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N:/MM/REFERRAL MANAGEMENT/Service Grid by Site 06/06/2022 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 SCREENING Consult not required Consult not required Consult not required COLONOSCOPY DIAGNOSTIC Consult 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 Dr. Joseph Vitello Dr. Carlos Galvani Dr. Joseph Vitello Dr. Carlos Galvani Elmhurst Memorial Hospital Green Elmhurst Memorial Hospital Red Elmhurst Memorial Hospital Green Dr. Jevitz (630) 834-3391 Dr. Jevitz (630) 834-3391 Dr. Jevitz (630) 834-3391 Colonoscopy @ Hospital Colonoscopy @ Hospital Colonoscopy @ Hospital Colonoscopy @ Hospital Colonoscopy @ Hospital Colonoscopy @ Hospital Only if ordered by Cardiologist Red Only if ordered by Cardiologist Red Only if ordered by Cardiologist Red Per Health Plan (800) 626-2698 Renal Care Group of Villa Park DuPage Peritoneal Action 630-758-7000 Dependicare (800) 224-7404 Walgreens (800) 323-2828 or ANY Contracted Walgreens Home Medical (800) 323-2828 Action - if not see Aetna list (Attached) Group Allows Specialists to Request Referrals

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Page 1: 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

Elmhurst Memorial Hospital Green

Dr. Jevitz (630) 834-3391

Dr. Jevitz (630) 834-3391

Dr. Jevitz (630) 834-3391

Colonoscopy @ Hospital

Colonoscopy @ Hospital

Colonoscopy @ Hospital

Colonoscopy @ Hospital

Colonoscopy @ Hospital

Colonoscopy @ Hospital

Elmhurst Memorial Hospital

Green

Elmhurst Memorial Hospital

Green

Elmhurst Memorial Hospital

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

Page 2: 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 HUMANAHMOI/BADV # 312

Aetna (ELMO) Self-Funded Employer

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

Drs. Ronald Potkul and Donna Smith @ Loyola / Red

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

Lutheran General Providers Loyola Maternal Fetal Medicine

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

Elmhurst Memorial Hospital Green

Elmhurst Memorial Hospital Green

Elmhurst Memorial Hospital Green

Midwest Imaging Red

Midwest Imaging Red

Midwest Imaging Red

Page 3: 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 HUMANAHMOI/BADV # 312

Aetna (ELMO) Self-Funded Employer

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

Cole Vision Self Refer (800) 334-7591

ORTHOTIC/PROSTHETIC (See L Code List)

Scheck & Siress Hanger Prosthetic & Orthotics

MD Orthotics

Scheck & Siress Hanger Prosthetic & Orthotics

MD Orthotics

Elmhurst Clinic or

Aetna provider

Elmhurst Hospital Elmhurst Clinic

Elmhurst Hospital Elmhurst Clinic

Elmhurst Hospital Elmhurst Clinic

Elmhurst Memorial Hospital Elmhurst OP Surgical Center

Check Appendix B

Elmhurst Memorial Hospital Elmhurst OP Surgical Center

Elmhurst Memorial Hospital Elmhurst OP Surgical Center

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

If Cross PODS, becomes a Red

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

If Cross PODS, becomes a Red

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

If Cross PODS, becomes a Red

In the office of ORS/RHU Green

In the office of ORS/RHU Green

In the office of ORS/RHU Green

Given by Pain Clinic Spec. at EOSC or EMH

Given by Pain Clinic Spec. at EOSC or EMH

Given by Pain Clinic Spec. at EOSC or EMH

Medical Out Sourcing @Elmhurst Memorial Hospital

Medical Out Sourcing @Elmhurst Memorial Hospital

Medical Out Sourcing @Elmhurst Memorial Hospital

Elmhurst Memorial Hospital Green

Elmhurst Memorial Hospital Red

Elmhurst Memorial Hospital Green

Elmhurst Memorial Hospital Skilled Nursing Facility Or Manor Care

Elmhurst Memorial Hospital Skilled Nursing Facility Or Manor Care

Elmhurst Memorial Hospital (Green Referral)

