist as a PCP at any time. Our Medical Director will review the request to determine if the Enrollee meets the criteria and if that the specialist is willing to fulfill the PCP role, which includes, but is not limited to, provision of routine well care and immunization service. If approved by the Medical Director, the specialist will be assigned as the Enrollee’s PCP and a letter will be sent to the Enrollee, specialist and referring PCP to advise of the approval and the effective date of the approval. SpecialCare of Illinois will work with the Enrollee and previous PCP if necessary, to safely transfer care to the specialist.

The PCP must:

  • Be available for or provide on-call coverage through other source 24-hours a day for management of member care. After-hours access to the Health Home or covering SpecialCare of Illinois provider can be via:
    • Answering service
    • Pageror or phone transfer to another location
    • Recorded message instructing the enrollee to call another number or
    • Nurse Helpline
    • In each case, calls must be returned within 30 minutes
  • Educate members on how to maintain healthy lifestyles and prevent serious illness
  • Provide culturally competent care
  • Maintain confidentiality of medical information
  • Obtain authorizations for selected inpatient and outpatient services as listed on the current prior authorization list, except for emergency services up to the point of stabilization
  • Provide screening, well care and referrals to community health departments and other agencies in accordance with HFS (Health and Family Services) provider requirements and public health initiatives
  • You must cooperate with Cigna- HealthSpring Quality Improvement (QI) activities to improve the quality of care and services and the customers’ experience.
  • You must allow Cigna-HealthSpring to use your performance data; including the collection, evaluation and use of data in the participation of QI programs.
  • You must maintain customer information and records in a confidential and secure manner.
  • As a practitioner or provider of care you affirm to freely and openly discuss with customers all available treatment options regardless of whether the services may be covered services under the customer’s benefit plan. This includes all treatment options available to them, including medication treatment options, regardless of benefit limitations.
  • Customers have the right to receive full information from their providers when they receive medical care, and the right to participate fully in treatment planning and decisions about their health care. Cigna-HealthSpring providers must explain treatment choices, planning, and health care decisions in a way that customers can understand.
  • Customers have the right to know about all of the treatment choices that are recommended for their condition including all appropriate and medically necessary treatment options, regardless of the cost or whether they are covered by Cigna-HealthSpring. This includes the right to know about the different medication management treatment programs Cigna-HealthSpring offers and those in which customers may participate.
  • Customers have the right to be told about any risks involved in their care. Customers must be told in advance if any proposed medical care or treatment is part of a research experiment and be given the choice to refuse experimental treatments.

SpecialCare of Illinois PCP should refer to their contract for complete information regarding providers’ obligations and mode of reimbursement.

SpecialCare of Illinois primary care physicians have a limited right to request that a member be assigned to a new primary care physician. A provider may request to have a member moved to the care of another provider due to the following behaviors:

  • Fraudulent use of services or benefits
  • The member is disruptive, unruly, threatening or uncooperative to the extent that his/her membership seriously impairs SpecialCare of Illinois’s or the provider’s ability to provide services to the member or to obtain new members and the aforementioned behavior is not caused by a physical or behavioral health condition.
  • Threats of physical harm to a provider and/or office staff
  • Non-payment of required copayment for services rendered
  • Receipt of prescription medications or health services in a quantity or manner which is not medically beneficial or medically necessary
  • Repeated refusal to comply with office procedures essential to the functioning of the provider’s practice or to accessing benefits under the managed care plan
  • The member steadfastly refuses to comply with managed care restrictions (e.g., repeatedly using the emergency room in combination with refusing to allow the managed care organization to coordinate treatment of the underlying medical condition)

The provider should make reasonable efforts to address the member’s behavior, which has an adverse impact on the patient/physician relationship, through education and counseling, and if medically indicated referral to appropriate specialists. If the member’s behavior cannot be remedied through reasonable efforts, and the PCP feels the relationship has been irreparably harmed, the PCP should complete the member transfer request form and submit it to SpecialCare of Illinois.

SpecialCare of Illinois will research the concern and decide if the situation warrants a new PCP assignment. If so, SpecialCare of Illinois will document all actions taken by the provider and SpecialCare of Illinois to remedy the situation. This may include member education and counseling.

A SpecialCare of Illinois PCP cannot request a disenrollment based on adverse change in a member’s health status or utilization of services medically necessary for treatment of a member’s condition.

Procedure

  1. Once SpecialCare of Illinois has reviewed the PCP’s request and determined that the physician/ patient relationship has been irreparably harmed, the member will receive a minimum of thirty (30) days notice that the physician/patient relationship will be ending. Notification must be in writing, by certified mail, and SpecialCare of Illinois must be copied on the letter sent to the patient
  2. The physician will continue to provide care to the member during the thirty (30) day period or until the member selects or is assigned to another physician. SpecialCare of Illinois will assist the member in establishing a relationship with another physician
  3. The physician will transfer, at no cost, a copy of the medical records of the member to the new PCP and will cooperate with the member’s new PCP in regard to transitioning care and providing information regarding the member’s care needs

A member may also request a change in PCP for any reason. The PCP change that is requested by the member will be effective the first (1st) of the month following the receipt of the request, unless circumstances require an immediate change.

For members who have not selected a PCP within 30 days of their enrollment date, SpecialCare of Illinois will use an auto-assignment algorithm to assign an initial PCP. The algorithm assigns members to a PCP according to the following criteria in the sequence presented below:

  1. If a member’s age is less than 21 and the member has a language preference, a PCP that is closest to the member, provides care for patients under the age of 21, and satisfies the language preference will be chosen
  2. If a member’s age is less than 21, a PCP that is closest to the member and provides care for patients under the age of 21 will be chosen
  3. If a member has a language preference, a PCP that is closest to the member and satisfies the language preference will be chosen
  4. If no age or language restrictions exist, the member will be assigned to the PCP that is closest to the member’s residence

The PCP is responsible for coordinating the members’ health care services and making referrals to specialty providers when care is needed beyond the scope of the PCP. The specialty provider may order diagnostic tests without PCP involvement by following SpecialCare of Illinois referral guidelines. The specialty provider must abide by the prior authorization requirements when ordering diagnostic tests; however, the specialty provider may not refer to other Specialists or admit to the hospital without the approval of a PCP, except in a true emergency situation.

The specialty provider must:

  • Provide specialty health care services to members as needed
  • Collaborate with the member’s SpecialCare of Illinois PCP to enhance continuity of health care and appropriate treatment
  • Provide consultative and follow-up reports to the referring physician in a timely manner
  • Comply with access and availability standards as outlined in this manual including after-hours care
  • Comply with SpecialCare of Illinois’s preauthorization and referral process
  • Comply with SpecialCare of Illinois’s Quality Management and Utilization Management programs
  • Bill SpecialCare of Illinois on the CMS 1500 claim form in accordance with SpecialCare of Illinois’s billing procedures
  • Ensure that, when billing for services provided, coding is specific enough to capture the acuity and complexity of a member’s condition and ensure that the codes submitted are supported by proper documentation in the medical record
  • Refer members to appropriate SpecialCare of Illinois participating providers
  • Submit encounter information to SpecialCare of Illinois accurately and timely
  • Adhere to SpecialCare of Illinois’s medical record standards as outlined in this manual

SpecialCare of Illinois providers should refer to their contract for complete information regarding providers’ obligations and mode of reimbursement.

Providers must give SpecialCare of Illinois notice of voluntary termination following the terms of their participating agreement with our health plan. In order for a termination to be considered valid, providers are required to send termination notices via certified mail (return receipt requested) or overnight courier.

In addition, providers must supply copies of medical records to the member’s new provider upon request and facilitate the member’s transfer of care at no charge to SpecialCare of Illinois or the member.

SpecialCare of Illinois will notify affected members in writing of a provider’s termination. If the terminating provider is a PCP, SpecialCare of Illinois will request that the member select a new PCP. If a member does not select a PCP prior to the provider’s termination date, SpecialCare of Illinois will automatically assign one to the member.

Providers must continue to render covered services to members who are existing patients at the time of termination until the latest of 90 calendar days or until SpecialCare of Illinois can arrange for appropriate health care for the member with a participating provider.

SpecialCare of Illinois follows the accessibility requirements set forth by applicable regulatory and accrediting agencies. SpecialCare of Illinois monitors compliance with these standards on an annual basis. Providers must offer no fewer hours of operation than those offered to commercial enrollees or Medicaid fee- for-service enrollees.

After-hours accessibility
SpecialCare of Illinois PCP’s are required to maintain after-hours call coverage to ensure members have access to care twenty-four (24) hours per day, seven (7) days per week. The following are acceptable and unacceptable phone arrangements for contacting PCP’s after normal business hours:

Acceptable after-hours coverage:

  • Office telephone is answered after-hours by an answering service, which meets the language requirements of the provider’s patient population, and can contact the PCP or another designated provider. All calls answered by an answering service must be returned within thirty (30) minutes
  • Office telephone is answered after normal business hours by a recording, which meets the language requirements of the provider’s patient population and directs the member to call another number to reach the PCP or another provider designated by the PCP. Someone must be available to answer the designated provider’s telephone. Another recording is not acceptable
  • Office telephone is transferred after office hours to another location where someone will answer the telephone and be able to contact the PCP or another designated provider. All calls must be returned the call within thirty (30) minutes

Unacceptable After-hours coverage:

  • Office telephone is answered only during office hours
  • Office telephone is answered after-hours by a recording that tells members to leave a message
  • Office telephone is answered after-hours by a recording that directs members to go to an emergency room for services needed
  • Calls are not returned within thirty (30) minutes

 

Appointment availability standards
All SpecialCare of Illinois providers are required to offer timely appointments to members as indicated in the following Appointment Availability Standards:

Primary Care Access Standards

Appointment type

Access standard

Urgent/Emergent    
Immediately
Non-urgent/non-emergent
Within one(1) week

Routine and preventive    
Within 30 business days
On-call response (after hours)
Within 30 minutes for emergency

Waiting time in office    
30 minutes or less

 

Specialist Access Standards

Appointment type

Access standard
Urgent/Emergent    
Immediately
Non-urgent/non-emergent
Within one(1) week
Elective    
Within 30 days
High index of suspicion of malignancy
Less than seven (7) days
Waiting time in office    
30 minutes or less

 

Behavioral Health Access Standards

Appointment type

Access standard
Emergency and non-life threatening    
Within 6 hours of the referral
Urgent/symptomatic
Within 48 hours of the referral
Routine
   
Within ten (10) business days of the referral*
Waiting time in office
30 minutes or less

   

 

In addition to the above Accessibility Standards and in accordance with the requirements set forth by the Illinois Department of Healthcare and Family Services, a primary care provider’s panel size may not exceed 600 SpecialCare of Illinois members.

PCPs and specialty physicians must arrange for coverage with another SpecialCare of Illinois network provider during scheduled or unscheduled time off. The covering provider must have an active Illinois Medicaid ID number and an active NPI number in order to receive payment. The covering physician is compensated in accordance with the terms of his/her contractual agreement.

All PCPs reserve the right to limit the number of members they are willing to accept into their panel. SpecialCare of Illinois does not guarantee that any provider will receive a certain number of members.

If a PCP declares a specific capacity for their practice and wants to make a change to that capacity, the PCP must contact SpecialCare of Illinois provider services at 1-866-486-6065. A PCP shall not refuse to treat members as long as the provider has not reached their requested panel size.

Providers shall notify SpecialCare of Illinois at least 30 calendar days in advance of their inability to accept additional Medicaid covered persons under SpecialCare of Illinois agreements. In no event shall any established patient who becomes a covered person be considered a new patient. SpecialCare of Illinois prohibits all providers from intentionally segregating members from fair treatment and covered services provided to other non-Medicaid members.

The SpecialCare of Illinois Health Services Department utilizes a network of hospitals to provide services to the Illinois members.
Hospitals must:

  • Obtain authorizations for selected inpatient and outpatient services as listed on the current prior authorization list. Emergency Room care does not require prior authorization
  • Notify SpecialCare of Illinois’s Health services department of emergency hospital admissions, elective hospital admissions and new born deliveries within 24-48 hours of the admission
  • Notify the PCP, when possible, within 24-48 hours after the member’s visit to the emergency department
  • Notify SpecialCare of Illinois’s Health services department of members who may benefit from case management services – such as members who may have frequent visit to the emergency room
  • Notify SpecialCare of Illinois s Health services department an Illinois member’s emergency room visits for the previous business day.This can be done via fax or electronic file

 
The notification should include:

  • Member’s name
  • Medicaid ID number
  • Presenting symptoms
  • Diagnosis
  • Date of service
  • Member phone number

Hospitals should refer to their contract for complete information regarding the hospitals’ obligationsand reimbursement.

Advance Directives
The federal Patient Self-Determination Act ensures the patient’s right is to participate in health care decision-making, including decisions about withholding resuscitative services or declining/withdrawing life sustaining treatment. In accordance with guidelines established by the Centers for Medicare & Medicaid Services (CMS), HEDIS requirements, and our own policies and procedures, SpecialCare of Illinois requires all participating providers to have a process in place pursuant to the intent of the Patient Self-Determination Act.

All providers contracted directly or indirectly with SpecialCare of Illinois may be informed by the member that the member has executed, changed or revoked an Advance Directive. At the time a service is provided, the provider should ask the member to provide a copy of the Advance Directive to be included in his/her medical record. If the primary care physician (PCP) and/or treating provider cannot, as a matter of conscience, fulfill the member’s written Advance Directive, he/she must advise the member and SpecialCare of Illinois. SpecialCare of Illinois and the PCP and/or treating provider will arrange for a transfer of care. Participating providers may not condition the provision of care or otherwise discriminate against an individual based on whether the individual has executed an Advance Directive. However, nothing in the Patient Self- Determination Act precludes the right under state law of a provider to refuse to comply with an Advance Directive as a matter of conscience. To ensure providers maintain the required processes to Advance Directives, SpecialCare of Illinois conducts periodic patient medical record reviews to confirm that required documentation exists.

Cultural competency within SpecialCare of Illinois is defined as “the willingness and ability of a system to value the importance of culture in the delivery of services to all segments of the population. It is the use of a systems perspective, which values differences and is responsive to diversity at all levels in an organization. “Cultural competency is developmental, persons-served specific, community focused, and family oriented. In particular, it is the promotion of quality services to those underserved and categorized by racial/ethnic groups, and through the valuing of differences and integration of cultural attitudes, beliefs, and practices into diagnostic and treatment methods, and throughout the system to support the delivery of culturally relevant and competent care.”

SpecialCare of Illinois is committed to the development, strengthening, and sustaining of healthy provider/ member relationships. Members are entitled to dignified, appropriate, and quality care. When health care services are delivered without regard for cultural differences, members are at risk for sub-optimal care. Members may be unable or unwilling to communicate their health care needs in an insensitive environment, reducing effectiveness of the entire health care process.

SpecialCare of Illinois, as part of its credentialing, will evaluate the cultural competency level of its network providers and provide access to training and tool kits to assist providers in developing culturally competent and culturally proficient practices.

Network providers must ensure that:

  • Members understand that they have access to medical interpreters, signers and TDD/TTY services to facilitate communication without cost to them
  • Medical care is provided with consideration of the members’ race/ethnicity and language and its impact/influence of the members’ health or illness
  • Office staffs that routinely interact with members have access to and participate in cultural competency training and development
  • Office staff that is responsible for data collection makes reasonable attempts to collect race and language specific member information. Staff will also explain race/ethnicity categories to a member so that the member is able to identify the race/ ethnicity of themselves and their children
  • Treatment plans are developed and clinical guidelines are followed with consideration of the member’s race, country of origin, native language, social class, religion, mental or physical abilities, heritage, acculturation, age, gender, sexual orientation and other characteristics that may result in a different perspective or decision-making process

Office sites have posted and printed materials in English and Spanish, and if required by HFS, any other required language.

SpecialCare of Illinois network providers supply a variety of medical benefits and services, some of which are outlined on the following pages. For specific information not covered in this Provider Manual, please contact provider services at 1(866)486-6065 from 8 a.m. to 5p.m. CST, Monday through Friday (excluding holidays). A provider services Representative will assist you in understanding the benefits.

SpecialCare of Illinois Health Plan value added benefits

  • Dental: Additional preventive and comprehensive dental care for adults
  • Fitness: Gym membership at participating fitness location
  • Hearing services: Routine hearing exam, fittings, and hearing aids
  • Practice Visits: Members with developmental disabilities can go for practice visits to the dentist
  • Telemonitoring: Members can get tools to help check health problems at home
  • Transportation: Members can get a ride to the pharmacy right after a doctor visit
  • Vision: Routine eye exam and eyewear allowance
  • Wellness: Members can get one bath mat, cold and flu kit, and first aid kit each year. Members can also get $10 each month in over-the-counter items from OTC catalog

 

Medical Management

SpecialCare of Illinois will perform medical management functions for members enrolled in the SpecialCare of Illinois ICP program. SpecialCare of Illinois coordinates physical, behavioral health, LTSS and specialty services to ensure quality, timely, clinically-appropriate and cost-effective care that results in clinically desirable outcomes. SpecialCare of Illinois’s goal is to improve members’health and well-being through effective ambulatory management of chronic conditions, resulting in a reduction of avoidable inpatient admissions.

