service grid by site

N:/MM/REFERRAL MANAGEMENT/Service Grid by Site 04/08/2023

Elmcare, LLC TID # 36-3994179

P.O. Box 7759, Westchester, IL 60154 Health Plan Precert

Customer Service # : 708-432-4050 Medical Leadership Review

SERVICES HUMANA

ABORTION Planned Parenthood

ACUPUNCTURE See ED/PR See ED/PR See ED/PR

AMBULANCE Vandenburg

BARIATRIC Not A Covered Benefit

Cardiac Svc/Angioplasty/CABG Elmhurst Memorial Hospital Elmhurst Memorial Hospital Elmhurst Memorial Hospital

CHEMOTHERAPY

CHIROPRACTIC

COLONOSCOPY SCREENINGConsult not required Consult not required Consult not required

COLONOSCOPY DIAGNOSTICConsult required Consult required Consult required

CT SCAN

CT SCAN - 64 SLICE

BLOOD TRANSFUSION Green Green Green

DIALYSIS See Appendix E

DURABLE MED. EQUIPMENT/SUP.

EEG - 24 HOUR Tertiary Tertiary Tertiary

N/A N/A N/A

HMOI/BADV # 312

Aetna (ELMO) Self-Funded Employer

Plan

Check Benefit See BCBS

Contracted Vendor List

Check Benefit Per Healthplan

Superior (708) 832-2000 or ANY Contracted Ambulance

Chicago Ambulance Alliance (800) 558-6050

UIC Dr. Joseph Vitello Dr.

Carlos Galvani Dr. Subhashini Ayloo

UIC Dr. Joseph Vitello

Dr. Carlos Galvani

Dr. Subhashini Ayloo

Elmhurst Memorial Hospital Green

Elmhurst Memorial Hospital Red


Dr. Jevitz (630) 834-3391

Dr. Jevitz (630) 834-3391

Dr. Jevitz (630) 834-3391

Colonoscopy @ Hospital






Elmhurst Memorial Hospital

Green


Green


Green

Elmhurst Memorial Hospital Only if ordered

by Cardiologist Red

Elmhurst Memorial Hospital Only if ordered by Cardiologist Red

Elmhurst Memorial Hospital Only if ordered by Cardiologist Red

Per Health Plan (800) 626-2698

Renal Care Group of Villa Park DuPage Peritoneal

The first preferred DME is: Action 630-758-7000 Dependicare (800) 224-7404 Walgreens (800) 323-2828 or

ANY Contracted DME Vendor

Walgreens Home Medical (800) 323-2828

Action - if not see Aetna list (Attached)

Group Allows Specialists to Request Referrals





SERVICES HUMANAHMOI/BADV # 312


Plan

GREEN REFERRAL PROCESS Script with Elmcare stamp/sticker Script with Elmcare stamp/sticker Script with Elmcare stamp/sticker

GYNECOLOGICAL ONCOLOGY

HEARING AIDS Not Covered

HIGH RISK MATERNITY

HOME HEALTH CARE Advocate

IMMUNIZATIONS - TRAVEL

INFERTILITY

INPATIENT ADMISSIONS Elmhurst Memorial Hospital Elmhurst Memorial Hospital Elmhurst Memorial Hospital

INPATIENT ADMISSIONS-PSYCH

IV THERAPY Elmhurst Memorial Hospital Elmhurst Memorial Hospital Elmhurst Memorial Hospital

LITHOTRIPSY United Shockwave United Shockwave United Shockwave

MENTAL HEALTH Not Managed by Namm

MRI'S

MRI'S (OPEN)

MRA Green Green Green

NON-COMPLIANCE POLICY Yes - Bring to E.D. Yes - Bring to E.D. Yes - Bring to E.D.

Drs. Ronald Potkul and Donna Smith @ Loyola / Red



Check Benefits Per BCBS -

Hearing aids may be obtained from any vendor

Check Benefits Contracted Vendor

Lutheran General Providers Loyola Maternal Fetal Medicine



Elmhurst Home Health (or see attached list)

Elmhurst Home Health (or see attached list)

Loyola University Medical Center Public Health Department

Check Benefit Loyola University Medical Center Public Health Department

Check Benefit Loyola University Medical Center Public Health Department

Check Scope of Benefits Call for Benefits See Health Plan Prov. List

Fax the completed Humana Form/ Fertility Centers of Illinois

Enter in system as 99999 Patient to call 800-575-5999

Adult: Alexian Brothers Children: 1) Lutheran General 2) Alexian Brothers 3) Linden Oaks

See All red list Inpt. Peds at Lutheran

General

Self Refer (800) 331-9040




Midwest Imaging Red

Midwest Imaging Red

Midwest Imaging Red







Plan

NUTRITIONAL COUNSELING Green Referral Green Referral Green Referral

OBSERVATION - 23 HOUR Elmhurst Memorial Hospital Elmhurst Memorial Hospital Elmhurst Memorial Hospital

OPTOMETRY

OUTPATIENT LABS

OUTPATIENT PHP/IOP Elmhurst Memorial Hospital Not Managed Not Managed

OUTPATIENT SURGICAL PROCS

PACEMAKER CHECKS

PAIN MGMT CORTISONE

EPIDURAL INJECTIONS

PET SCANS

PULMONARY REHABILITATION Elmhurst Memorial Hospital Elmhurst Memorial Hospital Elmhurst Memorial Hospital

RADIATION THERAPY

SKILLED NURSING FACILITY Elmhurst Extended Care

SLEEP STUDY - ADULT

SLEEP STUDY - PEDS.

STERILIZATION Vasectomy Check benefit Check benefit Covered - Hospital

Tubal Ligation Check benefit Check benefit Covered - Hospital

SUBSTANCE ABUSE

Davis Vision (877)-393-8844 (effective 07/01/08)

Cole Vision Self Refer (800) 334-7591


ORTHOTIC/PROSTHETIC (See L Code List)

Scheck & Siress Hanger Prosthetic & Orthotics

MD Orthotics


MD Orthotics

Elmhurst Clinic or

Aetna provider

Elmhurst Hospital Elmhurst Clinic



Elmhurst Memorial Hospital Elmhurst OP Surgical Center

Check Appendix B



PODS ADE - Midwest Heart/Green PODS B-Elmhurst Clinic/Green

If Cross PODS, becomes a Red





In the office of ORS/RHU Green



Given by Pain Clinic Spec. at EOSC or EMH



Medical Out Sourcing @Elmhurst Memorial Hospital




Elmhurst Memorial Hospital Red


Elmhurst Memorial Hospital Skilled Nursing Facility Or Manor Care

Elmhurst Memorial Hospital Skilled Nursing Facility Or Manor Care

Elmhurst Memorial Hospital (Green Referral)



Loyola University Medical Center Lutheran General Hospital



Not Managed by Namm Call Health Plan









Plan

SYNAGIS

SYNVISC

TERTIARY HOSPITALS - ADULT

TERTIARY HOSPITALS - PEDS.

THERAPY - OCCUPATIONAL

THERAPY - PEDS. PT/OT/ST

THERAPY - PHYSICAL

THERAPY - SPEECH

TRANSPLANTS

TRANSPORTATION N/A N/A N/A

X-rays Allowed in Ortho. Office

XOLAIR Care Mark Therapeutics Care Mark Therapeutics Care Mark Therapeutics

Loyola University Physician Foundation - #800003Loyola University Medical Center - #200038

Durable Medical Equipment - Aetna Website: www.aetna.com/docfind/home.doESWT for Podiatry is a Non-Covered Benefit for ELMO

***THIS IS NOT AN ALL-INCLUSIVE LISTING

Ultra Care Elmhurst Mem Hosp.

