Ill. Admin. Code tit. 89, § 500.115 - Service Provider Requirements

Service providers shall:

a) Not bill families for authorized EI services.

b) Participate in evaluation/assessment activities and the development, review and revision of IFSPs in a timely and comprehensive manner, and provide EI services in a family centered, ethical and culturally competent manner. Family members are to be an integral part of service planning, the child's participation in EI services, and the outcomes identified in the IFSP.

c) Provide accurate services as set forth in the IFSP in a timely manner.

d) Contact the Service Coordinator to request multidisciplinary team approval for proposed changes in the delivery of services to eligible children and to request parental consent prior to implementing any changes to services listed on the IFSP.

e) Agree that they shall not bill or receive reimbursement from the Department's centralized billing system for services in excess of what is authorized in the IFSP.

f) Agree not to terminate services for an eligible child without written notification to the child's Service Coordinator and family at least 30 days prior to the anticipated date of service termination.

g) Meet and maintain all applicable standards and regulations for individual and program licensure, certification and credentialing. Comply with all applicable State and federal laws and regulations for physical facilities in which services are made available.

h) Provide evaluation reports and direct service reports to the Service Coordinator as required by this Part and as necessary to the provision of EI services consistent with federal and State requirements.

i) Submit invoice of charges for billable services following service delivery, according to Department billing requirements.

j) With the parent's informed consent to use private insurance, unless an exemption is granted to a family, bill private insurance and/or any and all other third party payors before submitting invoices for EI reimbursement.

1) Bill the child's insurance carrier for each unit of EI service for which coverage may be available.

2) When the service is not exempted, providers who receive a denial of payment on the basis that the service is not covered under any circumstance under the plan are not required to bill that carrier for that service again until the following insurance benefit year. That explanation of benefits denying the claim, once submitted to the central billing office, shall be sufficient to meet the requirements of this subsection (j)(2) as to subsequent services billed under the same billing code provided to that child during that insurance benefit year.

3) Any time limit on a provider's filing of a claim for payment with the central billing office that is imposed through a policy, procedure, or rule of the Department shall be suspended until the provider receives an explanation of benefits or other final determination of the claim it files with the child's insurance carrier.

4) In all instances when an insurance carrier has been billed for EI services, whether paid in full, paid in part, or denied by the carrier, the provider must provide the central billing office, within 90 days after receipt, a copy of the explanation of benefits form and other required information.

5) When the insurance carrier has denied the claim or paid an amount for the EI service billed that is less than the current State rate for EI services, the provider shall submit the explanation of benefits with a claim for payment, and the Department shall pay the provider the difference between the sum actually paid by the insurance carrier for each unit of service provided under the IFSP and the current State rate for EI services.

6) The State shall also pay the family's co-payment or co-insurance under its plan, but only to the extent that those payments plus the balance of the claim do not exceed the current State rate for EI services.

7) The provider may under no circumstances bill the family for the difference between its charge for services and that paid by the insurance carrier or by the State.

k) Allow the Department to recoup money improperly submitted to provider by:

1) offset from future reimbursements; or

2) submitting repayment in full or in installments negotiated with the Department.

l) Participate in routine monitoring and supervision activities as set forth by the Department, including self-assessment, on-site monitoring, data collection and reporting obligations, record reviews, financial audits, complaint investigation, and consumer satisfaction surveys.

m) Comply with any and all federal and State statutes and regulations, policies, guidelines, directives and procedures, including but not limited to those listed in Section 500.45(c)(7), and others that are applicable to the services being provided.

n) Provide services and communications to clients in a language or mode of communication understood by the client. If necessary, interpreters may be used.

o) Be knowledgeable about and inform families of their rights and procedural safeguards, including requirements set forth in IDEA ( 20 USC 1439 and 34 CFR 303.400 et seq.), and comply with those rights and procedural safeguard requirements.

p) Make himself/herself available as required for Due Process Hearings, Mediation and State Complaint or legal proceedings involving services under this Part.

q) Assist as required in maintaining the child's EI record at the regional intake entity.

r) The evaluators/assessors shall meet criteria as set forth in this Part.

1) Evaluators/assessors shall attend additional training as set forth by the Department and shall agree in writing to operate within the framework of the DHS EI philosophy and best practices, prior to being authorized to perform and bill for evaluations and assessments.

2) In order to be paid for an evaluation/assessment, evaluators/assessors shall meet all deadlines for submitting evaluations/assessments as set forth in this Part and in the EI Service Provider Agreement.

3) Evaluators/assessors shall participate in the IFSP meeting, for which they will be reimbursed. The meeting shall be held within 45 days after the child is referred to the system, unless there is a delay over which they have no control.

Notes

Ill. Admin. Code tit. 89, § 500.115

Amended at 38 Ill. Reg. 11086, effective 5/12/2014