The Utilization Management (UM) process provides an opportunity for SpecialCare of Illinois to:

  • Determine the appropriateness of the services
  • Ensure that services are provided at the most appropriate level of care
  • Ensure the services are provided by the most appropriate provider and in the most appropriate setting
  • Ensure that services are covered under the member’s benefit plan
  • Verify and coordinate other insurance benefits 
  • Monitor participating providers’ practice patterns 
  • Improve utilization of resources by identifying and correcting patterns of over and under utilization
  • Identify high-risk members
  • Provide utilization data for use in the re-credentialing process

Transition of care
Health services staff will assist in the coordination of medical care and support services for SpecialCare of Illinois enrollees across the delivery system (whether in or out of the network) and to assure continuity of care after discharge from an inpatient facility setting.

Utilization review criteria
Utilization review decisions are made in accordance with currently accepted medical or health care practices, taking into account the special circumstances of each case that may require deviation from the norm as stated in the screening criteria. SpecialCare of Illinois utilizes InterQual Criteria and other state-specific criteria for approving medically necessary physical and behavioral health services. At least annually, SpecialCare of Illinois assesses the consistency with which reviewers apply the criteria. Criteria are available for review and inspection by the Illinois Department of Insurance Commissioner or designated representative and, upon written request for a specific case, to individual providers.

All medical necessity denials for coverage of health care services or reductions in the scope, duration or amount of services requested by a member or provider are reviewed by the Medical Director. Only a Medical Director has the authority to render adverse determinations for medical necessity requests. Special circumstances include, but are not limited to, a person with a disability, acute condition or life- threatening illness. Utilization review decision-making is based only on appropriateness of care and service. SpecialCare of Illinois’ compensation to providers, associates or other individuals conducting utilization review on its behalf does not contain incentives, direct or indirect, to approve or deny payment for the delivery of any health care service.

Referral and Prior Authorization process
SpecialCare of Illinois members should access care through their PCPs. If the PCP determines that specialty care, diagnostic testing or other ancillary services are required, the PCP should refer the member to an in-network provider. The use of a specific referral form is not necessary for in-network referrals. Approval from SpecialCare of Illinois for in-network referrals is not necessary, unless the requested service is listed in Appendix D of this
Provider Manual.

Appendix D is SpecialCare of Illinois’ list of Prior Authorization services. This list is also referenced on the provider tab on SpecialCare of Illinois’ website at www.specialcareil.com. The list of Prior Authorization services is intended to provide an overview of services requiring authorization. If a member requires a service that is not listed in Appendix D, the provider should contact Health services to inquire about the need for Prior Authorization. The presence or absence of a procedure or service on the list does not determine a member’s coverage or benefits.

To initiate the Prior Authorization process, providers should follow the procedures listed below.

  1. The provider evaluates a SpecialCare of Illinois member and determines that a “Prior Authorization service” is required.

  2. At least five (5) business days prior to the requested date of service, the provider completes an Outpatient Prior Authorization Request Form found in Appendix E of this Provider Manual. The provider should include all pertinent information such as results of any diagnostic tests or laboratory services results, if available. Failure to request authorization five (5) days prior to the date of service could result in an Adverse Determination.

  3. The provider faxes the completed form to SpecialCare of Illinois at one of the following confidential fax lines available twenty-four (24) hours per day, seven (7) days per week:
    • Behavioral health inpatient and outpatient services: 1(866)949-4846
    • Inpatient: 1(877)809-0786
    • Skilled Nursing Facility: 1(877)809-0788
    • Home Health: 1(877)809-0790
    • Other Outpatient Authorization Requests: 1(877)809-0787
    • Alternately, providers may initiate a Prior Authorization request through SpecialCare of Illinois’s provider portal at https://healthspring.hsconnectonline.com/HSConnect by calling the SpecialCare of Illinois Prior Authorization Department at 1(877)562-4402. The Prior Authorization department is available Monday through Friday, 8 a.m. to 5 p.m. CT. When calling for a Prior Authorization, providers should provide the following information over the telephone:

    • Member name and ID number
    • Location of service e.g., hospital or surgery center setting
    • PCP name
    • Servicing/Attending physician name
    • Date and units of service
    • Diagnosis
    • Service/Procedure/Surgery description and CPT or HCPCS code
    • Clinical information supporting the need for the service to be rendered Regardless of the method which a physician requests Prior Authorization, SpecialCare of Illinois prioritizes all Prior Authorization requests according to medical necessity. SpecialCare of Illinois reviews requests made after-hours on the following business day

  4. A Prior Authorization request may be referred to a nurse or other clinical staff who completes the medical necessity screening. It may be necessary to collect additional information from the ordering provider such as projected itemized costs or clinical information that is necessary to make the decision

  5. If the Prior Authorization request is approved, SpecialCare of Illinois will issue an authorization number that can be used when billing for the approved services. SpecialCare of Illinois will fax the approved Prior Authorization Request Form, along with the authorization number, back to the requesting provider according to the following timeframes:

    • Standard request
      If all required information is submitted at the time of the request, SpecialCare of Illinois will respond to a Prior Authorization Request Form within two (2) business days of receipt of the request

    • Urgent request
      An urgent request can be requested if/ when the provider believes that waiting for a decision under the standard request timeframe could place the member’s life, health, ability to regain maximum function in serious jeopardy. For these cases, providers may make an urgent request. SpecialCare of Illinois will respond to an urgent Prior Authorization request within one (1) business day or sooner required by the member’s condition

    • Emergency admissions and services
      Prior Authorization is not required for Emergency services. However, providers must notify SpecialCare of Illinois of Emergency services within twenty-four (24) hours or by the next business day, whichever is later

    • Post-stabilization request
      Post-stabilization requests can be made for covered services related to an Emergency Medical Condition provided after a member has been stabilized. These are services to maintain the stabilized condition or, under certain circumstances, are not pre-approved but are administered to maintain, improve or resolve the member’s stabilized condition. SpecialCare of Illinois will respond to post-stabilization requests within one (1) hour

  6. If the request for authorization does not meet medical necessity requirements, the request will be denied. The ordering provider will be notified of the denial by phone and in writing. The member will be notified of the denial in writing

Limits of authorization
Authorizations for Acute Care services are usually issued for thirty (30) days. Authorizations for LTSS are issued for up to twelve (12) months depending on the service requested. It is the provider’s responsibility to check the member’s eligibility every month, as the member’s coverage is subject to change.

Failure to obtain Prior Authorization for services that require authorization may result in non-payment of services.It is important to note that Prior Authorization does notguarantee payment.

Direct access services
SpecialCare of Illinois members may access the following services without seeking direction from their PCP first:

  • OB/GYN
  • Specialty care provider
  • Family planning 
  • Behavioral health 
  • Value-added services

Out of network referrals
If a service is not available within SpecialCare of Illinois’s provider network, a PCP may refer out-of- network. Prior to referring out-of-network, the PCP should document the justification for out-of-network services and obtain Prior Authorization from SpecialCare of Illinois according to the Prior Authorization Process described above.

Continuity of care
SpecialCare of Illinois ensures that new members transition smoothly into SpecialCare of Illinois and that care is not interrupted unnecessarily. New members in active treatment by a specialty care provider or behavioral health provider require special attention to ensure continuity of care and to ensure their health is not jeopardized.

Pregnant women
Pregnant members with sixteen (16) weeks or less remaining before the expected delivery date must be allowed to remain under the care of their current OB/ GYN through the member’s post-partum checkup if the OB/GYN provider is or becomes, out-of-network. The member may also select an OB/GYN within the network, if she chooses to do so, and if the new OB/ GYN provider agrees to accept her.

Member moves out of service area
Members who move out of the service delivery area are responsible for obtaining a copy of their medical records from their current provider on behalf of their new PCP. Participating SpecialCare of Illinois providers are required to furnish members with copies of their medical records.

Pre-existing conditions
SpecialCare of Illinois does not have a pre-existing condition limitation. SpecialCare of Illinois provides all covered services to new members beginning on the member’s date of enrollment into SpecialCare of Illinois, regardless of any pre-existing conditions, prior diagnoses and/or receipt of prior health care services.

SpecialCare of Illinois makes special provisions for new members who are considered in an “Active Course of Treatment.” An Active Course of Treatment is a planned program of services rendered by a provider that starts on the date a provider first renders services to correct or treat the diagnosed condition. An Active Course of Treatment covers a defined number of services or a period of treatment.

For members in an Active Course of Treatment with an out-of-network provider at the time of enrollment, SpecialCare of Illinois will authorize out-of-network services until the member’s records, clinical information and care can be transferred to an in-network provider or until one hundred eighty (180) days from enrollment in SpecialCare of Illinois, the active course of treatment is completed or the member is no longer enrolled in SpecialCare of Illinois, whichever of the three is shortest.

SpecialCare of Illinois Medical Management will coordinate all necessary referrals and pre-certifications to ensure care is not interrupted during a new member’s transition. Out-of-network providers who continue treating SpecialCare of Illinois members during a transition period must:

  • Continue to provide the members’ treatment and follow-up
  • Accept SpecialCare of Illinois reimbursement rates
  • Share information regarding the treatment plan with SpecialCare of Illinois
  • Refer in-network for laboratory, radiology services, or hospital services

All requests for out-of-network continuity of care are reviewed on a case-by-case basis by SpecialCare of Illinois. All requests not meeting the conditions for continuity of care will be forwarded to the Medical Director who will review the request on a priority basis.

Inpatient services
Inpatient medical and behavioral health services are covered benefits for ICP members. For inpatient services, SpecialCare of Illinois is responsible for medical management functions, such as Prior Authorization and concurrent review. SpecialCare of Illinois Members should access inpatient services at in-network facilities. For a listing of in- network facilities, providers should refer to the SpecialCare of Illinois provider Directory that is available at www.specialcareil.com.

For inpatient behavioral health services, SpecialCare of Illinois is responsible for all medical management functions, such as Prior Authorization and concurrent review.

Concurrent review of inpatient admissions
Concurrent Review is the process of initial assessment and continual reassessment of medical necessity and appropriateness of inpatient care during an Acute Care hospital admission, Rehabilitation admission or Skilled Nursing Facility admission. Concurrent review helps ensure that covered services are provided at the most appropriate level of care. Hospital providers are required to provide SpecialCare of Illinois with notification of the following types of admissions:

  • Elective Admissions
  • ER and Urgent Admissions
  • Transfers to Acute rehabilitation, Long- term Acute Care Facilities (LTACs) and Skilled Nursing Facilities (SNFs)
  • Admissions following outpatient procedures
  • Admissions following Observation Status


Notifications must be made within twenty-four (24) hours of admission or by the next business day, whichever is later. If the admission occurs during a holiday or weekend, then notification must be made by close of the next business day. Admission notification may be made by calling SpecialCare of Illinois’ Health services department at 1(877)562-4402 and requesting to speak with the Inpatient Intake Unit or by faxing an Inpatient Prior Authorization Form to 1(877)809-0786. The “Inpatient Prior Authorization Request Form” can be found in Appendix F of this Provider Manual.

If notification is not provided according to the guidelines above, authorization will not be granted and claims for services will be denied. Denials for no authorization may be appealed and will be subject to retrospective medical review. It may be necessary to provide documentation of the reason for failing to provide timely notification as well as clinical documentation.

Once SpecialCare of Illinois has been notified of the admission, SpecialCare of Illinois’s preferred method for concurrent review
is a dialogue between the concurrent review nursing staff and the facility’s UM staff. The dialogue should take place within twenty-four (24) hours of notification or on the last covered day. If clinical information is not received within seventy-two (72) hours of admission or by the last covered day, the case will be reviewed for medical necessity with the information SpecialCare of Illinois has available.

Following an initial determination, the concurrent review nurse will request additional updates from the facility on a case-by-case basis. SpecialCare of Illinois will render a determination within twenty-four (24) hours of receipt of pertinent clinical information. A SpecialCare of Illinois nurse will make every attempt to collaborate with the facility’s case management staff and request additional clinical information in order to provide a favorable determination. Providers should fax clinical updates to the SpecialCare of Illinois Concurrent Review department at 1(877)809-0788 twenty-four (24) hours prior to the next review and behavioral health at 1(866)780-8546. All inpatient or institutional days, which do not meet medical necessity criteria, are communicated verbally to the facility case managers. A SpecialCare of Illinois Medical Director will make the final decision on cases not meeting medical necessity criteria. If the SpecialCare of Illinois Medical Director deems that the confinement does not meet criteria, he/she will issue a denial. SpecialCare of Illinois encourages and will provide contact information for peer-to-peer communication between the attending physician and SpecialCare of Illinois Medical Director to discuss the lack of medical necessity and appropriateness of continued inpatient stay. Following this peer-to-peer discussion, the Medical Director will make a determination to approve or deny the admission or service in question.

Discharge planning
Discharge Planning is a critical component of the UM process that begins upon admission with an assessment of the member’s potential discharge care needs. It includes preparation of the member and his/ her family for continuing care needs and initiation of arrangements for placement or services needed after Acute Care discharge.

Examples of medical and behavioral health care that can be arranged in the discharge planning phase include:

  • Home health care
  • Physical therapy 
  • Speech therapy 
  • Occupational therapy
  • Skilled nursing facility placement 
  • Rehabilitation therapy facility placement 
  • Home infusion therapy
  • Durable medical supplies as well as coordination with community agencies when applicable

The member’s assigned care coordinator participates in the discharge planning process to ensure seamless transition to appropriate providers and services.

Role of the Behavioral Health Provider
SpecialCare of Illinois provides comprehensive mental health and substance abuse services to its members. Its goal is to treat the member in the most appropriate, least restrictive level of care possible, and to maintain and/or increase functionality.

SpecialCare of Illinois’s network is comprised of mental health and substance abuse services and providers who identify and treat members with behavioral health care needs.

Integration and communication among behavioral health and physical health providers is most important. SpecialCare of Illinois encourages and facilitates the exchange of information between and among physical and behavioral health providers. Member follow-up is essential. High risk members are evaluated and encouraged to participate in SpecialCare of Illinois’ Behavioral Health focused Case Management Program where education, care coordination and support are provided to increase member’s knowledge and encourage compliance with treatment and medications. SpecialCare of Illinois works with its providers to become part of the strategy and the solution to provide quality behavioral health services.

Behavioral Health Services
Behavioral Health Services are available and provided for the early detection, prevention, treatment and maintenance of the member’s behavioral health care needs. Behavioral Health Services are interdisciplinary and multidisciplinary. A member may need one or multiple types of behavioral health providers, and the exchange of information among these providers is essential. Mental health and substance abuse benefits cover the continuum of care from the least restrictive outpatient levels of care to the most restrictive inpatient levels of care.

Behavioral Health Services include, but are not limited to:

  • Access to SpecialCare of Illinois’ member services for orientation and guidance
  • Routine outpatient services to include psychiatrist, addictionologist, licensed psychologist and LCSWs, and psychiatric Nurse Practitioners and other behavioral health practitioners. PCPs may provide Behavioral Health services within his/her scope of practice
  • Initial evaluation and assessment 
  • Individual and group therapy
  • Psychological testing according to established guidelines and needs
  • Substance Abuse services
  • Inpatient hospitalization
  • Inpatient and out-patient detoxification treatment
  • Medication management 
  • Partial hospitalization programs 
  • Covered Community Mental Health Center services
  • Case Management Services as indicated

Responsibilities of Behavioral Health Providers
SpecialCare of Illinois encourages behavioral health providers to become part of its network. Their responsibilities include but are not limited to:

  • Provide treatment in accordance with accepted standards of care
  • Provide treatment in the least restrictive level of care possible
  • Communicate on a regular basis with other medical and behavioral health practitioners who are treating or need to treat the member.
  • Behavioral health providers must provide the PCP with a written summary report following the initial visit and quarterly thereafter.
  • Direct members to community resources as needed to maintain or increase member’s functionality and ability to remain in the community.
  • Participate in utilization management activities.

ICP Behavioral Health Covered Services
ICP Behavioral Health Services means covered services for the treatment of mental, emotional or substance use disorders. SpecialCare of Illinois provides a behavioral health benefit package to ICP members that includes all medically necessary treatment covered under the traditional, fee-for-service Medicaid programs. Please refer to the Behavioral Health Benefit Grid found in the appendix of this Provider Manual.

SpecialCare of Illinois ensures that behavioral health services are available at the appropriate time and in the most appropriate setting possible, where they can safely be provided without adversely affecting the member’s physical and/or behavioral health or quality of the care.

Communication among behavioral health and physical health providers is key to accomplishing this goal. SpecialCare of Illinois utilizes an integrated system for documenting members’ physical and behavioral health information. This facilitates collaboration among providers, allowing them to work jointly in the same environment as they coordinate all of the members’ needs efficiently.

