Current through Register Vol. 48, No. 38, September 20, 2024
a)
This Section applies to physicians, dentists, Advanced Practice Registered
Nurses (APRN) (see Section
140.435), optometrists,
podiatrists, chiropractors, Licensed Clinical Psychologists (LCP) (see Section
140.423) and Licensed Clinical
Social Workers (LCSW) (see Section
140.424).
1) Practitioners are required to bill the
Medical Assistance Program at the same rate they charge patients paying their
own bills and patients covered by other third party payers.
2) A practitioner may bill only for services
the practitioner personally provides or that are provided, under the
practitioner's supervision, or by the practitioner's staff, except as provided
in subsection (f). An APRN, as described in Section 140.435, LCP, as described
in Section 140.423, or LCSW, as described in Section 140.424, may bill only for
the services the practitioner personally provided.
3) Payment will be made only in the
practitioner's name or a Department approved alternate payee.
4) Except as described otherwise in this
Section, payments will be made according to a schedule of statewide pricing
screens established by the Department, except that LCP and LCSW will be
reimbursed for covered services at 75% of the physician reimbursement rate.
Covered services provided by qualifying providers under the Maternal and Child
Health Program will be reimbursed at enhanced rates as described in subsection
(b). The pricing screens are to be established based on consideration of the
market value of the service. In considering the market value, the Department
will examine the costs of operations and material. Input from advisory groups
designated by statute, generally recognized provider interest groups and the
general public will be taken into consideration in determining the allocation
of available funds to rate adjustments. Increases in rates are contingent upon
funds appropriated by the General Assembly. Reductions or increases may be
affected by changes in the market place or changes in funding available for the
Medical Assistance Program. Screens will be related to the average statewide
charge. Except as described otherwise in this Section, the upper limit for
services shall not exceed the lowest Medicare charge levels.
b) Practitioners who meet the
qualifications for and enter into a Primary Care Provider Agreement for
participation in the Maternal and Child Health Program, as described in Subpart
G, will receive enhanced reimbursement in accordance with Section
140.930(a)(1).
c) For services rendered on or after June 1,
2013, a practitioner (radiologist) that meets the qualifications for and
participates in the Department's Breast Cancer Quality Screening and Treatment
Initiative shall be paid for mammography services at the effective Chicago
Metropolitan Area Medicare Level established rate (Established Rate). To
qualify for this Established Rate, a practitioner shall:
1) Enter into a Supplemental Provider
Agreement with the Department; and
2) Provide mammography services to
participants in the Department's Medical Programs with the same timeliness as
the practitioner provides to patients with other forms of insurance;
3) Within 30 days after submitting the
Supplemental Provider Agreement, and annually thereafter on or before August
31, submit a completed radiologist survey, using the Department's survey form;
and
4) Assist the Department with
the development and implementation of improved quality standards and
services.
d) The
Department will distribute (initially and upon revision of the amounts) to
practitioners the maximum allowable amounts for the most commonly billed
procedures codes. Interested individuals may request a copy of the maximum
allowable amounts from the Department by directing the request to the Bureau of
Professional and Ancillary Services, Prescott E. Bloom Building, 201 South
Grand Avenue East, Springfield, Illinois 62763-0001. In addition, a
participating individual practitioner may request the maximum allowable amounts
for less commonly billed specific procedures that relate to the individual's
practice. This request must be in writing and identify specific procedure codes
and associated descriptions.
e)
Supplemental payments to universities for certain practitioner services
1) Supplemental payments are available for
services that are provided by practitioners who are employed by an Illinois
public university and are providing services eligible for payment under Titles
XIX and XXI of the Social Security Act.
A) For
dates of service on or after September 1, 2020, supplemental payment will be
made on a quarterly basis as described in this subsection (e).
B) Supplemental payments under this
subsection (e) are subject to federal approval.
C) Supplemental payments shall be funded
through cooperative agreements between the Department and the State
university.
2)
Definitions
A) "Average Commercial Rate" means
the average contractually defined payment amount paid to the university for
practitioner services, including patient share amounts, for each CPT code. This
average shall be based on the participating university's payments from the five
largest private insurance carriers for CPT services.
B) "Average Commercial Payment Ceiling" means
the following computation:
i) Multiplying the
Average Commercial Rate by the number of paid claims provided in a quarter and
paid to the university for clients eligible under Titles XIX and XXI of the
Social Security Act.
ii) Summing
the products for all procedure codes as described in subsection
(e)(2)(B)(i).
3) The supplemental payments shall be
determined as follows:
A) The supplemental
payment to the university shall equal the current period payment ceiling at the
Medicare Equivalent of the Average Commercial Rate less all payments otherwise
made by the Department for the same services for procedure codes rendered in
the current period and paid to the university. These supplemental payments
shall be based on all available payments and adjustments on file with the
Department at the time the payment amount is determined.
B) The sum of payments made for each
qualifying CPT service shall not exceed the Average Commercial Rate
Ceiling.
4) Periodic
Updates to the Base Period Medicare Equivalent of the Average Commercial Rate:
The Department shall update the Average Commercial Rate annually, using the
most recent data available.
f) The Department will make payment to a
provider for services provided by a substitute physician when the substitute
physician is performing the duties of a qualified attending physician, and all
of the following conditions are met:
1) The
attending physician is ill, on vacation, or otherwise unavailable because of an
emergency situation;
2) The
substitute physician is a Doctor of Medicine (M.D.) or Osteopathy (D.O.) who
holds a license to practice medicine in all its branches;
3) The substitute practitioner is not
terminated, suspended, barred or otherwise excluded from participation or has
not voluntarily withdrawn from the Medical Assistance Program as part of a
settlement agreement; and
4) The
substitution does not exceed 14 days for a single incident and up to a maximum
of 90 days per year for the attending physician. If the substitute period
extends beyond the 14 days per single incident, the substitute physician must
enroll with the Department.