Infusion Ctr Medical review if no Milliman

Ultra Care Elmhurst Mem Hosp. Infusion Ctr Medical review if no

Milliman

Ultra Care Elmhurst Mem Hosp. Infusion Ctr Medical review if no

Milliman

Ortho (Green)

Injection (Red)

Ortho (Green) Injection

(Red)

Ortho (Green)

Injection (Red)

Lutheran General Hospital, Loyola, Rush (See list if Ortho), or University

of Illinois Loyola Physician Foundation- #800003

Loyola Medical Center- #200038


of Illinois


of Illinois

Lutheran Generan Hospital, Loyola, Rush, University of Illinois, Advocate

Hope Children's

Lutheran General Hospital, Loyola, Rush, University of Illinois, Advocate

Hope Children's

Lutheran General Hospital, Loyola, Rush, University of Illinois, Advocate

Hope Children's

THALLIUM STRESS TEST (Red or Green referral)




Elmhurst Memorial Hospital Elmhurst

Rehab

Elmhurst Memorial Hospital Elmhurst Rehab


Elmhurst Memorial Hospital / Loyola University Medical Center

Lutheran General Hospital











See Scope of Benefits Audrey Johnson-Tarver

(312) 997-6615 Fax (312) 938-4682

Per Healthplan (800) 626-2698

Per Aetna Network (877) 212-8811

X-rays Allowed in Ortho Office (Fracture Care)

Yes

Yes

Yes

Yes

Yes

Yes







Plan


Health Options of Illinois TID # 36-3680139



SERVICES

ABORTION

ACUPUNCTURE

AMBULANCE Any contracted ambulance

Dr. Michael Scheer @ Vista East

BLOOD TRANSFUSION Red

Cardiac Svc/Angioplasty/CABG Vista East

CHEMOTHERAPY

CHIROPRACTIC

COLONOSCOPY SCREENING

COLONOSCOPY DIAGNOSTIC

CT SCAN

CT SCAN 64 SLICE Vista East

DIALYSIS See Appendix E

DURABLE MED. EQUIPMENT/SUP. Any contracted DME vendor

EEG - 24 HOUR Vista East


HMOI/BADV # 275

Check Benefit See BCBS Contracted Vendor List

Lewis Chiropractic Center (847) 336-3400

BARIATRIC - MUST MEET MILLIMAN SURGICAL CRITERIA AND HOI GUIDELINES PRIOR TO CONSULT (CONSULT-RED REFERRAL)

Dr. Mehta, Dr. Kapadia Check BCBS self injection drug list, if MD is requesting a drug code on the list, please "O" note

self inj. not covered under referral. Member to obtain drug through pharmacy benefit

Lewis Chiropractic Center (847) 336-3400

Consult not required if over 50 Colonoscopy @

Hospital (HP Pre-cert not required)

Consult required (Red) Colonoscopy at Hospital

(HP Pre-cert not required)

Vista East or Vista West Green

OB/GYN Only (May only refer to selected specialties--See

Attached)





SERVICES HMOI/BADV # 275

GREEN REFERRAL PROCESS

GYNECOLOGICAL ONCOLOGY NorthShore University / Red

HEARING AIDS

HIGH RISK MATERNITY NorthShore University HealthSystem

HOME HEALTH CARE Per BCBS List


INFERTILITY

INPATIENT ADMISSIONS

IV THERAPY Vista East

LITHOTRIPSY

MENTAL HEALTH Outpatient - See Red List

Inpt-Vista East and Vista West

MRI'S

MRI'S (OPEN)

MRA Red

NON-COMPLIANCE POLICY Yes

NUTRITIONAL COUNSELING Red Referral

OBSERVATION - 23 HOUR Vista East

Check Benefits Per BCBS - Hearing aids may be obtained

from any vendor

Passport Health - Gurnee (888) 499-7277

Check Scope of Benefits Call for Benefits

See Health Plan Prov. List

Vista East / Vista West

United Shockwave (Has a unit at Condell Hospital that bills

under United Shockwave)

MRI Institute Only if criteria not met

Vista MRI Institute Only if criteria not met






OPTOMETRY

Any contracted vendor

INPATIENT LABS

OUTPATIENT PHP/IOP N/A


PACEMAKER CHECKS

PAIN MANAGEMENT CORTISONE

EPIDURAL INJECTIONS

PET SCANS Vista West MRI

PULMONARY REHABILITATION Vista East

RADIATION THERAPY

SKILLED NURSING FACILITY Per BCBS List

SLEEP STUDY - ADULT Vista East

SLEEP STUDY - PEDS. Children's Hospital of Wisconsin

STERILIZATION Vasectomy

Tubal Ligation

SUBSTANCE ABUSE

SYNAGIS Ultra Care or Peds Office

SYNVISC Ortho Office

Davis Vision (877) 393-8844

(effective 07/01/08)

ORTHOTIC/PROSTHETIC (See L code List)

Quest Vista East -

STAT only

Vista East (Victory) or Vista Surgical & Tx Ctr. Only if criteria not met check Appendix B

Cardiac E.P. Consultants, SC Red

In the office of ORS Red

In the office of Dr. Arber Red

Dr. Kurup Dr. Mehta

Check Benefit In the office of Dr. Khan

Check Benefit Vista East

Not Managed by NAMM Contact Healthplan








THERAPY - OCCUPATIONAL Vista Physical Medicine

THERAPY - PEDS. PT/OT/ST Vista Physical Medicine

THERAPY - PHYSICAL Vista Physical Medicine

THERAPY - SPEECH Vista Physical Medicine

TRANSPLANTS

TRANSPORTATION N/A

Yes

X-rays Allowed in Ortho. Office No

XOLAIR Walgreens


Northshore University Health System

Northshore University Health System Children's Hospital of Wisconsin--See

Attached


Vista East Green

See Scope of benefits Audrey Johnson-Tarver

312-997-6615 Fax 312-938-4682


N:/MM/REFERRAL MANAGEMENT//Service Grid by Site 04/08/2023

Hinsdale Physicians Healthcare TID # 36-3851702



SERVICES HUMANA UNICARE

ABORTION

ACUPUNCTURE

AMBULANCE Superior (708) 832-2000

BARIATRIC Loyola University Medical Center Loyola University Medical Center Loyola University Medical Center

Cardiac Svc/Angioplasty/CABG

CHEMOTHERAPY

CHIROPRACTIC See Red List

COLONOSCOPY SCREENINGConsult Required (Green) Consult Required (Green) Consult Required (Green)

Colonoscopy @ Hospital Colonoscopy @ Hospital Colonoscopy @ Hospital

COLONOSCOPY DIAGNOSTICConsult Required (Green) Consult Required (Green) Consult Required (Green)


CT SCAN

CT SCAN - 64 SLICE

BLOOD TRANSFUSION Red Red Red

DIALYSIS See Appendix E Per Health Plan Per Health Plan


EEG - 24 HOUR

GREEN REFERRAL PROCESS Patient obtains Green Referral Patient obtains Green Referral Patient obtains Green Referral

HMOI/BADV # 257

Check Benefit See BCBS Contracted

Vendor List



Dr. Xlaoping Xu (630) 655-9988

Check Benefit Dr. Xlaoping Xu

(630) 655-9988

Check Benefit Dr. Xlaoping Xu

(630) 655-9988

Superior (708-832-2000) or ANY Contracted Ambulance


Hinsdale Hospital LaGrange Hospital



HPH Hematology/Onc Specialist

Green


Green


Green

Check Benefit See Red List

Check Benefit See Red List


Glen Oaks Medical Center Bolingbrook

(Green)



(Green)



(Green)

Cardiologist or contracted Hospital Green



Dependicare (800) 224-7404 Walgreens (800) 323-2828 or

Any Contracted DME Vendor


Check Benefit <$1000 No precert needed Dependicare/Walgreens

Hinsdale Hospital LaGrange Hospital Glen Oaks Medical Center Bolingbrook

(Red)


(Red)


(Red)


Yes - Capitated Specialists Only (Green List) Ortho - only for diagnostics May only refer for diagnostics at the Hospital & for procedures they are performing themselves





SERVICES HUMANA UNICAREHMOI/BADV # 257


HEARING AIDS

HIGH RISK MATERNITY

HOME HEALTH CARE Advocate HHC (800) 564-2025

IMMUNIZATIONS - TRAVEL Loyola University Medical Center

INFERTILITY

INPATIENT ADMISSIONS

IV THERAPY

LITHOTRIPSY United Shockwave United Shockwave United Shockwave

MENTAL HEALTH

MRI'S

MRI'S (OPEN)


NON-COMPLIANCE POLICY Yes Yes Yes

NUTRITIONAL COUNSELING

Drs. Sameer Sharma and Sudarshan Sharma @ Hinsdale / Red



Check Benefits Per BCBS - Hearing aids may be obtained from any vendor



Dr. Daniel Gauthier - Hinsdale Hospital (630) 856-6741 (For Dr. Gauthier, when entering Auth for Maternal Fetal Medicine the place of service is 22)

Dr. Meyer--Hinsdale Hospital

Health Care at Home (630) 856-6901 Orsini (847) 734-7373

Orsini (847) 734-7373 Chartwell (infusion) (800) 551-9355

Ultracare (800) 222-9444

Check Benefit Loyola University Medical Center

Check Benefit Loyola University Medical Center



Fax the completed Humana Form Fertility Centers of Illinois

Contact Unicare - HPH does not manage

INFUSION SERVICES - IVIG AND REMICADE

Coram Specialty Infusion Services (Effective May 13th). Coram nurse /

PCP to determine care setting.

