TITLE 89: SOCIAL SERVICES
CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES
SUBCHAPTER d: MEDICAL PROGRAMS
PART 140 MEDICAL PAYMENT
SECTION 140.400 PAYMENT TO PRACTITIONERS


 

Section 140.400  Payment to Practitioners

 

a)         This Section applies to physicians, dentists, Advanced Practice Nurses (APN) (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 he or she personally provides or that are provided, under his or her supervision, by his or her staff.  An APN, 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 he or she 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; and

 

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 Comprehensive Health 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 services eligible under Titles XIX and XXI of the Social Security Act.

 

A)        For dates of service on or after April 1, 2009, 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 Fee Schedule" means the average commercial fee schedule 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)        "Base Period Average Commercial Payment Ceiling" means the following computation:

 

i)          Multiplying the Average Commercial Fee Schedule by the number of paid claims provided in the base period 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).

 

C)        "Base Period Medicare Equivalent Payment Ceiling" means the following computation:

 

i)          Multiplying the Medicare allowed rate as reported in the April release of the Resources Based Relative Value Scale (RBRVS), by the number of paid claims provided in the based period and paid to the university for clients eligible under Title XIX or XXI of the Social Security Act.

 

ii)         Summing the products for all procedure codes as described in subsection (e)(2)(C)(i) of this Section.

 

D)        "Base Period Medicare Equivalent of the Average Commercial Rate" means the Base Period Average Commercial Payment Ceiling divided by the Base Period Medicare Equivalent Payment Ceiling.

 

3)         The supplemental payments shall be determined as follows:

 

A)        The Medicare Equivalent of the Average Commercial Rate for a practitioner service will be determined by multiplying the Base Period Medicare Equivalent of the Average Commercial Rate by the Medicare payment at the non-facility rate per CPT code for the current period.

 

B)        The rates determined in subsection (e)(3)(A) are multiplied by the number of claims for the current period, as reported through the Medicaid Management Information System, to determine the current period supplemental payment ceiling.

 

C)        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.

 

4)         Periodic Updates to the Base Period Medicare Equivalent of the Average Commercial Rate:  The Department shall update this ratio at least every three years.

 

(Source:  Amended at 41 Ill. Reg. 7526, effective June 15, 2017)