Member Access to Behavioral Health Services
SpecialCare of Illinois members may access behavioral health services in three (3) ways:

  1. A PCP may provide treatment within the scope of his or her practice and licensure using the DSM-IV multi-axial classifications
  2. A PCP or specialty care provider may refer a SpecialCare of Illinois member to an in-network behavioral health provider
  3. A member may self-refer for behavioral health services to any in-network behavioral health provider. To identify an in-network behavioral health provider, members can call their Care Coordinator at 1(866)-487-3002 option 4 . Members may also call the SpecialCare of Illinois member services department at 1(866)487-4331, Monday through Friday, 8 a.m. to 5 p.m. CT

Consent for Disclosure and Sharing of Information Between Behavioral Health
Provider and PCP

PCPs and behavioral health providers are required to obtain consent for the disclosure of information from the member permitting the exchange of clinical information between the behavioral health provider and the member’s physical health provider.

Provider Coordination of Care
Behavioral Health providers should screen SpecialCare of Illinois members for co-existing physical conditions. Behavioral Health providers may provide physical health services only if they are licensed to do so. After screening, behavioral health providers should obtain member’s consent and refer those with known, suspected or untreated physical health problems or preventive care needs to their PCP. Behavioral health providers should communicate concerns regarding a member’s medical condition to the PCP and work collaboratively on a plan of care.

Information should be shared among SpecialCare of Illinois behavioral health providers and physical health providers to ensure continuity of care and a cohesive and holistic treatment plan.  The primary care and behavioral health providers are encouraged to share pertinent history and test results in a timely manner and document review of the information received in the clinical record.

Continuity of Care Follow-Up
When a member does not keep a scheduled appointment, the behavioral health provider should contact the member to reschedule the missed appointment within twenty-four (24) hours. Providers should not bill members for missed appointments.

To ensure continuity of care, SpecialCare of Illinois requires its behavioral health providers to follow-up with members on an outpatient basis within seven (7) days after discharge from an inpatient setting. Also, behavioral health providers should follow-up telephonically or face-to-face with members who are non-adherent with medications and/or treatment. Providers are encouraged to contact SpecialCare of Illinois so appropriate and timely care coordination and intervention activities can occur.

Medical record and documentation
When filing claims for behavioral health services, providers must use DSM 5 diagnosis codes. Behavioral health services require the development of a treatment plan. Documentation must always indicate date of service. Co-morbid physical health conditions should be noted as part of the diagnosis.

Notification and Prior Authorization Requirements for Behavioral Health Services
Behavioral health providers should notify SpecialCare of Illinois when they are initiating treatment. The notification process provides an opportunity to:
Verify eligibility
Confirm benefits
Obtain Prior Authorization if necessary
Inform the member’s care coordinator

The Following Behavioral Health Services Require Prior Authorization from SpecialCare of Illinois:
Inpatient Psychiatric
Inpatient Detoxification
Residential Detoxification
Substance Abuse Residential
Mental Health Residential
SA Day Treatment
SA Partial Hospitalization
SA Intensive Outpatient
MH Intensive Outpatient
Electroconvulsive/Repetitive Transcranial Magnetic Stimulation Therapy
Psychological tests
*Neuropsychological testing (through medical UM review)
Assertive Community Treatment
Community Support Individual/Group
Community Support Residential
Community Support Team

Prior Authorization forms for behavioral health services can be obtained by visiting our provider portal at https://Providerportal.CignaHealthSpring.com/ProviderSelfService/screen/Service.aspx or calling Health services at 1(800)511-6932.

 

SpecialCare of Illinois will continue to offer the outpatient services listed below without the requirement of a Prior Authorization. Any service not listed will utilize the standard authorization process.

Services Requiring No Authorization by Participating Provider

 

Service Name
Code

Admission and Discharge Assessment H0002

Medication Monitoring H2010

Individual - Therapy/Counseling, Substance Abuse H0004

Group - Therapy/Counseling, Substance Abuse H0005

Individual - Intensive Outpatient, Substance Abuse H0004

Group - Intensive Outpatient, Substance Abuse H0005

 

CPT Code
Description

Report with Psychotherapy Add-On Codes


90791 Psychiatric diagnostic evaluation (no medical services)

90792
(or New Patient E & M codes)
Psychiatric diagnostic evaluation with medical services

Out Patient
9201-99205
99211-99215

Nursing Facility
99304-99306
99307-99310

New Patient Visit (10-60 min)
Established Patient (5-25 min)

 

New Patient Visit (10-45 min)
Established Patient (10-35 min)

Psychotherapy Add On Codes: (when appropriate)
90833-30 min
90836-45 min
90838-60 min

90832 Psychotherapy (30 min)

90834 Psychotherapy (45 min)

90846 Family Psychotherapy (without patient present)

90847 Family Psychotherapy (with patient present)

90853 Group Psychotherapy (other than of a multiple–family group)

Physicians Office Only ~ Facilities Require Prior Authorization.


Q3014 Telehealth

Community Mental Health Services (Rule 132) Only ACT and CSI, CST, CSR require authorization.

Other Rule 132 services do not require authorization.  *replace with the table above


FunctionPhone/AddressDescription of Services

Member Eligibility/Benefits 1(800)453-4464 (*IVR)
1(866)486-6065
Verification of coverage and benefits; for facility admissions and other facility services, consult the Common Working File if member does present ID card.
Authorization Line 1(866)780-8546
Fax: 1(866)949-4846
Prior authorization is required for services not listed above.
Inpatient Admissions 1(866)780-8546
Fax: 1(866)949-4846
Notification is required within 24 hours of admissions;
clinical staff available 24 hours a day/7 days a week to
assist with notifications and precertification.

Claims Submission (paper) Cigna-HealthSpring Claims Dept.
P.O. Box 981804
El Paso, TX 79998


Claims Submission (electronic)

Clearing Houses:
Emdeon, Relay Health, Capario, DST,
Gateway EDI, Office Ally, SSI Group,
Zirmed, MedAssets

Payor Id #63092



Claim Status Inquires 1(800)453-4464 (*IVR)
1(866)486-6065


*(IVR) Interactive Voice Response System

Medicaid Drug Formulary
Formulary listings, utilization management criteria, and formulary changes for Cigna-HealthSpring formularies can
be found at: http://www.specialcareil.com/druglist

Cigna-HealthSpring utilizes the USP classification system to develop Medicaid drug formularies that include drug categories and classes covering all disease states. Each category must include at least two drugs, unless only one drug is available for a particular category or class. All formularies are reviewed for clinical appropriateness by the Medicaid Cigna Pharmacy and Therapeutics (P&T) Committee, including the utilization management edits placed on formulary products.

Drugs excluded under Medicaid include the following drugs or classes of drugs, or their medical uses, which may be excluded from coverage or otherwise restricted under Medicaid (with the exception of smoking cessation products): drugs for anorexia, weight loss or weight gain; drugs to promote fertility; drugs for cosmetic purposes and hair growth; out-patient prescriptions for which manufacturers require the purchase of associated tests or monitoring services as a condition for getting the prescription (manufacturer tying arrangements); agents used for treatment of sexual or erectile dysfunction (ED) (except when prescribed for medically-accepted indications such as pulmonary hypertension).

Pharmacy Utilization Management
Cigna-HealthSpring formularies include utilization management requirements that include the preferred drug list, prior authorization, and quantity limits.

  • Prior Authorization (PA): For a select group of drugs, Cigna-HealthSpring requires the member or their physician to get approval for certain prescription drugs before the member is able to have the prescription covered at their pharmacy.
  • Preferred Drug List (PDL): For a select group of drugs, Cigna-HealthSpring requires the member to first try certain preferred drugs to treat their medical condition before covering another non-preferred drug for that condition.
  • Quantity Limits (QL): For a select group of drugs, Cigna-HealthSpring limits the amount of the drug that will be covered without prior approval.

How to file a Coverage Determination
A Coverage Determination (CD) is any decision that is made by or on behalf of a Medicaid plan sponsor regarding payment or benefits to which an enrollee believes he or she is entitled. Coverage determinations may be received orally or in writing from the member’s prescribing physicians. For the Provider Call Center, please call 1(866)224-0619 or fax 1(888)766-6341. The address is: SpecialCare of Illinois Coverage Determination & Exceptions, PO Box 20002, Nashville, TN 37202. The Provider Call Center is open from 8 a.m. - 6 p.m. CST, Monday – Friday. Any call received after 6 pm CST will be routed to a voicemail box and processed daily.

To ensure timely review of a CD and that the prescriber is aware of what Cigna-HealthSpring requires for the most commonly requested drugs, the CD request form is available online at http://www.specialcareil.com/SCcd and utilization management criteria can be found at http://www.specialcareil.com/druglist.

A provider will receive the outcome of a Coverage Determination by fax no later than twenty-four (24) hours (excluding weekends and national holidays) after receipt for requests or receipt of the supporting statement. The following information will be provided: 1) the specific reason for the denial, taking into account the member’s medical condition, disabilities and special language requirements, if any; 2) information regarding the right to appoint a representative to file an appeal on the member’s behalf; and 3) a description of both the standard and expedited redetermination processes and timeframes including conditions for obtaining an expedited redetermination and the appeals process. The fax cover sheet includes the peer-to-peer process if a Provider has questions and wants to review with a clinical pharmacist.

How to file a Medicaid Pharmacy Appeal
A Medicaid Pharmacy appeal can be filed within 60 calendar days after the date of the coverage determination decision, if unfavorable. Cigna-HealthSpring will ask for a statement and select medical records from the prescriber if a member requests a Medicaid Pharmacy appeal. For an expedited appeal, Cigna-HealthSpring will provide a decision no later than twenty-four (24) hours after receiving all information needed to review the appeal, and for a standard appeal, the timeframe is fifteen (15) days. If the request is regarding payment for a prescription drug the member already received, an expedited appeal is not permitted.

Medicaid Pharmacy appeals may be received orally or in writing from the member. If the prescribing physician wishes to file an appeal on behalf of the member, an Appointment of Representation form for that physician must first be submitted by the member.  Appeals can be requested by calling 1(615)695-1064 or fax 1(866)544-0627. The mailing address is: SpecialCare of Illinois Pharmacy Appeals, PO Box 24207 Nashville, TN 37202−9910.

PHARMACY QUALITY PROGRAMS
Medication Therapy Management
Medication Therapy Management (MTM)-eligible members are offered a comprehensive medication review (CMR) annually. In the welcome letters sent to the eligible members, Cigna-HealthSpring encourages each member to call to complete his/her CMR before their annual comprehensive visit with their primary care provider so the member can take their medication list to the appointment. After the completion of the CMR, any potential drug therapy problems (DTPs) that are identified are sent to the prescribing provider and/or primary care provider by mail or fax. Along with DTPs, the provider also receives a list of the member’s prescription history through the previous 6 months. If the member has any questions or comments about the DTP recommendations, a fax and phone number are provided for follow up.

Drug Utilization Review
Cigna-HealthSpring completes a monthly review of drug utilization data in order to determine the effectiveness, potential dangers and/or interactions of the medication(s). Retrospective Drug Utilization Review (rDUR) evaluates past data and Concurrent Drug Utilization Review (cDUR) ensures that a review of the prescribed drug therapy is performed before each prescription is dispensed, typically at the point-of-sale or point of distribution. Cigna-HealthSpring tracks and trends all drug utilization data on a regular basis to enable clinical staff to determine when some type of intervention may be warranted.

Targeted providers and/or members will receive information regarding quality initiatives by mail. Current Retrospective Drug Utilization Review (rDUR) studies that may be communicated to members or providers include:

  • Over-utilization of medications (≥10 drug prescriptions per month)
  • Failure to refill prescribed medications
  • Drug-to-drug interactions
  • Therapeutic duplication of certain drug classes
  • Narcotic safety including potential abuse or misuse
  • Use of medications classified as High Risk for use in the older population
  • Members with a probable diagnosis of diabetes without a prescription for a statin drug. 
  • Use of multiple antidepressants, antipsychotics, or insomnia agents concurrently
  • Multiple prescribers of the same class of psychotropic drug
  • Underutilization of certain drug classes as determined by failure to meet a PDC (Proportion of days covered) ≥ 80%

Letters to members will focus on the rationale for medication adherence and/ or the safety issues involved. Letters to providers will include the rationale of the particular concern being addressed and will include all claims data for the selected calendar period applicable to that initiative. From any initiative, if a provider indicates that they did not write a prescription that has been associated with them or that they were not providing care for the member at the time the prescription under investigation was written please notify Cigna-HealthSpring using the contact information on the letter.
A multidisciplinary team develops and determines the direction of pharmacy quality initiatives and the initiatives come from a variety of sources, including but not limited to, claims data analysis, Illinois Department of HealthCare and Family Services guidance, Pharmacy Quality Alliance (PQA), Food and Drug Administration (FDA) notifications, drug studies, and publications.

HOME DELIVERY PHARMACY
One of the most important ways to improve the health of your patients is to make sure they receive and take their medications as you prescribe. Home Delivery Pharmacy can help. Members utilizing home delivery pharmacy have 20% higher adherence rates when compared to those who use retail pharmacies alone. Home delivery pharmacies send a three-month supply in one fill, making it easier for your patient by only having to fill four times a year. Lastly, many home delivery pharmacies offer refill reminders via email, phone or SMS text message, making it easier for patients to refill their prescriptions so they don’t miss a dose. Talk to your patients today about home delivery pharmacy for better health. Doctors and staff can reach our network home delivery pharmacies using the contact information below.

Walgreens Mail Service Pharmacy, call 1(800)759-0823 or fax prescriptions to 1(800)332-9581

Walmart Home Delivery Pharmacy, call 1(800)273-3455

A Transplant Coordinator will provide support and coordination for members who need organ transplants. All members considered as potential transplant candidates should be immediately referred to the SpecialCare of Illinois Health services department for assessment and care coordination services. Each candidate is evaluated for coverage requirements and will be referred to the appropriate agencies and transplant centers.

Billing and claims administration

Claims addresses
Providers should submit claims in the following manner:

Paper Claims:
SpecialCare of Illinois ATTN: Claims
PO Box 981804
El Paso TX 79998

Electronic Claims:SpecialCare of Illinois Payor ID - 63092

Claims filing deadline
Providers must submit claims to SpecialCare of Illinois within twelve (12) months from the date the covered service was rendered. If the claim is not filed with SpecialCare of Illinois within twelve (12) months from the date of service, the claim will be denied. The required data elements for Medicaid claims must be present for a claim to be considered a Clean Claim. If SpecialCare of Illinois is the secondary payer, providers must includethe primary payer’s explanation of payment.

Clean claim definition
A Clean Claim is defined as a claim for a covered service that has no defect or impropriety. A defect or impropriety includes, without limitation:

  • Lack of data fields required by SpecialCare of Illinois or substantiating documentation
  • A particular circumstance requiring special handling or treatment which prevents timely payment from being made on the claim

The term shall be consistent with the Clean Claim definition set forth in applicable federal or state law, including lack of required substantiating documentation for non-participating providers and suppliers, or particular circumstances requiring special treatment that prevents timely payment from being made on the claim. If additional substantiating documentation involves a source outside of SpecialCare of Illinois, the claim is not considered clean.

Claim filing formats
SpecialCare of Illinois accepts claims in both hard copy and electronic formats. Acceptable hard copy claim formats are either the CMS 1500 or UB-04 claim forms. Electronic claims are the preferred method of submission. Electronic claims can be submitted to SpecialCare of Illinois through either Emdeon (formerly WebMD Envoy) or Availity (formerly T.H.I.N.), or PayerPath. Both the CMS-1500 and the UB-04 forms are accepted. The SpecialCare of Illinois Payer ID is 63092.

National Provider Identification (NPI) numbers
Providers are required to submit either their NPI or API number, whichever is applicable, to SpecialCare of Illinois. An NPI number is a standard, nationally- assigned, “non-intelligent” provider identifier that is required in all electronic health care transactions effective May 27, 2008. Providers who do not have an NPI number can obtain one by calling 1(800)465-3203 (TTY 1(800)692-2326) or emailing providers also may obtain an NPI by writing to NPI Enumerator, P.O. Box 6059, Fargo, ND 58108-6059. The information required for attestation includes the provider’s:

  • TPI
  • NPI or API 
  • Taxonomy 
  • Physical Address
  • National Plan and Provider Enumeration System Data

When filing electronic claims, providers must submit their NPI or API number, whichever is applicable, and their taxonomy code. Some LTSS providers are not eligible for an NPI. These providers must request an API number from SpecialCare of Illinois.

Coordination of benefits
When a SpecialCare of Illinois member has other insurance benefits, the provider must bill the other insurance carrier prior to billing SpecialCare of Illinois. Providers must supply the following information to SpecialCare of Illinois within 365 days of the date of service:

  • Name and address of the primary payer
  • Date the primary payer was billed 
  • Statement signed and dated by the provider indicating that disposition has not been received from the primary payer within 365 days of the date the claim was filed

Providers should submit the claim as soon as disposition is received from the other insurance company to ensure the payment deadlines are not missed.