Hinsdale Hospital LaGrange Hospital Glen Oaks Medical Center

Adventist Bolingbrook Hospital





PsycHealth Self Refer

(800) 753-5456

Mental Health Specialty Services Self Refer (800) 331-9040

Wellpoint Self Refer (800) 746-6294

Hinsdale Hospital (Hinsdale Ortho in off. without authorization) LaGrange Hospital Glen Oaks Medical Center Bolingbrook

(Green)

Hinsdale Hospital (Hinsdale Ortho in off. without authorization) LaGrange Hospital Glen Oaks Medical Center Bolingbrook

(Green)

Hinsdale Hospital (Hinsdale Ortho in off. without authorization)

LaGrange Hospital Glen Oaks Medical Center Bolingbrook

(Green)

Oakbrook MRI dba Open Advanced MRI of Oakbrook/Westbrook Open MRI/Midwest Imaging, Molecular

Imaging


Imaging


Imaging

Oakbrook Health and Nutrition Dr. Ghani or Dr. Auriemma








OBSERVATION - 23 HOUR

OPTOMETRY

Scheck & Siress

OUTPATIENT LABS

OUTPATIENT PHP/IOP


PACEMAKER CHECKS

PAIN MGMT CORTISONE

EPIDURAL INJECTIONS

PEDIATRIC PT/OT/ST

PET SCANS

PULMONARY REHABILITATION Hinsdale Hospital Hinsdale Hospital Hinsdale Hospital

RADIATION THERAPY

SKILLED NURSING FACILITY

SLEEP STUDY - ADULT












Scheck & Siress Hanger Prosthetics & Orthotics

MD Orthotics

Scheck & Siress Hanger Prosthetics & Orthotics

Quest Diagnostics Hinsdale Hospital LaGrange Hospital Glen Oaks Medical Center Bolingbrook Hospital

Quest Diagnostics Hinsdale Hospital LaGrange Hospital Glen Oaks Medical Center Bolingbrook Hospital

Quest Diagnostics Hinsdale Hospital

LaGrange Hospital Glen Oaks Medical Center

Bolingbrook Hospital

Hinsdale Hospital LaGrange Hospital Glen Oaks Medical Center Bolingbrook Med. Ctr Hinsdale Surgical Ctr. Westmont Surgical Ctr. (Can only

be used by Hinsdale Ortho) Check Appendix B

Hinsdale Hospital LaGrange Hospital Glen Oaks Medical Center Bolingbrook Med. Ctr Hinsdale Surgical Ctr. Westmont Surgical Ctr. (Can only

be used by Hinsdale Ortho)

Hinsdale Hospital LaGrange Hospital Glen Oaks Medical Center Bolingbrook Med. Ctr Hinsdale Surgical Ctr. Westmont Surgical Ctr. (Can only be

used by Hinsdale Ortho)

Highland Pacemaker Clinic Red



In the office of ORS Red Referral



Any Adventist facility Red Referral, review after

3rd inj.

In the office of Pain Spec. Red Referral

In the office of Pain Spec. Red Referral

Hinsdale Orthopaedics can provide Occupational & Physical Therapy services in their office. (They can also call in thier own requests) Effective

3/10/2009--RED REFERRAL, Diagnosis of Autism - 20 initial visits, otherwise 10 initial visits. Auth good for 60 days. Medical Director review required after completion of initial visits. If services are not available @ Paulsen

Rehab or Glen Oaks: Loyola (708) 216-9000 or Milestones (630)

792-1800

Molecular Imag., Regional PET Imaging, DBA-Hinsdale PET Scan,

LLC If no Milliman, needs review





LaGrange Hosp - Dr. Awan Hinsdale Hosp. - Dr. Feinstein

Green Referral


Green Referral


Green Referral

Manor Care Hinsdale(630) 325-9630 Manor Care Westmont(630)323-4400

Burgess Sq. Westmont(630) 971-2645

Manor Care Hinsdale(630) 325-9630 Manor Care Westmont(630)323-4400

Multiple Vendors including the Manor Care Facilities

Call Case Management

Hinsdale Hospital LaGrange Hospital Glen Oaks Medical Center Bolingbrook Hospital

Green


Green


Green






SLEEP STUDY - PEDS. Rush University Medical Center Rush University Medical Center

STERILIZATION: Vasectomy Check Benefit

Tubal Ligation Check Benefit

SUBSTANCE ABUSE

SYNAGIS

SYNVISC




THERAPY - PHYSICAL

THERAPY - SPEECH

TRANSPLANTS


X-rays Allowed in Ortho. Office Hinsadale Ortho Only Hinsadale Ortho Only Hinsadale Ortho Only

XOLAIR


*Please note that HPH PODS Leaders may review their partners' referrals. Referrals for their own members must be reviewed by the Medical Director.

Loyola University Medical Center University of Chicago Hospital





Not managed by Namm Call (800) 346-

3986

Not managed by Namm Call Healthplan

Not managed by Namm Call Healthplan

McKesson Ultra Care

Green

McKesson Ultra Care

Green

McKesson Ultra Care

Green

Ortho Office or PCP Office Injection ordered through

Ultracare


Ultracare


Ultracare

Loyola University Medical Center Rush University Medical Center University of Chicago Hospital


Loyola University Medical Center University of Chicago Hospital


Loyola University Medical Center University of

Chicago Hospital

Rush University Medical Center

Loyola University Medical Center

University of Chicago Hospital


Cardiologist or Hospital Illinois Heart & Vascular

Green


Green


Green

Hinsdale Orthopaedics can provide Occupational & Physical Therapy services in their office. (They can also call in thier own requests) Effective 3/10/2009--RED REFERRAL,

Post-Op Joint Replacement - 16 initial visits, Post-Op (Not Joint Replacement) - 10 initial visits, Back Pain - 6 initial visits. Auth good for 60 days. Medical Director review required after completion of initial visits. Paulsen Rehab Glen Oaks Sports & Spine LaGrange - Westbrook - Bolingbrook


(312) 997-6615 Fax (312) 938-4682



X-Rays Allowed in Ortho Office (Fracture Care)

Yes (3 visits, 1 x-

ray and casting)

Yes (3 visits, 1 x-

ray and casting)

Yes (3 visits, 1 x-ray

and casting)

McKesson Walgreens Ultracare



N:MM/REFERRAL MANAGEMENT/Service Grid by Site 04/08/2023

Holy Cross Health Partners TID # 36-4109153

P.O. Box 7488, Westchester, IL 60154

Customer Service # : 708-432-1620 Health Plan Precert

Medical Leadership Review

SERVICES UNICARE

ABORTION Must call Unicare for Auth (888) 234-8855

ACUPUNCTURE See PR for Letter of Agreement See PR for Letter of Agreement


BARIATRIC Dr. Ayloo @ U IC Dr. Ayloo @ U IC

BLOOD TRANSFUSION Red Red


CHEMOTHERAPY

CHIROPRACTIC See PR for Letter of Agreement See PR for Letter of Agreement

COLONOSCOPY SCREENINGConsult required (Green) Consult required (Green)

Colonoscopy @ Hospital Colonoscopy @ Hospital

COLONSCOPY DIAGNOSTICConsult required (Green) Consult required (Green)


CT SCAN

CT SCAN - 64 SLICE Advocate Illinois Masonic Advocate Illinois Masonic

DIALYSIS See Appendix E Per Health Plan

DURABLE MED EQUIPMENT/SUP

EEG - 24 HOUR U of C U of C

Office or Hospital Setting (Red Referral)Office Setting (Red Referral)

Hospital Setting (Red Referral)

HMOI/BADV # 334

Self Refer (312) 653-6600

Superior (708-832-2000) or Any Contracted Ambulance

Advocate Ill. Masonic Med. Ctr. U of C and UIC

Advocate Ill. Masonic Med. Ctr. U of C and UIC

HCHP Physician's Office (Green) Holy Cross Hospital (Red)

HCHP Physician's Office (Green) Holy Cross Hospital (Red)

Holy Cross Hospital Green


Integrated Dependicare(800) 224-7404 Walgreens (800) 323-2828

or Any Contracted DME

Check Benefit, <$1000 No precert needed

Dependicare/Walgreens

ENDOSCOPIES (INCLUDING CAPSULE ENDOSCOPIES)


Yes, In-network providers and home hospital only

Yes, In-network providers and home hospital only






SERVICES UNICAREHMOI/BADV # 334

GREEN REFERRAL PROCESS Script with Stamp Script with Stamp

GYNECOLOGICAL ONCOLOGY Dr. Yvonne Collins @ U I C / Red Dr. Yvonne Collins @ U I C / Red

HEARING AIDS

HIGH RISK MATERNITY

HOME HEALTH CARE

IMMUNIZATIONS - TRAVEL UIC Travel Clinic

INFERTILITY

INPATIENT ADMISSIONS Holy Cross Hospital

IV THERAPY Ultracare

LITHOTRIPSY United Shockwave United Shockwave

MENTAL HEALTH

MRI'S

MRI'S (OPEN)

MRA Green Green

NON-COMPLIANCE POLICY Yes Yes

NUTRITIONAL COUNSELING Red Referral Red Referral

Check Benefits Per BCBS - Hearing aids may be

obtained from any vendor


University of Chicago University of Illinois

University of Chicago University of Illinois

Refer to HMOI Contracted Providers

Must call Unicare for Auth (888) 234-8855

Check Benefit UIC Travel Clinic





Coram Specialty Infusion Services (Effective May 13th). Coram nurse / PCP to determine

care setting.