Elmhurst Memorial Hospital (Green Referral)

Elmhurst Memorial Hospital (Green Referral)

Loyola University Medical Center Lutheran General Hospital

Loyola University Medical Center Lutheran General Hospital

Loyola University Medical Center Lutheran General Hospital

Not Managed by Namm Call Health Plan

Not Managed by Namm Call Health Plan

Not Managed by Namm Call Health Plan

Page 4: 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 HUMANAHMOI/BADV # 312

Aetna (ELMO) Self-Funded Employer

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

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

of Illinois

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

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 Green

Elmhurst Memorial Hospital Green

Elmhurst Memorial Hospital Green

Elmhurst Memorial Hospital Elmhurst

Rehab

Elmhurst Memorial Hospital Elmhurst Rehab

Elmhurst Memorial Hospital Elmhurst Rehab

Elmhurst Memorial Hospital / Loyola University Medical Center

Lutheran General Hospital

Elmhurst Memorial Hospital / Loyola University Medical Center

Lutheran General Hospital

Elmhurst Memorial Hospital / Loyola University Medical Center

Lutheran General Hospital

Elmhurst Memorial Hospital Elmhurst Rehab

Elmhurst Memorial Hospital Elmhurst Rehab

Elmhurst Memorial Hospital Elmhurst Rehab

Elmhurst Memorial Hospital Elmhurst Rehab

Elmhurst Memorial Hospital Elmhurst Rehab

Elmhurst Memorial Hospital Elmhurst Rehab

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

Page 5: 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 HUMANAHMOI/BADV # 312

Aetna (ELMO) Self-Funded Employer

Plan

Page 6: Service Grid by Site

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

Health Options of Illinois TID # 36-3680139

P.O. Box 7760, Westchester, IL 60154 Health Plan Precert

Customer Service # : 847-656-0013 Medical Leadership Review

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

Group Allows Specialists to Request Referrals

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)

Page 7: Service Grid by Site

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

Health Options of Illinois TID # 36-3680139

P.O. Box 7760, Westchester, IL 60154 Health Plan Precert

Customer Service # : 847-656-0013 Medical Leadership Review

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

IMMUNIZATIONS - TRAVEL

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

Page 8: Service Grid by Site

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

Health Options of Illinois TID # 36-3680139

P.O. Box 7760, Westchester, IL 60154 Health Plan Precert

Customer Service # : 847-656-0013 Medical Leadership Review

SERVICES HMOI/BADV # 275

OPTOMETRY

Any contracted vendor

INPATIENT LABS

OUTPATIENT PHP/IOP N/A

OUTPATIENT SURGICAL PROCS

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

Page 9: Service Grid by Site

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

Health Options of Illinois TID # 36-3680139

P.O. Box 7760, Westchester, IL 60154 Health Plan Precert

Customer Service # : 847-656-0013 Medical Leadership Review

SERVICES HMOI/BADV # 275

TERTIARY HOSPITALS - ADULT

TERTIARY HOSPITALS - PEDS.

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

***THIS IS NOT AN ALL-INCLUSIVE LISTING

Northshore University Health System

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

Attached

THALLIUM STRESS TEST (Red or Green referral)

Vista East Green

See Scope of benefits Audrey Johnson-Tarver

312-997-6615 Fax 312-938-4682

X-rays Allowed in Ortho Office (Fracture Care)

Page 10: Service Grid by Site

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

Hinsdale Physicians Healthcare TID # 36-3851702

P.O. Box 7789, Westchester, IL 60154 Health Plan Precert

Customer Service # : 708-432-4053 Medical Leadership Review

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)

Colonoscopy @ Hospital Colonoscopy @ Hospital Colonoscopy @ Hospital

CT SCAN

CT SCAN - 64 SLICE

BLOOD TRANSFUSION Red Red Red

DIALYSIS See Appendix E Per Health Plan Per Health Plan

DURABLE MED. EQUIPMENT/SUP.