Prior Authorization
If a provider renders services that require Prior Authorization without first obtaining Prior Authorization, then the claim will be denied.

Claims payment
SpecialCare of Illinois processes Clean Claims, as defined by the SpecialCare of Illinois participating Provider Agreement, within thirty (30) days of receipt of the claim. SpecialCare of Illinois providers are reimbursed in accordance with their SpecialCare of Illinois participating Provider Agreements.

Claims status and resolution of claims issues
Provider services can assist providers with questions concerning:

  • Eligibility
  • Benefits 
  • Claims 
  • Claims status

To check claims status, providers can call the provider services department at 1(866)486-605 [print error]. If a claim needs to be reprocessed for any reason, provider services will coordinate reprocessing with the Claims department.

Balance billing
Participating SpecialCare of Illinois providers are prohibited from balance billing SpecialCare of Illinois members including, but not limited to, situations involving:

  • Non-payment by SpecialCare of Illinois
  • Insolvency of SpecialCare of Illinois 
  • SpecialCare of Illinois breach of its Agreement

Provider shall not bill, charge, collect a deposit from, seek compensation or reimbursement from, or have any recourse against members or persons, other than SpecialCare of Illinois, acting on behalf of members for covered services provided pursuant to the SpecialCare of Illinois participating Provider Agreement. The provider is not, however, prohibited from collecting copayments, co-insurances, or deductibles for non- covered services in accordance with the terms of the applicable member’s benefit plan.

In the event that a provider refers a member to a non- participating provider without Prior Authorization from SpecialCare of Illinois, if required, or provides non-covered services to a member, the provider must inform the member in advance, in writing:

  • Of the service(s) to be provided;
  • That SpecialCare of Illinois will not pay for or be liable for said service(s); and
  • That the member will be financially liable for such services

In the event the provider does not comply with the requirements of this section, the provider shall be required to hold the member harmless as described above.

SpecialCare of Illinois will initiate and maintain any action necessary to stop a network provider or employee, agent, assign, trustee or successor-in-interest of network provider from maintaining an action against HHSC, an HHS agency or any member to collect payment from HHSC, an HHS agency or any member above an allowable copayment or deductible, excluding payment services not covered by SpecialCare of Illinois.

If a SpecialCare of Illinois member decides to go to an out-of-network provider or chooses to get services that have not been authorized or are not a covered benefit, the member must document his/her choice by signing the Member Acknowledgement Statement provided in Appendix I of this manual. Once the member signs a Member Acknowledgment Statement, the provider may bill the member for any service that is not a benefit under SpecialCare of Illinois or ICP.

Private pay agreement
If a member elects to be a “private pay” patient, the provider must advise member at the time of service that he/she is responsible for paying for all services received. The provider should require the member to sign the Private Pay Form provided in Appendix J of this manual. This documents that the member has been properly notified of the private pay status. Providers are allowed to bill members as private pay patients if retroactive Medicaid eligibility is not granted. If the member becomes eligible retroactively, the member must notify the provider of the change in status. The provider must refund money paid by the member and file claims to the appropriate payer for all services rendered.

Ultimately, the provider is responsible for filing ICP claims in a timely manner.

How to complete a CMS 1500 Form
Below is the minimum data required to process a claim on a CMS 1500 form. Any missing or invalid data will result in a claim denial. Claim information must match the referral/authorization information.

Field Name
Box Number
Description of Information to Provider
 
Insured ID number  1a Member’s Medicaid ID number  
Name 2 SpecialCare of Illinois ICP member name  
Patients birth date 3 Date of birth and gende  
Patients address 5 Members address  
Patients authorization 12, 13 Members authorization (signature on file)  
Name of referring physician 17, 17a Provider’s name and NPI number  
ICD-9-CM 21-24e ICD-9 diagnosis codes – always bill to 4th or 5th digit when required  
Authorization Number 23 SpecialCare of Illinois authorization number  
Itemization of service

24

24a, b

24d

24e

24f

24g

Itemize the services provided to SpecialCare of Illinois ICP member

Dates and place of service

CPT or HCPCS codes, with modifier when applicable

Diagnosis code(s) specific to the procedure

Charges

Days of units

 
Taxonomy code 24ja Provider’s assigned taxonomy code  
NPI 24jb Provider NPI number  
Federal tax ID number 25 Federal tax ID number must match W-9 submitted  
Total charges 28 Total charges from column 24f  
Physician signature/date 31 Provider’s signature and date (signature stamp is acceptable  
Facility information 32 Address where services were rendered  
Provider’s name and address 33 Provider’s name and billing address  
Provider pay-to NPI 33a Pay-to provider NPI number/API number  
Rendering provider TPI number 33b Rendering provider TPI number  

 

How to complete a UB04
Below is the minimum data required to process a claim on a UB-04 form. Any missing or invalid data will result in a claim denial. Claim information must match the referral/authorization information. Providers can obtain a copy of a blank UB-04 form in Appendix G of this manual.

Field Name
Box Number
Description of Information to Provider
 
Provider’s Name and Address 1 Name and address as it appears on provider-specific W-9 form and as defined in SpecialCare of Illinois’s claims system  
Bill Type 4 4-digit bill type  
Federal Tax ID 5 Provider’s Federal tax ID  
Date of Service (Start and End Dates) 6 From and to dates of services authorized  
Patient Name 8b Member’s name  
Patient Address 9a-d Member’s home address  
Birthday 10 Member’s date of birth  
Sex 11 Member’s gender  
Revenue Code 42 Revenue code (as required by contract)  
Description 43 The description of the revenue code billed on the claim  
HCPCS Rate 44 HCPCS/Rate/HIPPS code  
Service Units 46 The number of units at the specific level  
Total Charges 47 Total charges for service dates  
Payer 50 SpecialCare of Illinois ICP  
Payer ID 51 Provider’s SpecialCare of Illinois ICP Payer ID number  
NPI 56 Provider's NPI number  
TPI 57 Provider's TPI number  
Member ID 60 Member's SpecialCare of Illinois ID Number  
Diagnosis Codes 67-81 ICD-9_CM diagnoses codes and written diagnoses codes –
bill to the 4th or 5th digit when required
 

Claim filing tips

  • If two identical claims are received for the same service on the same date for the same member, one of the claims will be denied as an ‘exact’ duplicate
  • For CMS 1500 claims, each separate date of service must be itemized on its own line;
  • The correct SpecialCare of Illinois member ID number must be on the claim
  • Use only valid procedure codes by consulting the current CPT® book, HCPCS Manual and/or the LTSS HCPCS Codes and ICP Modifiers Matrix. CPT® books are available at most book stores or they can be ordered by contacting the American Medical Association at 1(312)464-5000 or toll free at 1(800)621-8335. ICD-9-CM diagnosis code books can be found at most bookstores or by contacting the American Hospital Association at 1(312)422-3000 or toll free at 1(800)242-2626
  • When using a modifier, place it immediately following the 5-digit procedure code. Do not insert a space or a dash
  • CMS 1500 claim forms may be obtained at many bookstores or by contacting the American Medical Association at 1(312)464-5000 or toll free at 1(800)621-8335
  • Claims should be submitted for one member and one provider per claim form;
  • Multiple visits rendered over several days should be itemized by date of service
  • Unlisted procedures codes should be submitted only when a specific code to describe the service is not available or when indicated in the contract. Submit these codes with a complete description indicated on the CMS 1500 form
  • Providers who bill multiple units of the same procedure code should use the unit column on the CMS 1500 form
  • Assistant surgical procedures must be billed with modifiers 80, 81, 82or AS
  • Anesthesia procedures must be billed modifiers AA, AD, QK, QS, QX, QY or QZ
  • Professional components of laboratory, radiology or radiation therapy procedures must be billed with modifier 26
  • Technical components of laboratory, radiology or radiation therapy procedures must be billed with modifier TC
  • Providers billing as a group must list the:
    • Rendering provider’s NPI in the unshaded portion of box 24j
    • Rendering provider’s TPI in the shaded portion of box 24j
    • Group provider’s NPI in box 32a
    • Group’s TPI in box 32b
  • Providers should list only one authorization number per claim form
  • CMS 1500 claims must be billed with a valid place of services identifier. All V-diagnoses codes are acceptable as diagnoses codes except non-specific codes

 

Coordination of benefits and subrogation guidelines

General definitions

Coordination of Benefits (COB): Benefits that a person is entitled to under multiple plan coverage. Coordinating payment of these plans will provide benefit coverage up to but not exceeding one hundred (100) percent of the allowable amount. The respective primary and secondary payment obligations of the two coverage’s are determined by the Order of Benefits Determination Rule contained in the National Association of Insurance Commissioners (NAIC) COB Model Regulations Guidelines.

Order of Benefit Determination Rule: Rules which, when applied to a particular member covered by at least two plans, determine the order of responsibility each plan has with respect to the other plan in providing benefits for that member. A plan will be determined to have Primary or Secondary responsibility for a person’s coverage with respect to other plans by applying the NAIC rules.

Primary: This carrier is responsible for costs of services provided up to the benefit limit for the coverage or as if no other coverage exists.

Secondary: This carrier is responsible for the total allowable charges, up to the benefit limit for the coverage less the primary payment not to exceed the total amount billed (maintenance of benefits).

Allowable Expense: Any expense customary or necessary, for health care services provided as well as covered by the member’s health care plan.

Conclusion: COB is applying the NAIC rules to determine which plan is primarily responsible and plan would be in a secondary position when alternate coverage exists. If COB is to accomplish its purpose, all plans must adhere to the structure set forth in the Model COB regulations.

Basic NAIC rules for COB

Birthday Rule: The primary coverage is determined by the birthday that falls earliest in the year, understanding both spouses are employed and have coverage. Only the day and month are taken into consideration. If both members have the same date of birth, the plan that covered the member the longest is considered primary.

General Rules: The following are general rules to follow to determine a primary carrier:

Basic processing guidelines for COB
For SpecialCare of Illinois to be responsible as either the primary or secondary carrier, the member must follow all HMO rules (i.e. pay copays and follow appropriate referral process).

When SpecialCare of Illinois is the secondary insurance carrier:

  • All SpecialCare of Illinois guidelines must be met inorder to reimburse the provider (i.e. pre-certification, referral forms, etc.)
  • The provider collects only the co-payments required
  • Be sure to have the member sign the “assignment of benefits” sections of the claim form

Once payment and/or EOB are received from the other carriers, submit another copy of the claim with the EOB of SpecialCare
of Illinois for reimbursement. Be sure to note all authorization numbers on the claims and attach a copy of the referral form
if applicable.

When SpecialCare of Illinois is the primary insurance carrier:

  • The provider collects the co-payment required under the member’s SpecialCare of Illinois’s plan
  • Submit the claim to SpecialCare of Illinois first
  • Be sure to have the member sign the “assignment of benefits” sections of the claim form

Once payment and/or Remittance Advise (RA) have been received from SpecialCare of Illinois, submit a copy of the claim with the RA to the secondary carrier for adjudication.

Worker’s compensation
SpecialCare of Illinois does not cover worker’s compensation claims.

When a provider identifies medical treatment as related to an on-the-job illness or injury, SpecialCare of Illinois must be notified. The provider will bill the worker’s compensation carrier for all services rendered, not SpecialCare of Illinois.

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 carrier), not two health insurers.

Claims involving Subrogation or Third Party Recovery (TPR) will be processed internally by the SpecialCare of Illinois Claims department.

COB protocol, as mentioned above, would still apply in the filing of the claim.

Members who may be covered by third party liability insurance should only be charged the required co- payment. The bill can be submitted to the liability insurer. The provider should submit the claim to SpecialCare of Illinois with any information regarding the third party carrier (i.e. auto insurance name, lawyers name, etc.…). All claims will be processed per the usual claims procedures.

SpecialCare of Illinois uses an outside vendor for review and investigation of all possible subrogation cases. This vendor coordinates all requests for information from the member, provider and attorney’s office and assists with settlements.

For claims-related questions, please contact provider member services at 1(866)486-6065. A provider representative will gladly provide assistance.

All practitioner and organizational applicants to SpecialCare of Illinois must meet basic eligibility requirements and complete the credentialing process prior to becoming a participating provider. Once an application has been submitted, the provider is subject to a rigorous verification process that includes primary and secondary source verifications of all applicable information for the contracted specialty(s). Upon completion of the verification process, providers are subject to a peer review process whereby they are approved or denied participation with the Plan. No provider can be assigned a health plan effective date or be included in a provider directory without undergoing the credentialing verification and peer review process. All providers who have been initially approved for participation are required to re-credential at least once every three years in order to maintain their participating status.

 

Practitioner selection criteria

SpecialCare of Illinois utilizes specific selection criteria to ensure that practitioners who apply to participate meet basic credentialing and contracting standards.

At minimum these include, but are not limited to:

  • Holds appropriate, current and unencumbered licensure in the state of practice as required by state and federal entities
  • Holds a current, valid and unrestricted federal DEA and state controlled substance certificate as applicable
  • Is board certified or has completed appropriate and verifiable training in the requested practice specialtyMaintains current malpractice coverage with limits commensurate with the community standard in which practitioner practices
  • Participates in the IL Medicaid program and has a state issued Medicaid number or contract with the IDOA.
  • Has not been excluded, suspended and/ or disqualified from participating in any Medicare, Medicaid or any other government health related program
  • Has admitting privileges at a participating facility as applicable

Application process

  1. Submit a completed IL State Mandated Credentialing application or CAQH ID number with a current signed and dated Attestation and Consent and Release form that is less than 90 days old.
  2. If any of the Professional Disclosure questions are answered yes on the application, supply sufficient additional information and explanations.
  3. Provide appropriate clinical detail for all malpractice cases that are pending or resulted in a settlement or other financial payment.
  4. Submit copies of the following:
    • All current and active state medical licenses, DEA certificate(s) and state controlled substance certificate as applicable
    • Evidence of current malpractice insurance that includes the effective and expiration dates of the policy and term limits
    • Five years of work history documented in a month/year format either on the application or on a current curriculum vitae. Explanations are required for any gaps exceeding six (6) months
    • If a physician, current and complete hospital affiliation information on the application. If no hospital privileges and the specialty warrants hospital privileges, a letter detailing the alternate coverage arrangement(s) or the name of the alternate admitting physician should be provided
    • Medicaid # and/or proof of Medicaid participation

Credentialing and re-credentialing process
Once a Practitioner has submitted an application for initial consideration, SpecialCare of Illinois’s Credentialing department will conduct primary source verification of the applicant’s licensure, education and/ or board certification, privileges, lack of sanctions or other disciplinary action and malpractice history by querying the National Practitioner Data Bank. Once credentialing has been completed and the applicant has been approved, the Practitioner will be notified in writing of their participation effective date.

To maintain participating status, all practitioners are required to re-credential at least every three (3) years, in accordance with the state mandated Single Credentialing Cycle. Information obtained during the initial credentialing process will be updated and re-verified as required. Practitioners will be notified of
the need to submit re-credentialing information at least 4 months in advance of their three year anniversary date. Three (3) separate attempts will be made to obtain the required information via mail, fax, email or telephonic request. Practitioners who fail to return re- credentialing information prior to their re-credentialing due date will be notified in writing of their termination from the network.

Office site evaluations
Office site surveys and medical record keeping practice reviews may be required when it is deemed necessary as a result of a patient complaint, quality ofcare issue and/or as otherwise mandated by state regulations. Practitioner offices will be evaluated in the following categories:

  1. Physical appearance and accessibility
  2. Patient safety and risk management
  3. Medical record management and security of information
  4. Appointment availability

Providers who fail to pass the area of the site visit specific to the complaint or who score less than 90% on the site evaluation overall will be required to submit a corrective action plan and make corrections to meet the minimum compliance score. A follow-up site evaluation will be done within sixty (60) days of the initial site visit if necessary to ensure that the correction action has been implemented.