Holy Cross Hospital (Dr. Alston can deliver babies @ St.

Bernard and/or Trinity Hospital - Red Referral)



(800) 753-5456

Wellpoint Self Refer

(800) 746-6294



Regional MRI Preferred Open MRI

Regional MRI Preferred Open MRI







OBSERVATION - 23 HOUR Holy Cross Hospital Holy Cross Hospital

OPTOMETRY

OUTPATIENT LABS

OUTPATIENT PHP/IOP

OUTPATIENT SURGICAL PROCS Holy Cross Hospital

PACEMAKER CHECKS

PAIN MGMT CORTISONE In the Office of ORS/POD/AN In the Office of ORS/POD/AN

EPIDURAL INJECTIONS In the Office of Dr. Singa/AN In the Office of Dr. Singa/AN

PET SCANS Lake Shore PET Imaging or Life Scan Chicago Lake Shore PET Imaging or Life Scan Chicago

PULMONARY REHABILITATION U of C U of C

RADIATION THERAPY


SLEEP STUDY - ADULT Southwest Sleep Center Southwest Sleep Center

SLEEP STUDY - PEDS U of C U of C

STERILIZATION Vasectomy Check Benefit Check Benefit

Tubal Ligation Check Benefit Check Benefit

SUBSTANCE ABUSE



Self Refer Per Plan Vision Rider

ORTHOTIC/PROSTHETIC (See L code list)

Scheck & Siress Hanger Prosthetic & Orthotics, MD

Orthotics, Contracted physicians

Must call Unicare for Auth (888) 234-8855

Holy Cross Hospital (Green)


Holy Cross Hospital Check Appendix B



Radiation Therapy Consultants, Ltd.

Radiation Therapy Consultants, Ltd.

Refer to HMOI Contracted Providers:

Renaissance of Midway

Must call Unicare for Auth (888)

234-8855

Not Managed by NAMM Call Health Plan

No Managed by NAMM Call Health Plan







SYNAGIS

SYNVISC


TERTIARY HOSPITALS - PEDS. University of Illinois at Chicago University of Illinois at Chicago


THERAPY - OCCUPATIONAL Maximum Rehab Services, Ltd. Maximum Rehab Services, Ltd.

THERAPY - PHYSICAL

THERAPY - SPEECH

TRANSPLANTS

TRANSPORTATION N/A N/A

Yes Yes

X-rays Allowed in Ortho. Office

XOLAIR Walgreens Walgreens


Red Referral made out to Walgreen's Home Medical Supply or Ultra Care

Red Referral made out to Walgreen's Home Medical Supply or Ultra Care

Provider is Ultracare or Walgreens Home Care

Provider is Ultracare or Walgreens Home Care

U of C UIC Advocate Illinois Masonic Medical Center (Christ Hospital-Wound Clinic

ONLY)

U of C UIC Advocate Illinois Masonic Medical Center (Christ Hospital-Wound Clinic

ONLY)

THALLIUM STRESS TEST

Holy Cross Hospital Green Referral

Holy Cross Hospital Green Referral

Holy Cross Hospital (PT & ST) University of Chgo (OT)

Holy Cross Hospital (PT & ST) University of Chgo (OT)

Holy Cross Hospital Maximum Rehab Services, Ltd. Therapy Providers (Dr. Labanauskas-Surgical Only) (Green for Holy Cross Only)

Holy Cross Hospital Maximum Rehab Services, Ltd. Therapy Providers (Dr. Labanauskas-Surgical Only) (Green for Holy Cross Only)

Holy Cross Hospital Maximum Rehab Services, Ltd.

(Green for Holy Cross only)

Holy Cross Hospital Maximum Rehab Services, Ltd.

(Green for Holy Cross only)

See Scope of Benefits Audrey Johnson-Tarver 312-997-6615 Fax

312-938-4682



No (Unless Urgent)

No (Unless

Urgent)


Ingalls Provider Group TID # 36-3485578



SERVICES UNICARE

ABORTION

ACUPUNCTURE Vaught Chiropractic


BARIATRIC Gastric Bypass

Lap Band

BLOOD TRANSFUSION

Cardiac Svc/Angioplasty/CABG Ingalls Ingalls

CHEMOTHERAPY

CHIROPRACTIC Vaught Chiropractic

COLONOSCOPY SCREENINGConsult required (Green) Consult required (Green)


COLONOSCOPY DIAGNOSTICConsult required (Green) Consult required (Green)


CT SCAN

CT SCAN - 64 SLICE Not a covered benefit Not a covered benefit



EEG- 24 HOUR Ingalls Ingalls

HMOI/BADV # 213

Check Benefit See BCBS Contracted Vender

List


Check benefits Vaught Chiropractic

Superior (708-832-2000) or ANY Contracted Ambulance

Dr. James Madura/RUSH or Dr. John Alverdy/U of C

Must complete solutions program at Ingalls Wellness Center prior to

consult

Dr. John Alverdy/U of C only Must complete solutions program at Ingalls Wellness

Center prior to consultDr. Jonathan Myers/Rush or Dr. Vivek Prachand/U of C

Must complete solutions program at Ingalls

Wellness Center prior to consult

Dr. Vivek Prachand only Must complete solutions program at Ingalls

Wellness Center prior to consult

Ingalls Green

Ingalls Green

IPG Hematology/Onc Specialist

Green

IPG Hematology/Onc Specialist

Green

Check benefits Vaught Chiropractic

Ingalls Green

Ingalls Green

Dependicare (800) 224-7404 Walgreens (800) 323-2828

Any Contracted DME Vendor

Check Benefit <$1000 No precert needed Dependicare/Walgreens


Only general surgeons, ortho for surgery, oncology

Only general surgeons, ortho for surgery, oncology







GYNECOLOGICAL ONCOLOGY Dr. Yamada @ U of C / Red

HEARING AIDS

HIGH RISK MATERNITY University of Chicago Hospital University of Chicago Hospital

HOME HEALTH CARE Refer to HMOI Contracted Vendor

IMMUNIZATIONS - TRAVEL University of Chicago Travel Clinic

INPATIENT ADMISSIONS Ingalls Ingalls

IV THERAPY Ultracare

LITHOTRIPSY

MENTAL HEALTH

MRI'S

MRI'S (OPEN)

MRA

Yes Yes


Script Usually there is a 90 day

exp. date

Script Usually there is a 90 day

exp. date

Dr. Rotmensch @ Rush and Dr. Yamada @ U of C / Red

Check Benefits Per BCBS - Hearing aids

may be obtained from any vendor


Call Unicare for Authorization 888-234-8855

Check Benefit University of Chicago Travel Clinic

INFERTILITY Semen Analysis Referrals to Fertility Centers of Illinois--Orland Park (Red Referral)



Check benefits - IPG Risk No Precert needed from Unicare


Coram Specialty Infusion Services (Effective May 13th). Coram nurse / PCP

to determine care setting.

Per Healthplan 888-234-8855

United Shockwave Ingalls T.P.

United Shockwave Ingalls T.P.


800-753-5456

Wellpoint Self Refer 800-746-6294

Ingalls Green

Ingalls Green

Ingalls Memorial Hospital Green Referral

Ingalls Memorial Hospital Green Referral

Ingalls Green

Ingalls Green

NON-COMPLIANCE POLICY (Sanction)

Ingalls Memorial Hospital Dietician Red Referral

Ingalls Memorial Hospital Dietician Red Referral






OBSERVATION- 23 HOUR Ingalls Ingalls

OPTOMETRY

OUTPATIENT LABS Ingalls Memorial Hopsital Ingalls Memorial Hopsital

OUTPATIENT PHP/IOP


PACEMAKER CHECKS

PAIN MGMT CORTISONE

EPIDURAL INJECTIONS

PET SCANS

PULMONARY REHABILITATION Ingalls Ingalls

RADIATION THERAPY

SKILLED NURSING FACILITY HMOI Contracted Providers

SLEEP STUDY - ADULT

SLEEP STUDY - PEDS.