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

Check Benefit Per Healthplan

Check Benefit Per Healthplan

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

Chicago Ambulance Alliance (800) 558-6050

Hinsdale Hospital LaGrange Hospital

Hinsdale Hospital LaGrange Hospital

Hinsdale Hospital LaGrange Hospital

HPH Hematology/Onc Specialist

Green

HPH Hematology/Onc Specialist

Green

HPH Hematology/Onc Specialist

Green

Check Benefit See Red List

Check Benefit See Red List

Hinsdale Hospital LaGrange Hospital

Glen Oaks Medical Center Bolingbrook

(Green)

Hinsdale Hospital LaGrange Hospital

Glen Oaks Medical Center Bolingbrook

(Green)

Hinsdale Hospital LaGrange Hospital

Glen Oaks Medical Center Bolingbrook

(Green)

Cardiologist or contracted Hospital Green

Cardiologist or contracted Hospital Green

Cardiologist or contracted Hospital Green

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

Any Contracted DME Vendor

Walgreens Home Medical (800) 323-2828

Check Benefit <$1000 No precert needed Dependicare/Walgreens

Hinsdale Hospital LaGrange Hospital Glen Oaks Medical Center Bolingbrook

(Red)

Hinsdale Hospital LaGrange Hospital Glen Oaks Medical Center Bolingbrook

(Red)

Hinsdale Hospital LaGrange Hospital Glen Oaks Medical Center Bolingbrook

(Red)

Group Allows Specialists to Request Referrals

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

Page 11: Service Grid by Site

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

Hinsdale Physicians Healthcare TID # 36-3851702

P.O. Box 7789, Westchester, IL 60154 Health Plan Precert

Customer Service # : 708-432-4053 Medical Leadership Review

SERVICES HUMANA UNICAREHMOI/BADV # 257

GYNECOLOGICAL ONCOLOGY

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)

MRA Green Green Green

NON-COMPLIANCE POLICY Yes Yes Yes

NUTRITIONAL COUNSELING

Drs. Sameer Sharma and Sudarshan Sharma @ Hinsdale / Red

Drs. Sameer Sharma and Sudarshan Sharma @ Hinsdale / Red

Drs. Sameer Sharma and Sudarshan Sharma @ Hinsdale / Red

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

Check Benefits Contracted Vendor

Check Benefits Contracted 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

Check Scope of Benefits Call for Benefits

See Health Plan Prov. List

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

Hinsdale Hospital LaGrange Hospital Glen Oaks Medical Center

Adventist Bolingbrook Hospital

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

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

Imaging

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

Imaging

Oakbrook Health and Nutrition Dr. Ghani or Dr. Auriemma

Oakbrook Health and Nutrition Dr. Ghani or Dr. Auriemma

Oakbrook Health and Nutrition Dr. Ghani or Dr. Auriemma

Page 12: Service Grid by Site

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

Hinsdale Physicians Healthcare TID # 36-3851702

P.O. Box 7789, Westchester, IL 60154 Health Plan Precert

Customer Service # : 708-432-4053 Medical Leadership Review

SERVICES HUMANA UNICAREHMOI/BADV # 257

OBSERVATION - 23 HOUR

OPTOMETRY

Scheck & Siress

OUTPATIENT LABS

OUTPATIENT PHP/IOP

OUTPATIENT SURGICAL PROCS

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

Hinsdale Hospital LaGrange Hospital Glen Oaks Medical Center

Adventist Bolingbrook Hospital

Hinsdale Hospital LaGrange Hospital Glen Oaks Medical Center

Adventist Bolingbrook Hospital

Hinsdale Hospital LaGrange Hospital Glen Oaks Medical Center

Adventist Bolingbrook Hospital

Davis Vision (877) 393-8844

(effective 07/01/08)

Cole Vision Self Refer (800) 334-7591

Cole Vision Self Refer (800) 334-7591

ORTHOTIC/PROSTHETIC (See L Code List)