Practitioner rights

  • Review information obtained from any outside source to evaluate their credentialing application with the exception of references, recommendations or other peer-review protected information. The provider may submit a written request to review his/her file information at least thirty days in advance at which time the Plan will establish a time for the provider to view the information at the Plan’s offices
  • Right to correct erroneous information when information obtained during the credentialing process varies substantially from that submitted by the practitioner. In instances where there is a substantial discrepancy in the information, Credentialing will notify the provider in writing of the discrepancy within thirty (30) days of receipt of the information. The provider must submit a written response and any supporting documentation to the Credentialing department to either correct or dispute the alleged variation in their application information within thirty (30) days of notification
  • Right to be informed of the status of their application upon request. A provider may request the status of the application either telephonically or in writing. The Plan will respond within two business days and may provide information on any of the following: application receipt date, any outstanding information or verifications needed to complete the credentialing process, anticipated committee review date and approval status

Organizational provider selection criteria
When assessing organizational providers, SpecialCare of Illinois utilizes the following criteria:

  • Must be in good standing with all state and federal regulatory bodies
  • Has been reviewed and approved by an accrediting body
  • If not accredited, can provide appropriate evidence of successfully passing a recent state site review or meets other Plan criteria
  • Maintains current professional and general liability insurance as applicable
  • Has not been excluded, suspended and/or disqualified from participating in any Medicaid or other government health related program
  • Must participate in the IL Medicaid program

Organizational provider application and requirements

  1. A completed Ancillary/Facility Credentialing Application with a signed and dated attestation
  2. If responded Yes to any disclosure question in the application, an appropriate explanation with sufficient details/information is required
  3. Copies of all applicable state and federal licenses (i.e. facility license, DEA, Pharmacy license, etc.)
  4. Proof of current professional and general liability insurance as applicable. LTSS providers will be required to provide proof of general liability insurance of at least $25,000/$50,000. Services provided in the home must show evidence of coverage specific to the business. LTSS applicants who also provide professional medical services must show proof of liability insurance or a proof of Medicaid participation. LTTS providers will be required to provide evidence of current IDOA or other proof of Medicaid contract for each type of service applying for
  5. If accredited, proof of current accreditation
  6. If not accredited, a copy of any state or CMS site surveys that has occurred within the last three years including evidence that the organization successfully remediated any deficiencies identified during the survey

Organizational site surveys
As part of the initial assessment, an on-site review will be required on all hospitals, skilled nursing facilities, free-standing surgical centers, home health agencies and inpatient, residential or ambulatory mental health or substance abuse centers that do not hold acceptable accreditation status or cannot provide evidence of successful completion of a recent state or CMS site survey. Any organizational provider may also be subject to a site survey as warranted subsequent to the receipt of a complaint.

Organizational providers who are required to undergo a site visit must score a minimum of 85% on the site survey tool. Providers who fall below acceptable limits will be required to submit a written Corrective Action Plan (CAP) within thirty (30) days and may be reaudited at minimum within sixty (60) days to verify specific corrective action items as needed. Providers who fail to provide an appropriate CAP or who are unable to meet minimum standards even after reauditing will not be eligible for participation.

Credentialing committee/peer review process
All initial applicants and re-credentialed providers are subject to a peer review process prior to approval or reapproval as a participating provider. Providers who meet all of the acceptance criteria may be approved by the Medical Director. Providers who do not meet established thresholds are presented to the Credentialing Committee for consideration. The Credentialing Committee is comprised of contracted primary care and specialty providers, and has the authority to approve or deny an appointment status to a provider. All information considered in the credentialing and re-credentialing process must be obtained and verified within one hundred eighty (180) days prior to presentation to the Medical Director or the Credentialing Committee.

All providers must be credentialed and approved before being assigned a participating effective date.

Non-discrimination in the decision making process
SpecialCare of Illinois’s Credentialing Program is compliant with all guidelines from the National Committee for Quality Assurance (NCQA), Centers for Medicare and Medicaid Services (CMS), and the State of IL regulations. Through the universal application of specific assessment criteria, SpecialCare of Illinois ensures fair and impartial decision-making in the credentialing process and does not make credentialing decisions based on an applicant’s race, gender, age, ethnic origin, sexual orientation or type of procedures or patients in which the provider specializes.

Provider notification
All initial applicants who successfully complete the credentialing process are notified in writing of their plan effective date. Providers are advised to not see SpecialCare of Illinois members until they receive notification of their participation effective date.

Appeals process & notification of authorities
In the event that a provider’s participation is denied, limited, suspended or terminated by the Credentialing Committee, the provider is notified in writing within sixty (60) days of the decision. Notification will include a) the reasons for the action, b) outlines the appeals process or options available to the provider, and c) provides the time limits for submitting an appeal. All appeals will be reviewed by a panel of peers. When termination or suspension is the result of quality deficiencies, the appropriate state and federal authorities, including the National Practitioner Data Bank (NPDB) are notified of the action.

Confidentiality of credentialing information
All information obtained during the credentialing and re-credentialing process is considered confidential and is handled and stored in a confidential and secure manner as required by law and regulatory agencies. Confidential practitioner credentialing and re-credentialing information will not be disclosed to any person or entity except with the written permission of the practitioner or as otherwise permitted or required by law.

Ongoing monitoring
SpecialCare of Illinois conducts routine, ongoing monitoring of license sanctions and Medicare/ Medicaid sanctions between credentialing cycles. Participating providers who are identified as having been sanctioned, are the subject of a complaint review or are under investigation for or have been convicted of fraud, waste or abuse are subject to review by the Medical Director or the Credentialing Committee who may elect to limit, restrict or terminate participation. Any provider whose license has been suspended/revoked or has been excluded, suspended and/or disqualified from participating in any Medicare, Medicaid or any other government health related program will be automatically terminated from the Plan.

Provider directory
To be included in provider Directories or any other member information, providers must be fully credentialed and approved. Directory specialty designations must be commensurate with the education, training, board certification and specialty(s) verified and approved via the credentialing process. Any requests for changes or updates to the specialty information in the directory may only be approved by Credentialing.

Members have the following rights and responsibilities:

  • The right to receive the information in the member  Handbook in another language or format
  • The right to receive health care services as defined by Federal and State law. All covered services must be available and accessible to you. When medically appropriate, services must be available 24-hours a day, seven days a week
  • The right to receive information about SpecialCare of Illinois SpecialCare of Illinois, its services, practitioners and providers
  • The right to ask for an interpreter and have one providedto you, during any covered service
  • The right to receive information about SpecialCare of Illinois Member Rights and Responsibilities policy
  • You also have the right to make recommendations to SpecialCare of Illinois about this policy
  • The right to receive information about treatment options. This includes the right to request a second opinion about your condition and the ability to understand treatment information
  • The right to make decisions about your health care
  • This includes the right to refuse treatment
  • The right to be treated with respect and with care for your dignity and privacy
  • The right to complain to SpecialCare of Illinois, on the phone or in writing, about any issue
  • The right to appeal a decision made by SpecialCare of Illinois either on the phone or in writing
  • The right to have an interpreter present during any complaint or appeal process
  • The right to be free from any form of restraint or seclusion used as a means of force, control and/or retaliation
  • The right to request and receive a copy of your medical records
  • The right to request an amendment or correction to your medical records
  • The right to be given, upon request, reasonable assistance in filing a grievance through trained enrollee member  services representatives and member advocates
  • Members must choose a PCP under this plan
  • Members have a responsibility to participate in their own health care. This includes making and keeping appointments
  • If member s are not able to keep an appointment, they must inform their doctor as soon as possible
  • Members must present their SpecialCare of Illinois ID card when getting care or prescriptions
  • Members have the responsibility to tell their doctor anything he or she needs to know to treat them
  • Members have the responsibility to follow the treatment plan agreed upon by him or her and his or her doctor
  • Members have the responsibility to keep their information up-to-date including telling their case worker about any changes in income or address
  • If the member has other insurance, they must tell both their provider and their case worker immediately
  • You must also follow the guidelines of your other insurance

Physician rights:

  • SpecialCare of Illinois encourages your feedback and suggestions on how service may be improved within the organization
  • If an acceptable patient-physician relationship cannot be established with a SpecialCare of Illinois member who has selected you as his/her primary care physician, you may request that SpecialCare of Illinois have that member removed from your care
  • You may appeal any claims submissions in which you feel are not paid according to medical policy or in keeping with the level of care rendered
  • You may request to discuss any referral request with the medical director or chief medical officer after various times in the review process, before a decision is rendered or after a decision is rendered

Physician responsibilities:

  • Primary care physicians must provide continuous 24-hours, 7 days a week access to care for SpecialCare of Illinois members. During periods of unavailability or absence from the practice, you must arrange coverage for your SpecialCare of Illinois members and notify SpecialCare of Illinois of the physician who is providing coverage for your practice
  • Primary care physicians shall use best efforts to provide patient care to new members within four (4) months of enrollment with SpecialCare of Illinois
  • Primary care physicians shall use best efforts to provide follow-up patient care to members that have been in the hospital setting within ten (10) days of hospital discharge
  • Primary care physicians are responsible for the coordination of routine preventive care along with any ancillary services that need to be rendered with authorization
  • All providers are required to code to the highest level of specificity necessary to fully describe a member’s acuity level. All coding should be conducted in accordance with CMS guidelines and all applicable state and federal laws
  • Specialists must provide specialty services up on referral from the primary care physician and work closely with the referring physician regarding the treatment the member is to receive. Specialists must also provide continuous 24 hours, 7 days a week access to care for SpecialCare of Illinois members
  • Specialists are required to coordinate the referral process (i.e. obtain authorizations) for the further care that they recommend. This responsibility does not revert back to the primary care physician while the care of the member is under the direction of the Specialist
  • In the event you are temporarily unavailable or unable to provide patient care or referral services to a SpecialCare of Illinois member, you must arrange for another physician to provide such services on your behalf. This coverage cannot be provided by an Emergency Room
  • You have agreed to treat SpecialCare of Illinois members the same as all other patients in your practice, regardless of the type of amount of reimbursement
  • You have agreed to provide continuing care to participating members
  • You have agreed to utilize SpecialCare of Illinois’s participating physicians/facilities whenservices are available and can meet your patient’s needs. Approval prior to referring outside of the contracted network of providers may be required
  • You have agreed to participate in SpecialCare of Illinois’s peer review activities as they relate to the Quality Management/Utilization Review program
  • You may not balance bill a member for providing services that are covered by SpecialCare of Illinois. This excludes the collection of standard co-pays. You may bill a member for a procedure that is not a covered benefit if you have followed the appropriate procedures outlined in the Claims section of this manual
  • All claims must be received within the timeframe specified in your contract

 

The Federal Patient Self-Determination Act ensures thepatient’s right to participate in health care decision-making,including decisions about withholding resuscitative services or declining/withdrawing life sustaining treatment. In accordance with guidelines established by the Centers for
Medicare-Medicaid Services (CMS), HEDIS®* requirements,and Cigna-HealthSpring policies and procedures, participating Cigna-HealthSpring providers are required to have a process that complies with the Patient Self Determination Act. Cigna-HealthSpring monitors provider compliance with this requirement by conducting periodic medical record reviews confirming the presence of required documentation.

A Cigna-HealthSpring member may inform his/her providers that he/she has executed, changed, or revoked an advancedirective. At the time services are provided, providers should ask members to provide a copy of their advance directives. If a provider cannot, as a matter of conscience, fulfill a member’s written advance directive, he/she must advise the member and the Cigna-HealthSpring Service Coordinator.

The Service Coordinator will work with the provider to arrange for a transfer of care. Participating providers may not condition the provision of care
or otherwise discriminate against a member based on whether the member executed an advance directive. However, nothing in the Patient Self-Determination Act precludes the right under State law of a provider to refuse to comply with an advance directive as a matter of conscience.

Member complaint/grievance process
SpecialCare of Illinois member complaint/grievance process is designed to facilitate prompt resolution to member issues and promote member satisfaction. SpecialCare of Illinois Member Handbook contains a written description of SpecialCare of Illinois Complaint process in a format that is easy to understand. Additionally, SpecialCare of Illinois has member advocates who are available to help members file complaints, if necessary.

A complaint/grievance means an expression of dissatisfaction expressed by a Complainant, orally or in writing to the health plan, about any matter related to the health plan other than an Action. Possible subjects for complaints/grievances include, but are not limited to, the quality of care of services provided and aspects of interpersonal relationships such as rudeness of a provider or employee or failure to respect the Medicaid member’s rights.

An appeal is the request for review of a “Notice of Adverse Action”. A Notice of Adverse Action is the denial or limited authorization of a requested service, including the type or level of service; the reduction, suspension or termination of a previously authorized service; the denial, in whole or part of payment for a service excluding technical reasons; the failure to render a decision within the required timeframes; or the denial of a member’s request to exercise his/her right under 42 CFR 438.52(b)(2)(ii) to obtain services outside the SpecialCare of Illinois network. The review may be requested in writing or verbally within 60 days of the Notice of Adverse Action; however verbal requests for appeals must be followed by a written request.

An appeal is a formal process by which a member or his or her representative requests a review of the HMO’s Action, as defined below.

An authorized representative is any person or entity acting on behalf of the member, for whom SpecialCare of Illinois has received the member’s written consent. A provider may be an authorized representative.

Expedited appeal means an appeal to the HMO in which the decision is required quickly based on the member’s health status and the amount of time necessary to participate in a standard appeal could jeopardize the member’s life or health or ability to attain, maintain or regain maximum function.

Action means:

  • The denial or limited authorization of a requested Medicaid service, including the type or level of service
  • The reduction, suspension or termination of a previously authorized service
  • The denial in whole or in part of payment for service

Member complaint process
Member complaints can be filed verbally or in writing by contacting SpecialCare of Illinois as follows:

Cigna-HealthSpring Grievances Resolution Center
175 W. Jackson Blvd. Suite 1750
Chicago, IL 60604

Phone: 1(866)487-4331
Fax: 1(877)788-2830

8 a.m. - 5 p.m. Central Time, Monday through Friday

A member advocate is available to help file a Complaint if necessary. If a Complaint is received verbally by telephone, SpecialCare of Illinois member services representatives collect detailed information about the Complaint and route the Complaint electronically to the Grievances department for handling. Within five (3) business days of receipt of a Complaint, SpecialCare of Illinois sends the member or the member’s authorized representative a letter acknowledging receipt of the Complaint.


The acknowledgement letter will include the date the Complaint was received, a description of the Complaint process and the timeline for resolution. SpecialCare of Illinois will investigate the Complaint and take corrective action if necessary. SpecialCare of Illinois will issue a response letter to the member or the member’s authorized representative within thirty (30) calendar days from the date the Complaint was received. The response letter will include a description of the resolution and the process to appeal the Complaint if the member or the member’s authorized representative is not satisfied with SpecialCare of Illinois decision. SpecialCare of Illinois will ensure that every Complaint, whether received by telephone or in writing, will be recorded with the following details:

  • Date
  • Identification of the individual filing the Complaint
  • Identification of the individual recording the Complaint
  • Nature of the Complaint
  • Disposition of the Complaint (i.e., how the 
  • Complaint was resolved)
  • Corrective action required
  • Date resolved
  • Date of incident

Provider complaint process
SpecialCare of Illinois is committed to providing excellent service to its participating providers. In the event a provider feels SpecialCare of Illinois is falling short of this goal, he/she should contact provider services immediately by calling the provider services department at 1(866)486-6065. A provider service is available to assist providers with their concerns at any time.

Definitions overview

A Complaint means an expression of dissatisfaction expressed by a Complainant, orally or in writing, to the health plan, about any matter related to the health plan other than an Action. Possible subjects for Complaints include, but are not limited to, the quality of care of services provided and aspects of interpersonal relationships such as rudeness of a provider or employee or failure to respect the Medicaid member’s rights.

Action means:

  • The denial or limited authorization of a requested Medicaid service, including the type or level of service
  • The reduction, suspension or termination of a previously authorized service
  • The denial in whole or in part of payment for service

An appeal is a formal process by which a member or his or her representative requests a review of the HMO’s Action as defined above.

An authorized representative is any person or entity acting on behalf of the member, from whom SpecialCare of Illinois has received the member’s written consent. A provider may be an authorized representative.

A provider claim appeal is a claim that has been previously adjudicated as a clean claim and the provider is appealing the disposition through written notification to SpecialCare of Illinois in accordance with the provider claim appeal process as defined in the SpecialCare of Illinois Provider Manual.

Provider Complaints to SpecialCare of Illinois provider Complaints can be filed verbally or in writing by contacting SpecialCare of Illinois as follows:

Cigna-HealthSpring
Grievance Resolution Center
175 W. Jackson Blvd. Suite 1750

Chicago, IL 60604
Phone: 1(866)487-4331
Fax: 1(877)788-2830
8 a.m. - 5 p.m. Central Time, Monday through Friday

If a provider Complaint is received verbally, SpecialCare of Illinois’s provider services Representatives collect detailed information about the Complaint and route the Complaint electronically to the Grievances department for handling. Within five (3) business days from receipt of a Complaint, SpecialCare of Illinois will send an acknowledgement letter to the provider. SpecialCare of Illinois will resolve the Complaint within
thirty (30) days from the date the Compliant was received by SpecialCare of Illinois.

Provider claims appeals to SpecialCare of Illinois
An appeal is a reconsideration of a previous decision not to approve or pay for a service, including a level of care decision; includes not just outright denials, but also “partial” ones. Your appeal will receive an independent review (made by someone not involved in the initial decision). Requesting an appeal does not guarantee that your request will be approved or your claim paid. The appeal decision may still be to uphold the original decision.

An appeal must be submitted to the address/fax listed below within 60 days from the original decision or the time frame specified in your contract of the receipt of the decision. You must include with your appeal request a copy of your denial, any medical records that would support why the service is needed, and if for a hospital stay, a copy of the insurance verification done at the time of admission.

