Section 140.400 Payment to Practitioners

Section 140

Section 140.400  Payment to

Practitioners

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

ering 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

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

)         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

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.