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

Highland Pacemaker Clinic Red

Highland Pacemaker Clinic Red

In the office of ORS Red Referral

In the office of ORS Red Referral

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

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

LLC If no Milliman, needs review

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

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

Green Referral

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

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

Hinsdale Hospital LaGrange Hospital Glen Oaks Medical Center Bolingbrook Hospital

Green

Hinsdale Hospital LaGrange Hospital Glen Oaks Medical Center Bolingbrook Hospital

Green

Page 13: Service Grid by Site

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

Hinsdale Physicians Healthcare TID # 36-3851702

P.O. Box 7789, Westchester, IL 60154 Health Plan Precert

Customer Service # : 708-432-4053 Medical Leadership Review

SERVICES HUMANA UNICAREHMOI/BADV # 257

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

STERILIZATION: Vasectomy Check Benefit

Tubal Ligation Check Benefit

SUBSTANCE ABUSE

SYNAGIS

SYNVISC

TERTIARY HOSPITALS - ADULT

TERTIARY HOSPITALS - PEDS.

THERAPY - OCCUPATIONAL

THERAPY - PHYSICAL

THERAPY - SPEECH

TRANSPLANTS

TRANSPORTATION N/A N/A N/A

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

XOLAIR

***THIS IS NOT AN ALL-INCLUSIVE LISTING

*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

Check Benefit Per Healthplan

Check Benefit Per Healthplan

Check Benefit Per Healthplan

Check Benefit Per Healthplan

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

Ortho Office or PCP Office Injection ordered through

Ultracare

Ortho Office or PCP Office Injection ordered through

Ultracare

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

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

Loyola University Medical Center University of Chicago Hospital

Loyola University Medical Center Rush 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

THALLIUM STRESS TEST (Red or Green referral)

Cardiologist or Hospital Illinois Heart & Vascular

Green

Cardiologist or Hospital Illinois Heart & Vascular

Green

Cardiologist or Hospital Illinois Heart & Vascular

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

See Scope of Benefits Audrey Johnson-Tarver

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

Per Healthplan (800) 626-2698

Per Healthplan (866) 694-0724

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

McKesson Walgreens Ultracare

McKesson Walgreens Ultracare

Page 14: Service Grid by Site

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

AMBULANCE Superior (708) 832-2000

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

BLOOD TRANSFUSION Red Red

Cardiac Svc/Angioplasty/CABG

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)

Colonoscopy @ Hospital Colonoscopy @ Hospital

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

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)

Group Allows Specialists to Request Referrals

Yes, In-network providers and home hospital only

Yes, In-network providers and home hospital only

Page 15: Service Grid by Site

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 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

Check Benefits Contracted 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

Check Scope of Benefits Call for Benefits

See Health Plan Prov. List

Check Benefit Per Healthplan

INFUSION SERVICES - IVIG AND REMICADE

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)

Per Healthplan (888) 234-8855

PsycHealth Self Refer

(800) 753-5456

Wellpoint Self Refer

(800) 746-6294

Holy Cross Hospital Green

Holy Cross Hospital Green

Regional MRI Preferred Open MRI

Regional MRI Preferred Open MRI

Page 16: Service Grid by Site

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 UNICAREHMOI/BADV # 334

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

SKILLED NURSING FACILITY

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

Davis Vision (877) 393-8844

(effective 07/01/08)

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 (Green)

Holy Cross Hospital Check Appendix B

Holy Cross Hospital (Green)

Holy Cross Hospital (Green)

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

Page 17: Service Grid by Site

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 UNICAREHMOI/BADV # 334

SYNAGIS

SYNVISC

TERTIARY HOSPITALS - ADULT

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

THERAPY - PEDS. PT/OT/ST

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

***THIS IS NOT AN ALL-INCLUSIVE LISTING

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

Per Healthplan (866) 694-0724

X-Rays Allowed in Ortho Office (Fracture Care)

No (Unless Urgent)

No (Unless

Urgent)

Page 18: Service Grid by Site

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

Ingalls Provider Group TID # 36-3485578

P.O. Box 7790, Westchester, IL 60154 Health Plan Precert

Customer Service # : 708-432-4052 Medical Leadership Review

SERVICES UNICARE

ABORTION

ACUPUNCTURE Vaught Chiropractic

AMBULANCE Superior (708) 832-2000

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 @ Hospital Colonoscopy @ Hospital

COLONOSCOPY DIAGNOSTICConsult required (Green) Consult required (Green)

Colonoscopy @ Hospital Colonoscopy @ Hospital

CT SCAN

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

DIALYSIS See Appendix E Per Health Plan

DURABLE MED. EQUIPMENT/SUP.