Appeals addresses and fax numbers:
IL Appeals Department
PO BOX 24087
Nashville, TN 37202
Fax: 1(855)320-4409

Member appeal Process
If a covered service is denied, delayed, limited or stopped, SpecialCare of Illinois will notify the member in writing and provide an appeal form with instructions on how to file an appeal. Members have the option to request an appeal for denial of payment of services in whole or in part. Members
may request an appeal verbally or in writing by contacting SpecialCare of Illinois as follows:

 

Cigna-HealthSprIng appeals department CIgna-HealthSprIng member services department
P.O. Box 24087
Nashville, TN 37202
Fax: 1(855)320-4409
1(877)966-9272
8 a.m. - 5 p.m. Central Time,
Monday through Friday

A member Advocate is available to help file an appeal if necessary.

If an appeal is received verbally by telephone, SpecialCare of Illinois will send the member or member’s authorized representative an appeal form to document the appeal, unless an Expedited Appeal is requested. Instructions for where to return the completed appeal form will be included with the appeal form. If SpecialCare of Illinois does not receive the signed appeal form within thirty (30) days from the date the appeal request was received, the appeal will not be reviewed and the case will be closed. Within seven (7) days of receipt of a signed appeal form or a written appeal, SpecialCare of Illinois will send written acknowledgement to the member or the member’s authorized representative. The acknowledgement letter will include the date the appeal was received, a description of the appeal process and the timeline for resolution.

In order to ensure continuity of currently authorized services, the member may request continuation of services while an appeal is being reviewed. To do so, the member must file the appeal on or before the later of ten (10) days following the mailing of the Action. The member may be required to pay the cost of the services furnished while the appeal is pending, if the final decision is adverse to the member. If SpecialCare of Illinois receives an oral request for an appeal, it must be confirmed by an appeal form signed by the member or the member’s authorized representative, unless an Expedited Appeal is requested.

SpecialCare of Illinois mails an acknowledgement letter to a member or the member’s authorized representative within seven (7) business days of receipt of the written appeal, acknowledging the date of receipt and indicating the document(s) that the appealing party must submit for
review and date by which the document(s) is due.

Within (15) business days of receipt of the standard appeal, SpecialCare of Illinois responds in writing to the member or the member’s authorized representative and to the member’s provider. The member or SpecialCare of Illinois may request that the timeframe for resolving an appeal be extended by up to fourteen (14) calendar days if there is a need for more information that will influence the determination on the appeal. If an extension is requested, SpecialCare of Illinois sends a letter to the member or the member’s authorized representative and to the member’s provider, explaining the reason for the delay.

If the appeal is denied, the appeal determination letter includes a clear statement of the clinical basis for the denial, the specialty of the physician or other health care provider making the denial and the appealing party’s right to seek review of the denial through the Fair Hearing process.

Member expedited appeal
SpecialCare of Illinois maintains an expedited appeal process in the event that the member or the member’s authorized representative states orally or in writing in the appeal that the member’s health or life is in serious jeopardy is as a result of the Adverse Determination. A member Advocate is available to help file an Expedited Appeal, if necessary. If SpecialCare of Illinois accepts the request for an expedited resolution, a request for additional documentation that is needed will be sent within 24 hours. A resolution is provided to the member or the member’s authorized representative within 24 hours of receipt of all needed information.

If SpecialCare of Illinois determines the member’s health or life is not in serious jeopardy and denies the request for an expedited reconsideration, the member or the member’s authorized representative is informed orally within 24 hours and a written notice follows within two (2) calendar days. The appeal becomes subject to standard appeal timeframes.

Written notification of the outcome of the Expedited Appeal is issued as soon as possible, but no later than three (3) calendar days after the date SpecialCare of Illinois receives the appeal.

If the member or the member’s authorized representative is not satisfied with SpecialCare of Illinois’s decision, he/she may file an appeal with the State Fair Hearing Process.

Members have the right to appeal directly to the State after SpecialCare of Illinois’s appeal process.

Appeals process for waiver participants
IL ICP members have certain appeal rights within the Plan as well as external review rights that include the right to a State Fair Hearing. A summary of those processes follows. Any notice of action (denial) the member or authorized representative disagrees with may be appealed. Appeals at the Plan level must be exhausted prior to accessing further appeal levels.

Members have sixty (60) calendar days of the date on the Notice of Action (denial) to file an appeal. For services to be continued during the appeal process, members must request the continuation when they appeal and file the appeal no later than ten (10) calendar days from the date on the Notice of Action.

The list below includes actions that may result in an appeal (as appears in the member handbook):

  • Not approving or paying for a service or item amember’s provider asks for
  • Stopping a service that was approved before
  • Not giving a member the service or items in a timely manner
  • Not advising a member of his/her right to freedom of choice of providers
  • Not approving a service for a member because it was not in our network

Notice of Action

If Cigna-HealthSpring SpecialCare of Illinois decides that a requested service or item cannot be approved, or if a service is reduced or stopped, members are sent a “Notice of Action” letter. The letter explains what was denied, the rationale and all appeal rights. It includes the member’s right to request a representative, including their provider, an attorney, a family member and that the request must be made in writing and sent along with the appeal. Additional services are available through the CAP (Client Assistance Program) at 1(800)641-3929 (Voice) or 1(888)460-5111 (TTY) if a member is in the Disabilities Waiver, Traumatic Brain Injury Waiver or HIV/AIDS Waiver.

The notice also explains how a member may continue receiving services during the appeal process and that a member may be liable for those services if the appeal decision is unfavorable to them.

Members may file an appeal either verbally by calling the member services line at 1(866)487-4331 or in writing to Appeals Department PO Box 24087, Nashville, TN 37202.

Verbal appeals must be followed up in writing.

Language services are available and access information is provided.

Appeals are acknowledged within seven (7) business days of receipt and additional information may be requested then as well, except for expedited appeals. Additional information is requested within 24 hours of receipt

A provider with the same or similar specialty as the member’s treating provider will review the appeal and will not be the same provider who made the original decision to deny, reduce or stop the medical service.

Appeal decisions are phoned to the appellant and sent in writing within fifteen (15) business days of the date of receipt of the appeal request, but an extension of up to fourteen (14) more calendar days may be made if additional information is needed. Members may also ask us for an extension, if the member needs more time to obtain additional documents to support the appeal.

If the denial is overturned the service is authorized immediately. Members have the following opportunities during the appeal process:

  • Provide additional information at any time
  • The option to see the appeal file
  • The option to appear in person at the appeal review

Expedited appeals
If the member or provider believes the standard timeframe of fifteen (15) business days to make a decision will seriously jeopardize the member’s life or health, the member can ask for an expedited appeal by writing or calling us. We have twenty-four (24) hours to request additional information. Once all information is provided, we will notify the member via telephone within twenty-four (24) hours to inform of the appeal decision and will also mail the Decision Notice to the member and/or authorized representative.

Withdrawing an appeal
Members have the right to withdraw an appeal for any reason, at any time, during the appeal process; however, the request must be made in writing, using the same address as used for filing the appeal. Withdrawals are acknowledged in writing by sending a notice to the member or authorized representative.

What happens next?
After receipt of the appeal decision, if the member disagrees with the decision, the member can ask for a State Fair Hearing appeal and/or an External Review of the appeal within thirty (30) calendar days of the date on the Decision Notice. Members may ask for either a State Fair Hearing appeal or an External Review or both.

State fair hearing
The State Fair Hearing appeal must be made within thirty (30) calendar days of the date on the Decision Notice, but for services to be continued during the process, the State Fair Hearing appeal must be made within ten (10) calendar days of the date on the Decision Notice. The member may be liable for services provided during the appeal process if the decision is unfavorable.

Again, the member may be represented by a representative at the State Fair Hearing.

State Fair Hearings may be requested in one of the following ways:

  • Through the local Family Community Resource Center
  • If the State Fair Hearing appeal is related to medical services or items, or Elderly Waiver (Community Care Program (CCP)) services, the request for a State Fair Hearing must be made in writing to:

Illinois Department of Health Care and Family
Services Bureau of Administrative Hearings
401 S Clinton Street, 6th Floor
Chicago, IL 60607
Fax: 1(312)793-2005

Or the member may call
1(855)418-4421, TTY: 1(800)526-5812

If the appeal is related to Persons with Disabilities Waiver services, Traumatic Brain Injury Waiver services, HIV/AIDS Waiver services or any Home Services Program (HSP) service, a State Fair Hearing may be requested by sending the request in writing to:

Illinois Department of Human Services
Bureau of Hearings
401 S Clinton Street, 6th Floor
Chicago, IL 60607
Fax: 1(312)793-8573
Or the member may call
1(800)435-0774, TTY: 1(877)734-7429

State fair hearing process

The hearing will be conducted by an Impartial Hearing Officer authorized to conduct State Fair Hearings. You will receive a letter from the appropriate Hearings office informing you of the date, time and place of the hearing. A letter providing information about the hearing, including the date, time and place of the hearing, will be sent to the member by the hearing office.

At least three (3) business days before the hearing, the member, along with the Impartial Hearing Officer, will receive information from SpecialCare of Illinois that includes all evidence we will present at the hearing. The member also must provide any evidence (s)he will present at the hearing to SpecialCare of Illinois and to the Impartial Hearing Officer at least three (3) business days before the hearing. This includes a list of any witnesses who will appear on the member’s behalf, as well as all documents the member will use to support the appeal.

Continuance or postponement
The member may request a continuance during the hearing or a postponement prior to the hearing, which may be granted if good cause exists. If the Impartial Hearing Officer agrees, all parties to the appeal will be notified in writing of a new date, time and place. The time limit for the appeal process to be completed will be extended by the length of the continuation or postponement.

Failure to appear at the hearing
The member’s appeal will be dismissed if the member or authorized representative fail to appear at the hearing at the time, date and place on the notice and no postponement has been requested in writing. If the hearing is conducted via telephone, the appeal will be dismissed if the member does not answer the telephone at the scheduled appeal time. A Dismissal Notice will be sent to all parties to the appeal.

The hearing may be rescheduled, if the member lets the Hearing Office know within ten (10) calendar day from the date of receipt of the Dismissal Notice if the reason for failure to appear was:

  • A death in the family
  • Personal injury or illness which reasonably would prohibit your appearance
  • A sudden and unexpected emergency

If the appeal hearing is rescheduled, the Hearings Office will send the member or authorized representative a letter rescheduling the hearing with copies to all parties to the appeal.

If we deny your request to reset your hearing, the member will receive a letter in the mail informing you of our denial.

The state fair hearing decision
A Final Administrative Decision will be sent to the member and all interested parties in writing by the appropriate Hearings Office. This Final Administrative Decision is reviewable only through the Circuit Courts of the State of Illinois. The time the Circuit Court will allow for filing of such review may be as short as thirty- five (35) days from the date of this letter.

External Review (for medical services only) Within thirty (30) calendar days of the date of receipt of SpecialCare of Illinois’s
appeal Decision Notice, the member may choose to ask for a review by an external reviewer. The outside reviewer must meet the following requirements:

  • Board certified provider with the same or like specialty as the member’s treating provider
  • Currently practicing
  • Have no financial interest in the decision
  • Not know the member and will not know the member’s identity during the review

External Review is not available for appeals related to services received through the Elderly Waiver; Persons with Disabilities Waiver; Traumatic Brain Injury Waiver; HIV/Aids Waiver; or the Home Services Program.

The request letter must ask for an external review of that action and should be sent to:
Appeals Department Attn: External Review
PO Box 24087
Nashville, TN 37202
1(855)320-4409

 

What Happens Next?

  • Within five (5) business days SpecialCare of Illinois will review the request to see if it meets the qualifications for external review and notify the member if the requirements are met.
  • The member will have five (5) business days from receipt of that letter to submit additional information about the appeal to the external reviewer.
  • The external reviewer will send the member and/or your representative and SpecialCare of Illinois a letter with their decision within five (5) calendar days of receiving all the information they need to complete their review.

 

Overview
The purpose of SpecialCare of Illinois’s Corporate Compliance Program is to articulate SpecialCare of Illinois’s commitment to compliance. It also serves to encourage our employees, contractors and other interested parties to develop a better understanding of the laws and regulations that govern SpecialCare of Illinois’s operations. Further, SpecialCare of Illinois’s Corporate Compliance Program also ensures that all practices and programs are conducted in compliance with those applicable laws and regulations.

SpecialCare of Illinois and its subsidiaries are committed to full compliance with federal and state regulatory requirements applicable to all of our lines of business. Non-compliance with regulatory standards undermines SpecialCare of Illinois’s business reputation and credibility with the federal and state governments, subcontractors, pharmacies, providers and most importantly, its members. SpecialCare of Illinois and its employees are also committed to meeting all contractual obligations set forth in SpecialCare of Illinois’s contracts with the Centers for Medicare and Medicaid Services (CMS).

The Corporate Compliance Program is designed to prevent violations of federal and state laws governing SpecialCare of Illinois’s lines of business, including but not limited to, healthcare fraud and abuse laws. In the event such violations occur, the Corporate Compliance Program will promote early and accurate detection, prompt resolution and, when necessary, disclosure to the appropriate governmental authorities.

SpecialCare of Illinois has in place policies and procedures for coordinating and cooperating with MEDIC (Medicare Drug Integrity Contractor), CMS, State Regulatory Agencies, Congressional Offices and law enforcement. SpecialCare of Illinois also has policies that delineate that SpecialCare of Illinois will cooperate with any audits conducted by CMS, MEDIC or law enforcement or their designees.

Fraud, waste and abuse
SpecialCare of Illinois has policies and procedures to identify fraud, waste and abuse in its network, as well as other processes to identify overpayments within its network to properly recover such overpayments.

These procedures allow us to report potential fraud or misconduct to the appropriate government authority as specified at 42 C.F.R. § 422.503(b)(4) (vi) and 42 C.F.R. §423.504(b)(4)(vi)(H)and SpecialCare of Illinois has policies and procedures in place for cooperating with CMS and law enforcement entities.

The evaluation and detection of fraudulent and abusive practices by SpecialCare of Illinois encompasses all aspects of SpecialCare of Illinois’s business and its business relationship with third parties, including health care providers and members. All employees, contractors and other parties are required to report compliance concerns and suspected or actual misconduct without fear of retaliation for reports made in good faith.

The Compliance Officer may be contacted in the following manner:

  • Anonymously by calling the toll-free Ethics Helpline at 1-800-472-8348. The Ethics Helpline is a completely confidential resource that can be used by employees, contractors, agents, members or other parties to voice concerns about any issue that may affect SpecialCare of Illinois’s ability to meet legal or contractual requirements and/or to report misconduct that could give rise to legal liability if not corrected.
  • By phone at: 1-615-236-6150
  • Through web based reporting at https://cignaethicshelpline/alertline.com/gcs/welcome

All such communications will be kept as confidential as possible but there may be times when the reporting individual’s identity may become known or need to be disclosed to meet requirements of any governmental review actions. Any employee, contractor or other party that reports compliance concerns in good faith can do so without fear of retaliation.

In addition, as part of an ongoing effort to improve the delivery and affordability of health care to our members, SpecialCare of Illinois conducts periodic analysis of all levels of Current Procedural Terminology (CPT), ICD-9 and HCPCS, codes billed by our providers. The analysis allows SpecialCare of Illinois to comply with its regulatory requirements for the prevention of fraud, waste and abuse (FWA)and to supply our providers with useful information to meet their own compliance needs in this area. SpecialCare of Illinois will review your coding and may review medical records of providers who continue to show significant variance from their peers. SpecialCare of Illinois endeavors to ensure compliance and enhance the quality of claims data, a benefit to both SpecialCare of Illinois’s medical management efforts and our provider community. As a result, you may be contacted by SpecialCare of Illinois’s contracted partners to provide medical records to conduct reviews to substantiate coding and billing.

In order to meet your FWA obligations, please take the following steps:

You may request a copy of the SpecialCare of Illinois Compliance Program document by contacting your SpecialCare of Illinois provider Relationship Representative.

Reporting critical incidents of abuse and elderly abuse, neglect and exploitation
Cigna-HealthSpring shall comply with all health, safety and welfare monitoring and reporting required by state or federal statute or regulation, but not limited to, the following: critical incident reporting regarding abuse, neglect and exploitation (ANE); critical incident reporting regarding any incident that has the potential to place an Enrollee or an Enrollee’s services, at risk, but which does not rise to the level of abuse, neglect, or exploitation; and performance measures relating to the areas of health, safety and welfare and required for operating and maintaining a HCBS Waiver.

Cigna-HealthSpring trains all of Cigna-HealthSpring’s employees, affiliated providers, affiliates and subcontractors to recognize potential concerns related to ANE, on your responsibility to report suspected or alleged ANE, and how you can report. If you, in good faith, report suspicious or alleged ANE to the appropriate authorities, you shall not be subjected to any adverse action from Cigna-HealthSpring, its affiliated providers, affiliates or subcontractors. As part of its provider education, Cigna-HealthSpring shall include information related to identifying, preventing and reporting abuse, neglect, exploitation and
critical incidents.