Check Benefit


SUBSTANCE ABUSE

Davis Vision (877) 393-8844 (effective 07/01/08)

Cole Vision Self Refer

800-334-7591



MD Orthotics


MD Orthotics

Ingalls Harvey or Tinley Park Midwest Eye Surgical Center

Check Appendix B

Ingalls Harvey or Tinley Park

Ingalls Red

Ingalls Red



Drs. Holly Carobene, Howard Robinson & John Hong / Red

Drs. Holly Carobene, Howard Robinson & John Hong / Red

Ingalls Green

Ingalls Green

Ingalls Cancer Care Ctr. Tx Only-Red

Ingalls Cancer Care Ctr. Tx Only-Red

Must call Unicare for Authorization 888-234-8855

Ingalls Green

Ingalls Green

Ingalls Green

Ingalls Green

STERILIZATION: Vasectomy Semen Analysis Referrals to Fertility Centers of Illinois--Orland Park (Red Referral)



Not Managed by NAMM Call Healthplan

Not Managed by NAMM Call Healthplan






SYNAGIS Dependicare from PCP Office Dependicare from PCP Office

SYNVISC Ultracare Ultracare

TERTIARY HOSPITALS - ADULT University of Chicago

TERTIARY HOSPITALS - PEDS

THERAPY - OCCUPATIONAL Ingalls Ingalls

THERAPY - PEDS. PT/OT/ST Ingalls Ingalls

THERAPY - PHYSICAL

THERAPY - SPEECH Ingalls Ingalls

TRANSPLANTS


Yes Yes

X-rays Allowed in Ortho. Office No No

XOLAIR Walgreens Walgreens


Rush Presbyterian University of Chicago

University of Chicago Children's Memorial Hospital

Hope Children's Hospital

University of Chicago Children's Memorial Hospital


Ingalls Green

Ingalls Green

Ingalls or ICOR (Ingalls Center for Outpatient

Rehab.)

Ingalls or ICOR (Ingalls Center for Outpatient

Rehab.)


(312) 997-6615 Fax (312) 938-4682


X-rays Allowed in Ortho office (Fracture Care)


Northwest Community Health Partners TID # 36-2340313



SERVICES HUMANA

ABORTION

ACUPUNCTURE

AMBULANCE Any contracted ambulance

BARIATRIC Gastric Bypass Dr. Joyce @ Silver Cross Dr. Joyce @ Silver Cross

Lap Band Dr. S. Sarker @ Loyola Dr. S. Sarker @ Loyola

BLOOD TRANSFUSION

Northwest Community Hospital

CHEMOTHERAPY

CHIROPRACTIC

COLONOSCOPY SCREENING Colonoscopy @ Hospital Colonoscopy @ Hospital

COLONOSCOPY DIAGNOSTIC Colonoscopy @ Hospital Colonoscopy @ Hospital

CT SCAN

CT SCAN - 64 SLICE



EEG - 24 HOUR


HMOI/BADV # 336

Check Benefit See BCBS Contracted Vender

List


Des Plaines Chiropractic Center (847) 299-3440

Des Plaines Chiropractic Center (847) 299-3440


Red (Including Type & Cross)

Red (Including Type & Cross)


Northwest Community Hospital (EP Study--Dr. Lin)

Office of NWC Hematology/Onc Specialist

Tx only Red

Office of NWC Hematology/Onc Specialist

Tx only Red

Des Plaines Chiropractic Ctr. (847) 299-3440 Clark Chiro & Rehab, PC (847) 259-9864

Des Plaines Chiropractic Ctr. (847) 299-3440 Clark Chiro & Rehab, PC

(847) 259-9864

Northwest Community Hospital Green


Medical Director conversation with the Cardiologist is required

Medical Director conversation with the Cardiologist is required

Dependicare(800) 224-7404 Walgreens (800) 323-2828





Yes--All Specialists performing surgery (Submitted on a

Surgical Request Form rather than a Red Referral)

Yes--All Specialists performing surgery (Submitted on a

Surgical Request Form rather than a Red Referral)

A short referral form needs to be completed in order to refer to a green list

physician

A short referral form needs to be completed in order to refer to a green list

physician







HEARING AIDS

HIGH RISK MATERNITY

HOME HEALTH CARE


IMMUNIZATIONS - ROUTINE

INFERTILITY

INPATIENT ADMISSIONS Northwest Community Hospital Northwest Community Hospital

IV THERAPY Contracted vendor Contracted vendor

LITHOTRIPSY United Shockwave United Shockwave

MENTAL HEALTH

MRI'S

MRI'S (OPEN)

MRA



Drs. J. Tunca, R. Weiss and S. Kwon @ NWC / Red

Drs. J. Tunca, R. Weiss and S. Kwon @ NWC / Red

Check Benefit Northwest Community Hospital


St. Alexius Group Suburban Maternal Fetal Medicine (Dr.Smith's High Risk OB Pt's -

NorthShore University HealthSystem)

St. Alexius Group Suburban Maternal Fetal Medicine (Dr.Smith's High Risk OB Pt's -

NorthShore University HealthSystem)

Northwest Community Hospital Home Health Care

Northwest Community Hospital Home Health Care

NWCH Occupational Health Dept. Provider ID # 800003

Red

Check Benefit NWCH Occupational Health Dept.

Red

NWCH Occupational Health Dept. Provider ID # 800003 Red

Copy to ED/PR Rep

Check Benefit NWCH Occupational Health Dept. Red

Copy to ED/PR Rep





(800) 753-5456

Self Refer (800) 331-9040



Northwest Community Hospital NWCH Schaumburg Tx. Center

MRI of Arlington Hgts

Northwest Community Hospital NWCH Schaumburg Tx. Center

MRI of Arlington Hgts

NWCH Green

NWCH Green

Northwest Community Hospital Green Referral

Northwest Community Hospital Green Referral






OBSERVATION - 23 HOUR Northwest Community Hospital Northwest Community Hospital

OPTOMETRY

Any contracted vendor Any contracted vendor

OUTPATIENT LABS

OUTPATIENT PHP/IOP


PACEMAKER CHECKS

PAIN MGMT CORTISONE

EPIDURAL INJECTIONS

PET SCANS

PULMONARY REHABILITATION Northwest Community Hospital Northwest Community Hospital

RADIATION THERAPY

SKILLED NURSING FACILITY Any contracted vendor Any contracted vendor

SLEEP STUDY - ADULT

SLEEP STUDY - PEDS. Children's Memorial Hospital (>3 y/o) Children's Memorial Hospital (>3 y/o)

STERILIZATION Vasectomy Check Benefit Check Benefit


SUBSTANCE ABUSE Not Managed by NAMM - Call Health Plan

SYNAGIS





Quest Diagnostic Northwest Community Hospital -

Stats only

Quest Diagnostic Northwest Community Hospital -

Stats only

Northwest Community Hospital or Day Surgery Center

Check Appendix B

Northwest Community Hospital or Day Surgery

Center

Northwest Community Hospital Red

Northwest Community Hospital Red

In the office of ORS Green

In the office of ORS Green

In the office of AN Red




Provided by Radiation/Onc at Northwest Community Hospital

Provided by Radiation/Onc at Northwest Community Hospital



Check Benefit

Red Referral and McKesson order form (See attached form) Apply Millimen






SYNVISC Ortho Office Ortho Office





THERAPY - PHYSICAL

THERAPY - SPEECH Northwest Community Hospital Northwest Community Hospital

TRANSPLANTS


Yes Yes

X-rays Allowed in Ortho. Office Yes Yes

XOLAIR McKesson McKesson


Loyola University Hospital U of C

Loyola University Hospital U of C

U of C Children's Memorial Hospital

U of C Children's Memorial Hospital




Northwest Community Hospital (Age 10 and up)


Assential Therapies Physiotherapy Assoc. (Pediatric Place) Arlington Pediatric Therapy

Assential Therapies Physiotherapy Assoc. (Pediatric Place) Arlington Pediatric Therapy



See Scope of Benefits Audrey Johnson-Tarver (312) 997-6615 Fax (312) 938-4682




Oak West Primary Physician Assoc. TID # 36-4008699


Customer Service # : 708-432-1287

Health Plan Precert


SERVICES UNICARE

ABORTION

ACUPUNCTURE No Coverage


BLOOD TRANSFUSION

Cardiac Svc/Angioplasty/CABG Westlake

CHEMOTHERAPY

CHIROPRACTIC



COLONOSCOPY DIAGNOSTICColonoscopy @ Hospital Colonoscopy @ Hospital Colonoscopy @ Hospital

CT SCAN Westlake

CT SCAN - 64 SLICE Westlake

DIALYSIS Per Appendix E


Please notify Lourdes Reyes for all FHN Inpt/Outpt procedures

312-491-1956 x17, Fx 312-738-3116 or e-mail at

[email protected]

HMOI/BADV # 335

FHN Eligibility # 312-491-1956

Self Refer (800) 892-2803

Self Refer (888) 234-8855

Limited Coverage Refer to FHN/Valerie

(312) 491-1956 X48


Door to Door Transportation L and L Transportation

BARIATRIC - MUST MEET MILLIMAN SURGICAL CRITERIA AND OAK GUIDELINES PRIOR TO CONSULT (CONSULT-RED REFERRAL)

Dr. Tiesenda @ Westlake Dr. Diniotis at Our Lady

of Res.