EEG- 24 HOUR Ingalls Ingalls

HMOI/BADV # 213

Check Benefit See BCBS Contracted Vender

List

Check Benefit Per Healthplan

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

Group Allows Specialists to Request Referrals

Only general surgeons, ortho for surgery, oncology

Only general surgeons, ortho for surgery, oncology

Page 19: Service Grid by Site

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

Ingalls Provider Group TID # 36-3485578

P.O. Box 7790, Westchester, IL 60154 Health Plan Precert

Customer Service # : 708-432-4052 Medical Leadership Review

SERVICES UNICAREHMOI/BADV # 213

GREEN REFERRAL PROCESS

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

NUTRITIONAL COUNSELING

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

Check Benefits Contracted 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 Scope of Benefits Call for Benefits

See Health Plan Prov. List

Check benefits - IPG Risk No Precert needed from Unicare

INFUSION SERVICES - IVIG AND REMICADE

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.

PsycHealth Self Refer

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

Page 20: Service Grid by Site

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

Ingalls Provider Group TID # 36-3485578

P.O. Box 7790, Westchester, IL 60154 Health Plan Precert

Customer Service # : 708-432-4052 Medical Leadership Review

SERVICES UNICAREHMOI/BADV # 213

OBSERVATION- 23 HOUR Ingalls Ingalls

OPTOMETRY

OUTPATIENT LABS Ingalls Memorial Hopsital Ingalls Memorial Hopsital

OUTPATIENT PHP/IOP

OUTPATIENT SURGICAL PROCS

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

Tubal Ligation Check Benefit

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

Scheck & Siress Hanger Prosthetic & Orthotics

MD Orthotics

Ingalls Harvey or Tinley Park Midwest Eye Surgical Center

Check Appendix B

Ingalls Harvey or Tinley Park

Ingalls Red

Ingalls Red

In the office of ORS Red

In the office of ORS 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)

Check Benefit Per Healthplan

Check Benefit Per Healthplan

Not Managed by NAMM Call Healthplan

Not Managed by NAMM Call Healthplan

Page 21: Service Grid by Site

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

Ingalls Provider Group TID # 36-3485578

P.O. Box 7790, Westchester, IL 60154 Health Plan Precert

Customer Service # : 708-432-4052 Medical Leadership Review

SERVICES UNICAREHMOI/BADV # 213

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

TRANSPORTATION N/A N/A

Yes Yes

X-rays Allowed in Ortho. Office No No

XOLAIR Walgreens Walgreens

***THIS IS NOT AN ALL-INCLUSIVE LISTING

Rush Presbyterian University of Chicago

University of Chicago Children's Memorial Hospital

Hope Children's Hospital

University of Chicago Children's Memorial Hospital

THALLIUM STRESS TEST (Red or Green referral)

Ingalls Green

Ingalls Green

Ingalls or ICOR (Ingalls Center for Outpatient

Rehab.)

Ingalls or ICOR (Ingalls Center for Outpatient

Rehab.)

See Scope of Benefits Audrey Johnson-Tarver

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

Per Healthplan (866) 694-0724

X-rays Allowed in Ortho office (Fracture Care)

Page 22: Service Grid by Site

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

Northwest Community Health Partners TID # 36-2340313

P.O. Box 7819, Westchester, IL 60154 Health Plan Precert

Customer Service # : 708-432-4054 Medical Leadership Review

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

DIALYSIS See Appendix E Per Health Plan

DURABLE MED. EQUIPMENT/SUP.