Reporting hotlines:

  • Reports regarding Enrollees who are age eighteen (18) and older and living in the community are to be made to the Illinois Department on Aging by utilizing the Adult Protective Services (APS) Hotline number at 1(866)800-1409 (voice) and 1(888)206-1327 (TTY).
  • Reports regarding Enrollees aged 18-59 receiving mental health or developmental disability services in DHS operated, licensed, certified or funded programs are to be made to the Illinois Department of Human Services Office of the Inspector General Hotline at 1(800)368-1463 (voice and TTY).
  • Reports regarding Enrollees in Nursing Facilities must be made to the Department of Public Health’s Nursing Home Complaint Hotline at 1(800)252-4343.
  • Reports regarding Enrollees in Supportive Living Facilities (SLF) must be made to the Department of Healthcare and Family Services’ SLF Complaint Hotline at 1(800)226-0768.

Reporting shall occur within 4 hours of discovery. Here are examples of reportable events:

Critical incident definitions
Death, HSP member: All deaths will be reported via incident reporting, and will be reported to the DHS Office of Inspector General. Follow-up will be provided on deaths of an unusual nature per OIG direction. Criteria for investigating such incidents and reporting via the Incident reporting system may include a recent allegation or abuse/ neglect/exploitation, member was receiving home health services at time of passing, etc.

Death, other parties: Events that result in significant event for member. For example, member’s caregiver dies in the process of giving member bath, thereby leaving member stranded in home without care for several days. Passing of immediate family members is not necessary unless the passing creates a resulting turn events that are harmful to member.

Physical abuse of member: Non-accidental use of force that results in bodily injury, pain or impairment. Includes but not limited to being slapped, burned, cut, bruised or improperly physically restrained.

Verbal/Emotional abuse of member: Includes but is not limited to name calling, intimidation, yelling and swearing. May also include ridicule, coercion and threats.

Sexual abuse of member: Unwanted touching, fondling, sexual threats, sexually inappropriate remarks or other sexual activity with an adult with disabilities.

Exploitation of member: The illegal use of assets or resources of an adult with disabilities. It includes, but is not limited to, misappropriation of assets or resources of the alleged victim by undue influence, by breach of fiduciary relationship, by fraud, deception, and extortion or in any manner contrary to law.

Neglect of member: The failure of another individual to provide an adult with disabilities with, or the willful withholding from an adult with disabilities of the necessities of life including but not limited to food, clothing, shelter or medical care.

Sexual harassment by provider: Unwelcome sexual advances, requests for sexual favors and other verbal or physical conduct of a sexual nature that tends to create a hostile or offensive work environment.

Sexual harassment by member: Unwelcome sexual advances, requests for sexual favors and other verbal or physical conduct of a sexual nature that tends to create a hostile or offensive work environment.

Sexually problematic behavior: Inappropriate sexual behaviors exhibited by either the member or individual provider, which impacts the work environment adversely.

Significant medical event of provider: A recent event to a provider that has the potential to impact upon a member’s care.

Significant medical event of member: This includes a recent event or new diagnosis that has the potential to impact on the member’s health or safety. Also included are unplanned hospitalizations or errors in medication administration by provider.

Member arrested, charged with or convicted of a crime:
In instance where the arrest, charge or conviction has a risk or potential risk upon the member’s health and safety should be reported.

Provider arrested, charged with or convicted of a crime:
In instance where the arrest, charge or conviction has a risk or potential risk upon the member’s health and safety should be reported. Fraudulent activities or theft on the part of the member or the provider: Executing or attempting to execute a scheme or ploy to defraud the Home Services program, or obtaining information by means of false pretenses, deception or misrepresentation in order to receive services from our program. Theft of member property by a provider, as well as theft of provider property by a member is included.

Self-Neglect: Individual neglects to attend to their basic needs, such as personal hygiene, appropriate clothing, feeding or tending appropriately to medical conditions.

Member is missing: Member is missing or whereabouts are unknown for provision of services. Problematic possession or use of a weapon by a member: Members should never display or brandish a weapon in staff’s presence. Any perceived threat through use of weapons should be reported. In some cases, persons with SMI are not allowed to possess firearms and this should be documented if observed.

Member displays physically aggressive behavior: Member uses physical violence that results in harm or injury to the provider. Property damage by member of $50 or more: Member causes property damage to in the amount of $50 or more to provider property.

Suicide attempt by member: Member attempts to take own life.

Suicide ideation/threat by member: An act of intended violence or injurious behavior towards self, even if the end result does not result in injury.

Suspected alcohol or substance abuse by member: Use of alcohol or other substances that appears compulsive and uncontrolled and is detrimental to member’s health, personal relationships, safety of self and others, and social and legal status.

Seclusion of a member: Seclusion is defined as placing a person in a locked or barricaded area that prevents
contact with others.

Unauthorized restraint of a member: Any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely.

Media involvement/media inquiry: Any inquiry or report/article from a media source concerning any aspect of a member’s case should be reported via an incident report. Additionally, all media requests will be forwarded to the DHS Office of Communications for response.

Threats made against DRS/HSP Staff: Threats and/or intimidation manifested in electronic, written, verbal, physical acts of violence or other inappropriate behavior.

Falsification of credentials or records: To falsify medical documents or other official papers for the expressed interest of personal gain, either monetary or otherwise.

Report against DHS/HSP employee: Deliberate and unacceptable behavior initiated by an employee of DRS against a member or provider in HSP.

Bribery or attempted bribery of a HSP Employee: Money or favor given to an HSP employee in exchange to influence the judgment or conduct of a person in a position of authority.

Fire/Natural Disaster: Any event or force of nature that has catastrophic consequences, such as flooding, tornados or fires.

 

Elder abuse and neglect program:
Elder abuse refers to the following types of mistreatment to any Illinois resident 60 years of age or older who lives in the community and must be committed by another person on the elder:

  • Physical Abuse means causing the inflictions of physical pain or injury to an older person
  • Sexual Abuse means touching fondling, sexual threats, sexually inappropriate remarks or any other sexual activity with an older person when the older person is unable to understand, unwilling to consent, threatened or physically forced to engage in sexual activity
  • Emotional Abuse means verbal assaults, threats of maltreatment, harassment or intimidation intended to compel the older person to engage in conduct from which he or she wishes and has a right to abstain or to refrain from conduct in which the older person wishes and has a right to engage
  • Confinement means restraining or isolating, without legal authority, an older person for other than medical reasons, as ordered by a physician
  • Passive Neglect means a caregiver’s failure to provide an eligible adult with the necessities of life including, but not limited to, food, clothing, shelter or medical care. This definition does not create any new affirmative duty to provide support to eligible adults; nor shall it be construed to mean that an eligible adult is a victim of neglect because of health care services provided or not provided by licensed health care professionals
  • Willful Deprivation means willfully denying medications, medical care, shelter, food, therapeutic devices or other physical assistance to a person who, because of age, health or disability, requires such assistance and thereby exposes that person to the risk of physical, mental or emotions harm because of such denial; except with respect to medical care or treatment when the dependent person has expressed an intent to forego such medical care or treatment and has the capacity to understand the consequences
  • Financial Exploitation means the misuse or withholding of an older person’s resources by another person to the disadvantage of the older person or the profit or advantage of a person other than the older person

Incident reporting for supportive living facilities:
Examples of incidents that must be reported to the department include, but are not limited to the following:

  • Abuse or suspected abuse of any nature by anyone, including another resident, staff, volunteer, family, friend, etc.
  • Allegations of theft when a resident chooses to involve local law enforcement
  • Elopement of residents/missing residents
  • Any crime that occurs on facility property
  • Fire alarm activation for any reason that results in on-site response by local fire department personnel. This does NOT include fire department response that is a result of resident cooking mishaps that only cause minimal smoke limited to a resident’s apartment and that do not result in any injuries or damage to the apartment. Examples of what do not need to be reported include, but are not limited to: burnt toast or burnt popcorn
  • Physical injury suffered by residents during a mechanical failure or force of nature
  • Loss of electrical power in excess of an hour
  • Evacuation of residents for any reason

Quality Management Program Principles for SpecialCare of Illinois:

  • Provide services that are clinically driven, cost effective, and outcome oriented;
  • Provide services that are culturally informed, sensitive, and responsive;
  • Provide services that enable members to live in the least restrictive, most integrated community setting appropriate to meet their health care needs;
  • Ensure that guidelines and criteria are based on professional standards and evidence-based practices that are adapted to account for regional, rural and urban differences;
  • Foster an environment of quality of care and service within SpecialCare of Illinois and through our provider Partners; and
  • Promote member safety as an overriding consideration in decision making SpecialCare of Illinois is committed to providing access to quality health care for all members in all product lines through the continuous planning, implementation, assessment to improve the quality of care and services to our members. The Quality Management Program assumes that there is no permanent threshold for good performance. Our members expect and should be provided a comprehensive and therapeutic health care delivery system that is always evolving and improving. 
  • The Quality Management Program accomplishes this by integrating, analyzing and reporting on data from across the Plan as well as other data sources
  • The Quality Management Program prioritizes quality initiatives based on relevance to the population SpecialCare of Illinois serves, and works with other departments to manage plan resources in the most cost effective manner to maximize patient health outcomes. The following is a brief overview of the Quality Management Program’s functions.
  • Collects and investigates internal and external reporting of quality of care concerns. Substantial quality concerns are presented to the Quality Improvement Committee (QIC) to formulate corrective action plans and monitor the results
  • Coordinates and facilitates Quality Improvement activities.
  • The QIC is charged with providing oversight (identification, prioritization and coordination) of all quality improvement activities related to the care and services provided to our members
  • Coordinates with various internal departments in preparation for mandatory Centers for Medicare and Medicaid Services (CMS) and state activities, such as Healthcare Effectiveness Data and Information Set (HEDIS) and Consumer Assessment of Healthcare Providers and Systems (CAHPS)
  • Works to encourage optimal health outcomes for our members through annual review of best practice standards. Preventive standards are leveraged from The United States Preventive Services Task Force Standards (USPSTF), which standards are derived from the American Diabetes Association, the American Cancer Society as well as other nationally recognized organizations. Guidelines for preventive and chronic care are revised and modified to reflect the latest in clinical best practices

If you have any questions about SpecialCare of Illinois’s Quality Management Program or would like a comprehensive description of the Program, its Annual Goals or a list of activities toward achieving those goals, please feel free to contact member services. Information will be provided upon request.

Quality Improvement Committee (QIC)
The QIC is responsible for the overall design and implementation of quality improvement activities for the SpecialCare of Illinois organization, as well as for the oversight of quality improvement activities carried out by other quality sub-committees. The QIC reports these activities to the Board
of Directors. The QIC ensures that member and provider feedback and recommendations are used when designing activities to improve care and services.

Quality Management Program
The primary objective of the Quality Improvement program is to promote and build quality into the organizational structure and processes to meet the organization’s mission of improving the health of the community we serve by delivering the highest quality and greatest value in health care benefits and services. The goals the organization has established to meet this objective are:

  • Maintain an effective quality committee structure that:
  • Fosters communication across the enterprise, 
  • Collaboratively works towards achievement of established goals;
  • Monitors progress of improvement efforts to established goals; and
  • Provides the necessary oversight and leadership reporting
  • Ensure patient care and service is provided according to established goals and metrics
  • Ensure identification and analysis of opportunities for improvement with implementation of actions and follow-up as needed
  • Promote consistency in quality program activities
  • Ensure the QI Program is sufficiently organizationally separate from the fiscal and administrative management to ensure that fiscal and administrative management does not unduly influence decision-making regarding organizational determinations and/or appeals of adverse determinations of covered benefits
  • Assure timely access to and availability of safe and appropriate physical and behavioral health services for the population served by SpecialCare of Illinois.
    • Objective: Establish and maintain a comprehensive network of providers (primary care, specialty care, facility, ancillary, behavioral health, etc.) in adequate numbers necessary to meet the needs and expectation of the plan’s enrollees
    • Objective: Ensure enrollees have timely access in accordance with their care needs by implementing policies that establish accessibility standards and procedures for adherence to those standards
  • Ensure services are provided by qualified individuals and organizations including those with the qualifications and experience appropriate to service members with special needs
  • Promote the use of evidence-based practices and care guidelines
  • Improve the ability of all SpecialCare of Illinois staff to apply quality methodology through a program of education, training and mentoring
  • Establish a rigorous delegation oversight process
  • Ensure adequate infrastructure and resources to support the Quality Improvement Program
  • Assure provider involvement in maintaining and improving the health of SpecialCare of Illinois members, through a comprehensive provider partnership
  • Ensure the SpecialCare of Illinois Medicaid enrollees receive safe and effective patient centered care that is consistent with established standards
    • Objective: Ensure that clinical services are provided by qualified individuals and organizations including those with the qualifications and experience appropriate to service members with special needs
    • Objective: Ensure the safety of all members in all treatment settings
    • Objective: Improve the medical and mental health of the plan’s enrollees
  • Encourage and support a culture of quality improvement internally, for providers and for members
    • Objective: Improve member and provider service levels and satisfaction
    • Objective: Educate members, providers and internal stakeholders on scope and purpose of quality improvement activities

 

HEDIS (The Health Care Effectiveness Data and Information Set) is developed and maintained by the National Committee for Quality Assurance (NCQA), an accrediting body for managed care organizations. The HEDIS measurements enable comparison of performance among managed care plans. The sources of HEDIS data include administrative data (claims/encounters) and medical record review data. HEDIS measurements include measures such as Comprehensive Diabetes Care, Adult Access to Ambulatory and Preventive Care, Glaucoma Screening for Older Adults, Controlling High Blood Pressure, Breast Cancer Screening, and Colorectal Cancer Screening. Plan-wide HEDIS measures are reported annually and represent a mandated activity for health plans contracting with the Centers for Medicare and Medicaid Services (CMS).

Each Spring, Cigna-HealthSpring Representatives are required to collect from practitioner offices copies of medical records to establish HEDIS scores. Selected practitioner offices will be contacted and requested to assist in these medical record collections.

All records are handled in accordance with Cigna-HealthSpring’s privacy policies and in compliance with the Health Insurance Portability and Accountability Act (HIPAA) Privacy rules. Only the minimum necessary amount of information, which will be used solely for the purpose of this HEDIS initiative, will be requested during HEDIS Medical Record Review. This information can be faxed to our Stars Department at 877-440-9344 or emailed to FaxTNNashQICharts@healthspring.com. HEDIS is considered a quality-related health care operation activity and is permitted by the HIPAA Privacy Rule [see 45 CFR 164.501 and 506].

Timeline of HEDIS Medical Record Review

HEDIS Medical Record Review Timeline

 

Cigna-HealthSpring’s HEDIS results are available upon request. Contact the Health Plan’s Quality Improvement Department, at 1-888-280-5367, to request information regarding those results.

If you would like to provide Cigna-HealthSpring with medical records for the current year, please fax them to our Stars Department at 877-440-9344 or email FaxTNNashQICharts@healthspring.com.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Cigna-HealthSpring has implemented the Health Level Seven (HL7) standard messaging format for the transmission of lab results data, versions 2.3 and 2.5.1. This data is essential for HEDIS® reporting, in support of early detection and quality improvement for our customers. HL7 provides a robust and standardized approach to data exchange that is widely recognized and used in the health care industry. Where not explicitly stated otherwise, the HL7 standards are the required format for the transmission of lab results data to Cigna-HealthSpring. A companion guide, containing additional details and instructions for submitting lab results data in this format, can be found on our website at: http://www.cigna.com/iwov-resources/ medicare-2015/docs/hcp-companion-guide.pdf.

Health Services Content

Cigna-HealthSpring SpecialCare of Illinois manages the full spectrum of Medicaid covered services through an integrated care delivery system to adults 60 years and older and adults aged 19 and over with disabilities who are eligible for Medicaid but are not eligible for Medicare in the Illinois counties of Lake, Kane, DuPage, Will and Cook. Cigna-HealthSpring SpecialCare of Illinois improves members’ health and social outcomes and access to care by integrating service delivery through an Integrated Care Coordination Program. Care Coordination encompasses:

  • Acute care
  • Long Term Services and Supports (LTSS): Home and Community Based Waiver Services and members residing in a facility 
  • Behavioral health 
  • Disease management 
  • Non-covered services

As a part of our care coordination for the Integrated Care Program Cigna-HealthSpring SpecialCare of Illinois provides Early Periodic Screening, Diagnosis, and Treatment (EPSDT).


EPSDT is Medicaid’s comprehensive and preventive health program for individuals under the age of 21. EPSDT was defined by law as a part of the Omnibus Budget Reconciliation Act of 1989 (OBRA ’89) legislation and includes periodic screening, vision, dental, and hearing services. In addition, Section 1905 (r) (5) of the Social Security Act (the Act) requires that any medically necessary health care service listed at Section 1905 (a) of the Act be provided to an EPSDT recipient even if the service is not available under the State’s Medicaid plan to the rest of the Medicaid population.