Dr. Tiesenda @ Westlake Dr. Diniotis at Our

Lady of Res.

Dr. Tiesenda @ Westlake Dr. Diniotis at Our

Lady of Resurrection (Contact - Lourdes Reyes 312-491-1956 x 17)

Pods A - B/Westlake Pods C/Our Lady of Resurrection Pods A -B/Cardiac

rehab to be sent to Our Lady of Resurrection .(cross pod)

Pods A - B/Westlake Pods C/Our Lady of Resurrection

Pods A-B/ Dr. Banerji,Lyster,Rosi

Pods C/ Dr. Nathan,Drazkiewicz

Pods A-B/ Dr. Banerji,Lyster,Rosi

Pods C/ Dr. Nathan,Drazkiewicz

In the office of Dr. Ebie Red

Failed conservative tx. Eval. w/Dr. F. Robinson, D.O.



Consult not required (Red ref. for PODS C only)




Red


Red


Red


Red


Contact Health Plan Valerie (312) 491-1956 Ext. 48

Dependicare Walgreens

or Any contracted DME vendor

Check Benefit Purchase<$1000 No precert needed

Dependicare/Walgreens

Dependicare Apria

UltraCare





Health Plan Precert


SERVICES UNICARE


312-491-1956 x17, Fx 312-738-3116 or e-mail at

[email protected]

HMOI/BADV # 335


EEG - 24 HOUR Westlake

Yes Yes



HEARING AIDS Yes

HIGH RISK MATERNITY Loyola University Medical Ctr. Loyola University Medical Ctr. Mt. Sinai Hospital

HOME HEALTH CARE Resurrection Home Health Resurrection Home Health

IMMUNIZATIONS - TRAVEL Loyola University Medical Ctr. Mt. Sinai Hospital

INFERTILITY No Coverage

INPATIENT ADMISSIONS Westlake

IV THERAPY Westlake

LITHOTRIPSY United Shockwave United Shockwave Mt. Sinai Hospital

MENTAL HEALTH

MRI'S Westlake



Group Allows Specialists to Request Referrals and Imaging

Schwab Rehab Hospital Audiology Dept.

(773) 522-5870

Patient obtains Green Referral and Script from PCP



Dr. Donna Smith @ Loyola Red



Check Benefits Per BCBS - Hearing aids

may be obtained from any vendor. Hearing test no longer done @Westlake

Hosp.


Check Benefit Loyola University Medical Ctr.

Call for Benefits Any contracted BCBS infertility provider

Diagnostic to be done by IPA/GYNE Infertility Review Form to be

completed


Coram Specialty Infusion Services (Effective May 13th). Coram nurse /

PCP to determine care setting.





Procare Dr. Piyaka


(800) 746-6294

Self Refer PsycHealth (800) 753-5456


Red


Red





Health Plan Precert


SERVICES UNICARE


312-491-1956 x17, Fx 312-738-3116 or e-mail at

[email protected]

HMOI/BADV # 335


MRI'S (OPEN) Westlake

MRA Red Red Red

NON-COMPLIANCE POLICY Yes Yes Yes

NUTRITIONAL COUNSELING Green Referral Green Referral Green Referral

OBSERVATION - 23 HOUR Westlake

OCCUPATIONAL THERAPY Westlake

OPTOMETRY

Hanger Prosthetic & Orthotics

INPATIENT LABS

OUTPATIENT PHP/IOP

OUTPATIENT SURGICAL PROCS Westlake

PACEMAKER CHECKS

PAIN MGMT CORTISONE In the office of ORS

EPIDURAL INJECTIONS

PET SCANS

PULMONARY REHABILITATION Schwab Rehab Hospital

Midwest Open MRI MRI Lincoln Imaging Center

Red

Midwest Open MRI MRI Lincoln Imaging Center

Red








Adult - No Coverage Under 21 - Self Refer

(800) 424-1155


Hanger Prosthetic & Orthotics MD Orthotics

or Any Contracted O/P Vendor

Scheck & Siress Hanger Prosthetic & Orthotics MD

Orthotics

Must use Westlake Hospital or Our Lady of Resurrection

Must use Westlake Hospital or Our Lady of

Resurrection

Must use Westlake Hospital or Our Lady of

Resurrection

Not managed by NAMM Patients need to call

Health Plan


Check Appendix B


Westlake Community Hospital or Our Lady of the Res.

Red


Red


Red






MRI Lincoln Imaging Center Regional PET Imaging

MRI Lincoln Imaging Center Regional PET Imaging

High Tech Lakeshore P.E.T. Imaging

POS AB - Westlake PODS

C - Our Lady of Res.

POS AB - Westlake

PODS C - Our Lady of Res.





Health Plan Precert


SERVICES UNICARE


312-491-1956 x17, Fx 312-738-3116 or e-mail at

[email protected]

HMOI/BADV # 335


RADIATION THERAPY


SLEEP STUDY - ADULT

SLEEP STUDY - PEDS University of Chicago Hospital

STERILIZATION Vasectomy

Tubal Ligation

SUBSTANCE ABUSE

SYNAGIS

SYNVISC Ortho Office Ortho Office



THERAPY - PEDS PT/OT/ST

THERAPY - PHYSICAL

THERAPY - SPEECH

TRANSPLANTS

Dr. Beck/Hem-Onc Assoc. POS 11

CT Planning-Gottlieb Hospital

Dr. Beck/Hem-Onc Assoc. POS 11 CT Planning-Gottlieb Hospital

Merit Sleep Management (888) 637-4848



Pods A - B/Merit Sleep Management Pods C/Our Lady of

Resurrection

Pods A - B/Merit Sleep Management Pods C/Our Lady

of Resurrection

Check Benefit Urology Office

Check Benefit Urology Office Limited Coverage Refer to

FHN/Valerie (312) 491-1956 X48Check Benefit

IPA-GYNE at Gottlieb HospitalCheck Benefit

IPA-GYNE at Gottlieb Hospital

Not managed by NAMM Patients need to call Health Plan

Not managed by NAMM Patients need to call Health

Plan

Not Managed by NAMM Patients need to call Healthplan

Ultra Care and/or Peds Office Medical Director review if

Milliman not met

Ultra Care and/or Peds Office Medical Director review if Milliman

not met

Ultra Care Red Referral from

PCP Office Medical Director review if Milliman

not met

Loyola University Medical Ctr. University of Chicago


Mt. Sinai Hospital



Mt. Sinai Hospital Rush Medical Center



Green


Green

Westlake Green

Pods A-B/Westlake Pods C/Our Lady of Resurrection Loyola University Medical Ctr/ST

Pods A-B/Westlake Pods C/Our Lady of Resurrection

Loyola University Medical Ctr/ST

Westlake Mt. Sinai Hospital

UNLIMITED



Westlake UNLIMITED



Westlake UNLIMITED


(312) 997-6615 Fax (312) 938-4682


Contact Healthplan Valerie (312) 491-1956 Ext.48





Health Plan Precert


SERVICES UNICARE


312-491-1956 x17, Fx 312-738-3116 or e-mail at

[email protected]

HMOI/BADV # 335


Transportation N/A N/A

Yes Yes Yes

X-rays Allowed in Ortho. Office No No No

XOLAIR Care Mark Care Mark Care Mark


L & L Medical Transport Self Refer (888) 346-4968

X-rays Allowed in ortho office (Fracture Care)


Senior Care PartnersTID # 20-4763091

WILL COUNTY

P.O. Box , Westchester, IL 60154

Customer Service #: 708-240-5221 Health Plan Precert Health Plan Precert

SERVICES

ABORTION N/A N/A

ACUPUNCTURE Not a covered benefit Not a covered benefit

AMBULANCE

BARIATRIC ?

BLOOD TRANSFUSION Metro South Medical Center Provena St. Joseph Hospital

CARDIAC REHABILITATION Metro South Medical Center Provena St. Joseph Hospital

Cardiac Svc/Angioplasty/CABG Metro South Medical Center Provena St. Joseph Hospital

CHEMOTHERAPY ?

