07/15/14
Informational Notice
To: All Enrolled Medical Assistance Program Providers
Re: Dental, Optical and Behavioral Health Services Now Covered Through All Managed Care Plans
The Department of Healthcare and Family Services (HFS) is continuing efforts to expand coordinated care to Illinois Medicaid and Family Health Plan beneficiaries.
Effective with dates of service on or after July 1, 2014, beneficiaries enrolled in any Managed Care Organization (MCO) or Managed Care Community Network (MCCN) will receive dental, optical, and behavioral health services billed by Community Mental Health Centers (Provider Type 036) through their health plan. Prior to July 1, 2014, those services were billable directly to the department through the fee-for-service system. Enrollees of Accountable Care Entities (ACE), Care Coordination Entities (CCE) or those receiving any covered services through the normal fee-for-service arrangement should continue to submit claims directly to either HFS or DentaQuest.
Effective with dates of service on or after July 1, 2014, providers cannot bill HFS for reimbursement of optical or behavioral health services for a HFS beneficiary enrolled in a MCO or MCCN. In addition, dental providers cannot bill DentaQuest for reimbursement of dental services for an HFS beneficiary enrolled in a MCO or MCCN (unless the MCO/MCCN’s dental subcontractor is DentaQuest). Providers must verify eligibility prior to providing services to determine if the beneficiary is in an MCO or MCCN. The department has not yet completed the system programming to reject optometric and behavioral health services provided by CMHCs when billed for beneficiaries enrolled in Family Health Plan MCOs and MCCNs. When the programming is complete, if a provider bills HFS for a MCO/MCCN enrollee, the claim will be rejected with a R39 (Recipient Enrolled in a MCO) or a G39 (Recipient in MCO – Integrated Care). Providers will have to enroll with the MCO to be able to receive reimbursement.
It is imperative that providers check HFS electronic eligibility systems regularly to determine beneficiaries’ enrollment in a plan. The Recipient Eligibility Verification (REV) System, the Automated Voice Response System (AVRS) at 1-800-842-1461, and the Medical Electronic Data Interchange (MEDI) system will identify the care coordination plan in which the beneficiary is enrolled. Providers of all types should join the care coordination networks available in their areas in order to continue to provide services to their patients and ensure timely payment.
HFS encourages providers to contact the care coordination plans in their region and begin the contracting process. Additional information is provided on the HFS website at Care Coordination, Care Coordination Expansion Map and All Medical Assistance Provider Releases. Further detailed information regarding the managed care regions, including contact information for each MCO, can be found in the May 23, 2014 Provider Notice (pdf).
Any questions may be directed to the department’s Bureau of Managed Care at 217-524-7478.
Theresa A. Eagleson, Administrator
Division of Medical Programs