The EPSDT Program consists of two mutually supportive, operational components: (1) assuring the availability and accessibility of required health care resources; and (2) helping members and their guardians effectively with these resources. These components enable Medicaid agencies to manage a comprehensive health program of prevention and treatment, to seek out eligible members, inform them of the benefits of prevention, the health services and assistance available and to help the member and their family with use health resources, including their own skills and knowledge, effectively and efficiently.  This also allows the member and their family to assess the health needs through initial and periodic examinations and evaluations and to see that the health problems found are diagnosed and treated early, before they become more complex and their treatment more costly. (Adapted from the CMS website at https://www.cms.gove/MedicaidEarlyPeriodicScrn/).

Illinois Specific Requirements for EPSDT
The Illinois Department of Healthcare and Family Services (HFS) produces a handbook for providers outlining specific requirements/responsibilities for providers in Illinois regarding EPSDT services, “Handbook for Providers of Healthy Kid Services”.  The handbook can be found at:
http://www.hfs.illinois .gov/assets/hk200.pdf.  Cigna-HealthSpring SpecialCare of Illinois is contractually required to follow the screening guidelines and procedures outlined in the HFS handbook.

Periodic Schedule
The Illinois Department of Healthcare and Family Services (HFS) publishes guidelines for EPSDT screening. To view the schedule on HFS’ website please visit http://www.hfs.illinois .gov/assets/hk200.pdf.

Cigna-HealthSpring SpecialCare of Illinois’ integrated care coordination program includes Interdisciplinary Care Team meetings (ICTs). All members are encouraged to participate in an ICT discussion.  The objective of the ICT is to provide a forum for members to express their goals and wishes, discuss obstacles/barriers that may be preventing the member to reach their goals, and/or new events that place the member’s independence at risk.  Primary care providers and individuals providing formal and informal support to the member are invited and encouraged to participate along with the member and/or their caregivers. The ICT is led by a Cigna-HealthSpring SpecialCare of Illinois care coordinator who is actively involved in working with the member.  The team discussion can occur at the physician’s office, at the member’s home, during an inpatient admission, and/or out in the community.

Sub-populations such as community transition members, Nursing Facility residents and HCBS waiver members have a designated team with specific additional training related to the membership needs. These designated care coordinators facilitate and lead ICT and ensure all pertinent support people are provided the opportunity to participate in the meetings.

The ICTs will have experience with:

  • The member population
  • The barriers and obstacles they face
  • Socioeconomic impacts on their ability to access services
  • Substance use
  • Family systems and dynamics

Cigna-HealthSpring SpecialCare of Illinois will use a holistic approach by integrating referral and access to:

  • Community resources
  • Transportation
  • Follow-up care
  • Medication review 
  • Specialty care 
  • Education
  • LTSS

Cigna-HealthSpring SpecialCare of Illinois works with CMS and HFS to determine eligibility of their members. Once eligibility has been determined a member of the care coordination team will contact the member, including those members that live in the community, reside in long term nursing facilities or supportive living facilities, and those receiving Home and Community Based Waiver Services. Cigna-HealthSpring SpecialCare of Illinois has internal processes to ensure transition to and from other entities such as another managed care organization and agencies such as Department on Aging, Department of Human Services, Division of Rehabilitative Services and the Department Healthcare and Family Service.  Cigna-HealthSpring SpecialCare of Illinois provides 180 days of continuity of services for members newly enrolled in managed care and 90 days of continuity of care for members enrolled from another MCO.  Cigna-HealthSpring SpecialCare of Illinois will not adjust services without the member’s consent during this time.

Cigna- HealthSpring SpecialCare of Illinois’ care coordination  staff will assist in the coordination of medical care and support services for members across the delivery system (whether in or out of the network) and to assure continuity of care after discharge from an in-patient and skilled nursing facility setting.

LTSS providers deliver care covering Home and Community Based Waiver Services (HCBS) and Long Term Care (LTC).  LTSS, delivered in combination with care coordination, medical health, behavioral health, disease management and other non-covered services, provides for more stable health opportunities while maintaining the member’s highest level of independent functioning as possible. 
Cigna-HealthSpring SpecialCare of Illinois is responsible for managing and coordinating the benefits for the following five Medicaid Waivers:

  • Supportive Living Facilities
  • Persons who are Elderly
  • Persons with Disabilities
  • Persons with HIV or AIDS
  • Persons with Brain Injuries.

For members residing in Long Term Care facilities, Cigna-HealthSpring SpecialCare of Illinois is responsible for managing and coordinating room and board.

LTSS providers are responsible for providing covered services to members, within the scope of their Cigna-HealthSpring SpecialCare of Illinois participating provider agreement and within the scope of their license (if applicable).   Providers are required to adhere to the member’s Person-Centered Care Plan and Service Plan.  Other LTSS responsibilities include:

  • Verifying member eligibility prior to rendering services, as well as monthly, if the provider is providing on-going treatment or services
  • Obtaining authorizations from Cigna-HealthSpring SpecialCare of Illinois prior to rendering services (with exception to room and board for members residing in Nursing facilities)
  • Providing continuity of care
  • Being culturally and linguistically sensitive to Cigna-HealthSpring SpecialCare of Illinois members
  • Ensuring on-going continuity of care between the member’s Care Coordinator and his/her PCP
  • Notifying Cigna-HealthSpring SpecialCare of Illinois of a change in the member’s physical condition or eligibility
  • Notifying Cigna-HealthSpring SpecialCare of Illinois when there is a break in HCBS services for any reason
  • Using a National Provider Identification (NPI) number or the Cigna-HealthSpring SpecialCare of Illinois-issued Alternative Provider Identification (API) number, whichever is appropriate
  • Billing and reporting services in compliance with the LTSS HCPCS Codes

 

The Illinois Department of Healthcare and Family Services (HFS) in collaboration with Illinois Department on Aging and Illinois Department of Human Services has a variety of waiver services available for people who qualify.  Cigna-HealthSpring SpecialCare of Illinois is responsible for managing five of these waivers in order to facilitate independence by supporting individuals to remain in their own homes or to live in a community setting thus reducing need for institutional living. These waivers provide additional benefits in addition to traditional fee for service Medicaid benefits.  Cigna-HealthSpring SpecialCare of Illinois manages the following five waivers:

1. Persons who are Elderly Waiver:

The Persons who are Elderly Waiver is for those people 60 years or older that live in the community and are at risk of nursing facility placement. Services include:

  • Adult Day Care Services
  • Transportation to an Adult Day Care center
  • Homemaker services
  • Personal Emergency Response System

2. Persons with Disabilities Waiver

The Persons with Disabilities Waiver is for individuals with disabilities who are under age 60 at the time of application and are at risk of placement in a nursing facility.  Individuals 60 years or older, who began services before age 60, may choose to remain in this waiver.  Services include:

  • Adult Day Care Services
  • Personal Emergency Response System
  • Home modifications
  • Home-delivered meals
  • Home health aide
  • Homemaker services
  • Occupational therapy
  • Personal Assistant
  • Physical therapy
  • Respite
  • Skilled nursing
  • Intermittent Nursing
  • Specialized medical equipment and supplies
  • Speech therapy

3. Persons with HIV or AIDS Waiver

The Persons with HIV or AIDS Waiver is for individuals of any age who are diagnosed with Human Immune Deficiency Virus (HIV) or Acquired Immune Deficiency Syndrom (AIDS) and are at risk of placement of a nursing facility. Services include:

  • Adult Day Care
  • Personal Emergency Response System
  • Home modifications
  • Homemaker services
  • Home-delivered meals
  • Personal assistant
  • Physical therapy
  • Occupational therapy
  • Respite
  • Skilled nursing
  • Intermittent Nursing
  • Home health aide
  • Speech therapy
  • Specialized medical equipment and supplies


4. Persons with Brain Injury Waiver

The Persons with Brain Injury Waiver is for individuals with brain injury, of any age, who are at risk of nursing facility placement due to functional limitations resulting from the brain injury. Services include:

  • Adult Day Care
  • Cognitive Behavioral Therapies Day Habilitation 
  • Home modifications
  • Home-delivered meals
  • Homemaker services
  • Occupational therapy
  • Personal assistant
  • Personal Emergency Response System
  • Physical Therapy
  • Prevocational services
  • Respite
  • Skilled nursing/Home health aide
  • Intermittent Nursing
  • Specialized medical equipment and supplies
  • Speech therapy
  • Supported employment services


5. Supportive Living Facilities Waiver

The Supportive Living Facilities Waiver is for individuals age 22-64 with a physical disability or persons age 65 or over in a Supportive Living Facility (SLF). The following services may be provided to you directly by the Supportive Living Facility.:

  • Nursing services
  • Personal care
  • Medication assistance
  • Health promotion and exercise programming
  • Meals and snacks
  • Laundry
  • Housekeeping
  • Maintenance
  • 24-hour response/security staff
  • Emergency call system
  • Well-being check
  • Ancillary services
  • Management of resident funds, if applicable

To ensure that members have the freedom of choice to apply for and, if eligible, to receive available Long Term Services and Support benefits  members have a right to choose nursing facility placement, supportive facility placement or Home and Community Based Services (HCBS).  Members also have a right to choose not to receive the above mentioned LTSS services.  Members also have the right to choose an appropriate authorized provider(s) that is willing and qualified in their geographic area of residence to receive services needed by the member.

At a minimum, Cigna-HealthSpring SpecialCare of Illinois must provide all LTSS currently covered under the traditional fee-for- service Medicaid program. The following is a non-exhaustive listing of community-based, long-term care services included under Cigna-HealthSpring SpecialCare of Illinois. Providers should refer to the ICP Handbook for a more inclusive listing of limitations and exclusions that apply to each benefit category.

Waiver Service
DOA Waiver
Disability Waiver
HIV Waiver
TBI Waiver
Adult Day Service
X X X X
Adult Day Transportation X X X X
Community Transition Services
X
(MFP only*)
X
(MFP only*)
X
(MFP only*)>
X
(MFP only*)
Environment Accessibility Services (home mod)
X X X
Supported Employment



X
Home Health Aide
X X X
Nursing, Intermittent

X X X
Nursing, Skilled (RN and LPN)
X X X
OT
X X X
PT
X X X
ST
X X X
Prevocational Services



X
Day Habilitation



X
Homemaker X X X X
Home-Delivered Meals
X X X
Personal Assistant
X
X
X
Personal Emergency Response system X
X X X
Respite
X X X
Specialized Med Equipment and Supplies
X X X
Cognitive Behavioral Therapy
    X

For individuals receiving LTSS through the Supportive Living Waiver (SLF), a set of services provided by the facility may include: Nursing, personal care, meals, snack, wellness checks, laundry, housekeeping, 24-hour response, ancillary services

*Money Follows the Person

In addition to traditional ICP benefits, Cigna-HealthSpring SpecialCare of Illinois offers certain “value-added” services to its members. Value-added services are benefits that only Cigna-HealthSpring SpecialCare of Illinois’ members receive. These benefits have been added to Cigna-HealthSpring SpecialCare of Illinois in order to promote healthy lifestyles and improve health outcomes for members.

Initially, Cigna-HealthSpring SpecialCare of Illinois notifies new members regarding the available value-added services and how to access them in their Welcome Kit. Thereafter, benefit education materials are sent to the members annually, outlining the available value-added services and how to access them. Additional details about value-added services are available at http://specialcareil.com/. Cigna-HealthSpring SpecialCare of Illinois members can get assistance accessing value-added services from their Care Coordinator by calling 1(866)487-3002 and selecting option 4 for CareCoordination services or option 7 for members enrolled in LTSS. Cigna-HealthSpring SpecialCare of Illinois’ value-added services are listed below.

  • 24 Hour Nurse Advice Line: Toll-free access to experienced registered nurses, 24 hours a day, 365 days per year, for immediate reliable information for any health concern.
  • Dental: Additional preventive and comprehensive dental care for adults
  • Vision: Routine eye exam and eyewear allowance 
  • Hearing Services: Routine hearing exam, fittings and hearing aids
  • OTC: Members can get $10 each month in over-the-counter items from the OTC catalog. 
  • Fitness: Gym membership at participating fitness location
  • Meals: After a member is discharged from a hospital stay (for traumatic or chronic illness), Cigna-HealthSpring SpecialCare of Illinois will have 20 frozen nutritional meals consisting of 10 lunches and 10 dinners delivered to their home.
  • Transportation: Unlimited transportation to and from member’s Doctor as well as to an in- network pharmacy immediately after a doctor visit.

Cigna-HealthSpring SpecialCare of Illinois offers an integrated care coordination approach, which offers enhanced assessment and management for our members. The processes, oversight committees, provider collaboration, care management and coordination efforts applied to address members needs result in a comprehensive and integrated person-centered plan of care. The care coordination program consists of an integrated team of licensed mental health professionals, licensed social workers, registered nurses and non-licensed staff with backgrounds and experience with broad populations.

The integrated care coordination program addresses the needs of the members who are often frail, elderly, and coping with disabilities, compromised activities of daily living, chronic co-morbid medical/behavioral illnesses, challenging social or economic conditions, and/or end-of-life care issues.  The program's combined provider and care coordination activities are intended to improve quality of life, health status, and appropriate treatment. The goal of the program is work collaboratively with the member and their primary care physician and/or other providers to achieve independence, highest level of wellness, and ensure quality of life.

The integrated care coordination program is initiated by a systematic process for identifying members upon eligibility, completing a health risk assessment, and developing and implementing an individualized, person-centric care plan that includes the member and their family/caregiver. Cigna-HealthSpring SpecialCare of Illinois’ care coordinators actively involve the member’s PCP and identifies support services from the community or within the health plan to assist the member. All attempts are made to include the PCP in the creation of the care plan as appropriate to assure that care plan incorporates considerations relating to the member’s medical and/or behavioral health treatment plan and any other observations by their physicians and provider(s). The care coordinators work with the members to ensure services are provided in a holistic approach to address their medical and behavioral health care as well as their social, functional, long term services and supports, and other needs. The integrated care coordination program and care plans address clinical needs, functional status, and barriers to care such as financial, transportation, and lack of support system. The completed care plans are shared with the PCP via mail.

Care Plans:
All high and moderate risk members actively enrolled in Cigna-HealthSpring Special Care of Illinois’ Integrated Care Coordination Program, including those receiving Long Term Services and Supports (LTSS) while residing in a nursing facility or receiving Home and Community Based Waiver Services, will have a care plan developed, implemented and shared with their providers.  For members receiving Home and Community Based Waiver Services, the care plan will be integrated with the service plan.

Contact Care Coordination
Cigna-HealthSpring SpecialCare of Illinois’ care coordination team is available to assist providers with improving the overall wellness of their members.   A provider can contact the care coordination team by calling 1(866)487-3002, option 4. For members receiving Long Term Services and Supports including Home and Community Based Waiver services and members residing in Nursing Facilities, please call 1(866)487-3002, option 7.

Cigna-HealthSpring SpecialCare of Illinois will perform medical management functions for members enrolled with our health plan. Cigna-HealthSpring SpecialCare of Illinois coordinates physical health, behavioral health, LTSS and specialty services to ensure quality, timely, clinically-appropriate, and cost-effective care that results in clinically desirable outcomes.

Cigna-HealthSpring SpecialCare of Illinois’ goal is to improve the members’ health and well-being through effective ambulatory management of chronic conditions, resulting in a reduction of avoidable in-patient admissions. The Utilization Management (UM) process provides an opportunity for Cigna-HealthSpring SpecialCare of Illinois to:

  • Determine the appropriateness of the services
  • Ensure that services are provided at the most appropriate level of care 
  • Ensure authorized services are provided timely
  • Ensure the services are provided by the most appropriate provider and in the most appropriate setting
  • Ensure that services are covered under the member’s benefit plan
  • Verify and coordinate other insurance benefits
  • Monitor participating providers’ practice patterns
  • Improve utilization of resources by identifying and correcting patterns of over and under utilization
  • Identify high-risk members
  • Provide utilization data for use in the re-credentialing process

It is essential that Cigna-HealthSpring SpecialCare of Illinois providers communicate with each other to ensure appropriate and timely member access to care. When referring members for care, PCPs should provide physical health and/or Behavioral Health providers with all relevant clinical information regarding the member’s care. This includes results of diagnostic tests and laboratory services. After seeing members, providers should forward to the member’s PCP a summary of the visit, clinical findings, and treatment plan. PCPs should document this information appropriately in the member’s medical records.

Cigna-HealthSpring CarePlan of Illinois provides disease management as a part of our care coordination program. The disease management program assists in providing the member with education on how to manage their chronic disease. Members are encouraged to take responsibility for understanding of the chronic disease state and how to improve their health and identify risk triggers.

All members participating in a disease management program will receive an assessment and participate in the development of a care plan. The member will be encouraged to set short and long term goals and develop interventions.

Cigna-HealthSpring SpecialCare of Illinois provides care coordination for expectant members.  Care coordination finds it crucial to identify expectant members as early as possible in their pregnancy.  Cigna-HealthSpring SpecialCare of Illinois care coordinators will work with the caring provider and requests the caring provider complete notification of pregnancy within five (5) business days of the initial pre-natal visit.  As part of pre-natal care the provider is to identify date of confinement, facility to deliver and provider order for prenatal vitamins.