CHIROPRACTIC

COLONOSCOPY SCREENINGConsult required (Red) Consult required (Red)


COLONOSCOPY DIAGNOSTICConsult required (Red) Consult required (Red)


CT SCAN

CT SCAN - 64 SLICE Provena St. Joseph Hospital

DIABETIC EDUCATION

DIALYSIS

EEG - 24 HOUR

EGD Consult required (Red) Consult required (Red)

EGD @ Hospital EGD @ Hospital

HealthSpring 847-993-1928


Superior Ambulance (708) 832-2000

Superior Ambulance (708) 832-2000

Not done in Network Dr. Cahill @ Little Company of Mary

(OON) (708) 422-5658

Joliet Oncology / Hematology Associates

Kurt Keppner, D.C. (708) 460-8688

John Hertko, D.C. (815) 725-7700

Metro South Medical Center Green

Will County Medical Associates Green

Metro South Medical Center

Westlake Our Lady of Resurrection Little Company of Mary Green

Will County Medical Associates (Sheri Magnuson, R.N. C.D.E.)

Green

Fresenius Medical NeoMedica

(Cannot go to South Holland location)

Fresenius Medical Naperville Dialysis Center NeoMedica

(Cannot go to South Holland location)

DURABLE MED. EQUIPMENT/SUP. DME products under $150.00 are not covered, are member responsibility.

Dependicare Total Home Health

Walgreens Home Medical

Dependicare Total Home Health

Walgreens Home Medical

Metro South Medical Center Red

Provena St. Joseph Hospital Red



WILL COUNTY



SERVICES HealthSpring 847-993-1928


Group Allows Specialists to Request Referrals No No

GYNECOLOGICAL ONCOLOGY Little Company of Mary / Red

HEARING AIDS

HIGH RISK MATERNITY N/A N/A

HOME HEALTH CARE

IMMUNIZATIONS - TRAVEL Not a covered benefit Not a covered benefit

INFERTILITY

Red Red

INPATIENT ADMISSIONS Metro South Medical Center Provena St. Joseph Hospital

IV THERAPY Metro South Medical Center Provena St. Joseph Hospital

LITHOTRIPSY

LUPRON INJECTIONS

MENTAL HEALTH

MRI'S

MRI'S (OPEN)

MRA Green

Joliet Oncology / Hematology Associates

Self Refer to Bell Tone 600 Theodore St. Joliet 815-722-

4240

Self Refer to Bell Tone 600 Theodore St. Joliet 815-722-

4240

SSM Home Health @ Metro South Medical Center

Provena Home Health CNS Home Health

Call HealthSpring for benefit determination


INJECTIBLE MEDICATIONS - EPOGEN, REMICAID, SYNVISC

United Shockwave Contact Nancy/Healthspring (847) 993-1928

United Shockwave Contact Nancy/Healthspring (847) 993-1928

Pre-cert required for any diagnosis except prostate cancer

Pre-cert required for any diagnosis except prostate cancer

Self Refer MHN (866) 780-8546


High Tech Advantage MRI (South Holland Only)

Green

Will County Medical Associates Green

High Tech Advantage MRI (South Holland Only)

Open MRI of Olympia Fields Joliet

Open MRI Prairie Open MRI

Green

Joliet Open MRI Green

Will County Medical Associates (Head Only), otherwise Provena St. Joseph Hospital

Green



WILL COUNTY







OBSERVATION - 23 HOUR Metro South Medical Center Provena St. Joseph Hospital

OPTOMETRY No Coverage No Coverage

ORTHOTIC/PROSTHETIC Scheck & Siress Scheck & Siress

OUTPATIENT LABS Metro South Medical Center

OUTPATIENT PHP/IOP

OUTPATIENT SURGICAL PROCS Metro South Medical Center Provena St. Joseph Hospital

PACEMAKER CHECKS

PAIN MGMT. CORTISONE

EPIDURAL STEROID

PET SCANS

PODIATRY Green

PULMONARY REHABILITATION Metro South Medical Center Provena St. Joseph Hospital

RADIATION THERAPY Dr. Tolentino

SCLEROTHERAPY Red ?

SKILLED NURSING FACILITY ? ?

SLEEP STUDY - ADULT

Westlake Hospital Green

Will County Medical Associates (Sheri Magnuson, R.N. C.D.E.)

Green

Will County Medical Associates (815) 725-2121



Heart Care Centers of Illinois Red


In the office of ORS or RHU Red Mauricio Orbegozo

(815) 725-6331 RedIn the office of AN

Red

High Tech Green

Provena St. Joseph Hospital Green


Drs. Bailey and Klemm

Provena St. Joseph Hospital (Cancer Treatment Group)

Drs. Griffin, Ommar, Crossan

DRW & Associates Metro South

Medical Center Green

Cardinal Sleep Center (815) 773-9090

Green



WILL COUNTY





SLEEP STUDY - PEDS. N/A N/A

STERILIZATION: Vasectomy

Tubal Ligation

SUBSTANCE ABUSE

SYNAGIS N/A N/A

TERTIARY HOSPITALS - ADULT Loyola Loyola

TERTIARY HOSPITALS - PEDS. N/A N/A


THERAPY - OCCUPATIONAL Will County Medical Associates

THERAPY - PEDS PT/OT/ST N/A N/A

THERAPY - PHYSICAL Will County Medical Associates

THERAPY - SPEECH Provena St. Joseph Hospital

TMJ/DENTAL PROCEDURES ? Dr. Stephen Morimoto

TRANSPLANTS

TRANSPORTATION

X-rays Allowed in Ortho Office (Fracture Care) Yes Yes

X-rays Allowed in Ortho. Office No No

XOLAIR N/A N/A


Office-no precert Hospital-Precert

Office-no precert Hospital-Precert





Metro South Medical Center Green

Provena St. Joseph Hospital Green




Contact Nancy/Healthspring (847) 993-1928

Contact Nancy/Healthspring (847) 993-1928

Fresh Air (30 One way rides per year)

Fresh Air (30 One way rides per year)


Silver Cross MCO TID # 36-3876019



SERVICES HUMANA UNICARE

ABORTION

ACUPUNCTURE


BARIATRIC

BLOOD TRANSFUSION Green Green Green

CARDIAC STRESS TEST


CHEMOTHERAPY

CHIROPRACTIC Davidson Chiropractic Davidson Chiropractic Davidson Chiropractic



COLONOSCOPY DIAGNOSTICConsult required (Green) Consult required (Green) Consult required (Green)


CT SCAN

CT SCAN - 64 SLICE

DIALYSIS Silver Cross Hospital Silver Cross Hospital Silver Cross Hospital

DURABLE MED. EQUIPMENT/SUP. Walgreens Home Medical

EEG - 24 HOUR

HMOI/BADV # 266

Check Benefit See BCBS Contracted Vender List



Peter Harvey, Eastern Healing, Inc. 630-653-

4358


4359


4360



Dr. Joyce or Dr.Lahmann for follow-up or lap band adjustments in office,

Per Dr. Hindo


Per Dr. Hindo


Per Dr. Hindo

Silver Cross Hospital Green

Silver Cross Hospital Red


Silver Cross Hospital Provena St. Joseph



Joliet Oncology/Hem Midwest Center for Hen/Onc.

Green


Red


Green

Silver Cross Hospital Homer Glen Facility-Non contrast Imaging

Green


Green


Green

Silver Cross Hospital Red Referral Must be reviewed by Dr. Hindo



CT SCAN-CORONARY CALCIUM SCORING

Silver Cross Hospital Homer Glen Facility

CPT 0144T Facility ID 10031

(PA Review Mandatory-Red Ref.)







Dependicare Walgreens Home Medical

or Any Contracted DME Vendor

Check Benefit Purchase<$1000 No precert needed

Dependicare/Walgreens Home Medical

Provena St. Joseph Med. Ctr Peds - Hope/Christ Hospital








EKG

GREEN REFERRAL PROCESS Stamp Script Stamp Script Stamp Script


GLOBAL OB

HEARING AIDS

HIGH RISK MATERNITY Loyola University Medical Center

HOME HEALTH CARE Silver Cross Home Health Interim & Advocate Call Unicare

IMMUNIZATIONS - TRAVEL University of Chicago University of Chicago University of Chicago

INFERTILITY Fertility Center of Illinois

INPATIENT ADMISSIONS Silver Cross Hospital Silver Cross Hospital Silver Cross Hospital

IV THERAPY

LABS

LITHOTRIPSY

MENTAL HEALTH





Green PCP Green Specialist

Green Providers to Green Providers

Green Providers to Green Providers

Dr. Rotmensch @ RUMC Red

Dr. Rotmensch @ RUMC Red

Loyola Red

Gloval OB referral not required for global OB care



Check Benefits Per BCBS - Hearing aids may

be obtained from any vendor



Women's Health Consultants/RUMC (Level II

Ultrasound's at Women's Health Consultants: Use Prov. ID 200041)


Women's Health Consultants/RUMC (Level II

Ultrasound's at Women's Health Consultants: Use Prov. ID 200041)


Call for Benefits Any contracted BCBS infertility provider



Coram Specialty Infusion Services (Effective May 13th). Coram nurse / PCP to

determine care setting.

89230 - Chloride Sweat Test / Sweat 82435 - Chloride Sweat Test / Blood These Labs Only, Direct to Provena St. Joseph

Hospital. Request will be generated by allergy providers via queue. (Red Referral)





United Shockwave "O" note-Ingalls Surg Ct.



Central Professional Group Green

Self Refer (800) 331-9040


(800) 746-6294






MRI'S

MRI'S (OPEN)


NON-COMPLIANCE POLICY N/A N/A N/A


OBSERVATION - 23 HOUR Silver Cross Hospital Silver Cross Hospital Silver Cross Hospital

OPTOMETRY

OUTPATIENT LABS

OUTPATIENT PHP/IOP

OUTPATIENT SURGICAL PROCS Silver Cross Hospital Silver Cross Hospital

PACEMAKER CHECKS Silver Cross Hospital - Red Silver Cross Hospital - Red Silver Cross Hospital - Red

PAIN MGMT CORTISONE In the office of ORS/Green In the office of ORS/Green In the office of ORS/Green

EPIDURAL INJECTIONS In the office of AN/Green In the office of AN/Green In the office of AN/Green

PET SCANS

PULMONARY FUNCTION TEST

PULMONARY REHABILITATION

RADIATION THERAPY

Silver Cross Hospital Homer Glen Facility (non contrast imaging only) Green



Open Advanced MRI Red



Silver Cross Hospital Green Referral





Eye Med Self Refer

(866) 273-0817




MD Orthotics

Scheck & Siress MD Orthotics


MD Orthotics




Silver Cross Hospital Check Appendix B

Alliance Healthcare Services, Inc (866) 667-7226

Provider ID # 1235282344






Silver Cross Hospital Red





Dr. Asaad@Hoffman Center Green

Dr. Asaad@Hoffman Center Red

Dr. Asaad@Hoffman Center Green







SLEEP STUDY ADULT

SLEEP STUDY PEDS.

STERILIZATION Vasectomy Check Benefit/Red Check Benefit/Red Check Benefit/Red


SUBSTANCE ABUSE

SYNAGIS

SYNVISC





THERAPY - PHYSICAL

THERAPY - SPEECH

TRANSPLANTS

Cardinal Sleep Center Green






Check Benefit

Check Benefit

Not managed by NAMM Patients need to call Healthplan



Red Referral and SCMCO order form (See attached guidelines/order form



Office orders from any vendor then we reimburse them at their invoice cost. They submit invoice with the claim to provider

relations.


relations.


relations.U of C Rush University Medical Center Loyola University Medical Center UIC Rehabilitation Institute of

Chicago

U of C Rush University Medical Center Loyola University Medical Center UIC Rehabilitation Institute of

Chicago

U of C Loyola University Medical Center UIC Rehabilitation

Institute of ChicagoU of C or UIC Advocate Hpoe Children's (Refer to SCMCO Approved Provider List) Rush University Medical Center

Loyola University Medical Center Children's Memorial Hospital Rehabilitation institute

of Chicago

U of C or UIC Advocate Hpoe Children's (Refer to SCMCO Approved Provider List) Rush University Medical Center

Loyola University Medical Center Children's Memorial Hospital Rehabilitation institute

of Chicago

U of C or UIC

Loyola University Medical Center Advocate Hpoe Children's (Refer to SCMCO Approved Provider List)

Children's Memorial Hospital Rehabilitation institute of Chicago


















(312) 997-6615 Fax (312) 938-4682









Yes Yes Yes

X-rays Allowed in Ortho. Office Yes Yes Yes

X-RAYS

XOLAIR Red Red Red







Swedish Covenant Managed Care TID # 36-4118659



HUMANA

SERVICES Commercial Medicare HealthSpring

ABORTION N/A

ACUPUNCTURE

AMBULANCE

BARIATRIC Dr. Denham @ Evanston Northwestern Dr. Denham @ Evanston Northwestern Dr. Denham @ Evanston Northwestern

BLOOD TRANSFUSION Red Red Red

Cardiac Svc/Angioplasty/CABG Swedish Swedish Swedish

CHEMOTHERAPY In the office of Dr. Philip In the office of Dr. Philip In the office of Dr. Philip

CHIROPRACTIC



COLONOSCOPY DIAGNOSTICConsult required (Green) Consult required (Green) Consult required (Green)


CT SCAN

CT SCAN - 64 SLICE

DIALYSIS Swedish Swedish Swedish


EEG - 24 HOUR Swedish Swedish Swedish

No No No

GREEN REFERRAL PROCESS Green referral form / script Green referral form / script Green referral form / script



Swedish - After all conservative treatments have been exhausted









Swedish Red

Swedish Red

Swedish Red

Swedish Evanston Hospital

Red


Red


Red

Walgreens Dependicare

Integrated Walgreens

Dependicare

Integrated Walgreens

Dependicare






HUMANA



HEARING AIDS

HIGH RISK MATERNITY Swedish Swedish N/A

HOME HEALTH CARE Swedish Swedish

IMMUNIZATIONS - TRAVEL Metro Infectious Disease Metro Infectious Disease Not a Covered Benefit

INFERTILITY N/A N/A

INPATIENT ADMISSIONS Swedish Swedish Swedish

IV THERAPY Swedish Swedish Swedish

LITHOTRIPSY Swedish Swedish Swedish

MENTAL HEALTH

MRI'S

MRI'S (OPEN)

MRA Red Red Red

NON-COMPLIANCE POLICY No No No

NUTRITIONAL COUNSELING Red Referral Red Referral Red Referral

OBSERVATION - 23 HOUR Swedish Swedish Swedish

OPTOMETRY Incident to Cataract Surgery Incident to Cataract Surgery Incident to Cataract Surgery

Drs. Gustavo Rodriquez and Herbert Beck @ ENH

Red


Red


Red




Swedish HRS Home Health

Call for Benefits Fertility Centers of Illinois



Not managed by NAMM Self refer to Mental

Health Network (800) 511-6946

Swedish Red

Swedish Red

Swedish Red

Swedish MRI Lincoln Imaging

Red


Red


Red





HUMANA


OUTPATIENT LABS Swedish Covenant Hospital Swedish Covenant Hospital Swedish Covenant Hospital

OUTPATIENT PHP/IOP

OUTPATIENT SURGICAL PROCS Swedish Swedish Swedish

PACEMAKER CHECKS

PAIN MGMT CORTISONE Swedish Pain Clinic/Dr. Xie Swedish Pain Clinic/Dr. Xie Swedish Pain Clinic/Dr. Xie

EPIDURAL INJECTIONS Swedish Pain Clinic/Dr. Xie Swedish Pain Clinic/Dr. Xie Swedish Pain Clinic/Dr. Xie

PET SCANS Swedish Swedish Swedish

PULMONARY REHABILITATION Evanston Hospital Evanston Hospital Evanston Hospital

RADIATION THERAPY Swedish Swedish Swedish

SKILLED NURSING FACILITY Swedish Swedish Swedish

SLEEP STUDY - ADULT

SLEEP STUDY - PEDS. N/A

STERILIZATION Vasectomy Check Benefit Check Benefit N/A

Tubal Ligation Check Benefit Check Benefit N/A

SUBSTANCE ABUSE

SYNAGIS

SYNVISC Provider is Walgreens Home Care Provider is Walgreens Home Care Provider is Walgreens Home Care

TERTIARY HOSPITALS - ADULT Evanston Hospital Evanston Hospital Evanston Hospital

ORTHOTIC/PROSTHETIC (See L Code list)







Swedish Covenant Hospital - Red "O" note Pacemaker Clinic



DRW & Associates (773) 805-1871








Red Referral made out to Walgreen's Home Medical Supply







HUMANA


TERTIARY HOSPITALS - PEDS. Evanston Hospital Evanston Hospital N/A

THERAPY - OCCUPATIONAL Swedish Swedish Swedish

THERAPY - PEDS. PT/OT/ST Swedish Swedish N/A

THERAPY - PHYSICAL Swedish Swedish Swedish

THERAPY - SPEECH Swedish Swedish Swedish

TRANSPLANTS Swedish Swedish Swedish


Yes Yes Yes

X-rays Allowed in Ortho. Office No No No

XOLAIR Walgreens Home Care Walgreens Home Care Walgreens Home Care



Swedish Green

Swedish Green

Swedish Green

X-rays Allowed in Ortho office (Fracture Care)

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