EEG - 24 HOUR

GREEN REFERRAL PROCESS

HMOI/BADV # 336

Check Benefit See BCBS Contracted Vender

List

Check Benefit Per Healthplan

Des Plaines Chiropractic Center (847) 299-3440

Des Plaines Chiropractic Center (847) 299-3440

Chicago Ambulance Alliance (800) 558-6050

Red (Including Type & Cross)

Red (Including Type & Cross)

Cardiac Svc/Angioplasty/CABG

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

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

Walgreens Home Medical (800) 323-2828

Northwest Community Hospital Green

Northwest Community Hospital Green

Group Allows Specialists to Request Referrals

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

Page 23: Service Grid by Site

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

Northwest Community Health Partners TID # 36-2340313

P.O. Box 7819, Westchester, IL 60154 Health Plan Precert

Customer Service # : 708-432-4054 Medical Leadership Review

SERVICES HUMANAHMOI/BADV # 336

GYNECOLOGICAL ONCOLOGY

HEARING AIDS

HIGH RISK MATERNITY

HOME HEALTH CARE

IMMUNIZATIONS - TRAVEL

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

NON-COMPLIANCE POLICY Yes Yes

NUTRITIONAL COUNSELING

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

Check Benefits Contracted Vendor

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

Check Scope of Benefits Call for Benefits

See Health Plan Prov. List

Fax the completed Humana Form Fertility Centers of Illinois

PsycHealth Self Refer

(800) 753-5456

Self Refer (800) 331-9040

Northwest Community Hospital Green

Northwest Community Hospital Green

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

Page 24: Service Grid by Site

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

Northwest Community Health Partners TID # 36-2340313

P.O. Box 7819, Westchester, IL 60154 Health Plan Precert

Customer Service # : 708-432-4054 Medical Leadership Review

SERVICES HUMANAHMOI/BADV # 336

OBSERVATION - 23 HOUR Northwest Community Hospital Northwest Community Hospital

OPTOMETRY

Any contracted vendor Any contracted vendor

OUTPATIENT LABS

OUTPATIENT PHP/IOP

OUTPATIENT SURGICAL PROCS

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

Tubal Ligation Check Benefit

SUBSTANCE ABUSE Not Managed by NAMM - Call Health Plan

SYNAGIS

Davis Vision (877) 393-8844

(effective 07/01/08)

Cole Vision Self Refer (800) 334-7591

ORTHOTIC/PROSTHETIC (See L Code List)

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

In the office of AN Red

Northwest Community Hospital Green

Northwest Community Hospital Green

Provided by Radiation/Onc at Northwest Community Hospital

Provided by Radiation/Onc at Northwest Community Hospital

Northwest Community Hospital Green

Northwest Community Hospital Green

Check Benefit

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

Page 25: Service Grid by Site

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

Northwest Community Health Partners TID # 36-2340313

P.O. Box 7819, Westchester, IL 60154 Health Plan Precert

Customer Service # : 708-432-4054 Medical Leadership Review

SERVICES HUMANAHMOI/BADV # 336

SYNVISC Ortho Office Ortho Office

TERTIARY HOSPITALS - ADULT

TERTIARY HOSPITALS - PEDS.

THERAPY - OCCUPATIONAL

THERAPY - PEDS. PT/OT/ST

THERAPY - PHYSICAL

THERAPY - SPEECH Northwest Community Hospital Northwest Community Hospital

TRANSPLANTS

TRANSPORTATION N/A N/A

Yes Yes

X-rays Allowed in Ortho. Office Yes Yes

XOLAIR McKesson McKesson

***THIS IS NOT AN ALL-INCLUSIVE LISTING

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

THALLIUM STRESS TEST

Northwest Community Hospital Green

Northwest Community Hospital Green

Northwest Community Hospital (Age 10 and up)

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

Northwest Community Hospital (Age 10 and up)

Northwest Community Hospital (Age 10 and up)

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

Per Healthplan (800) 626-2698

X-rays Allowed in Ortho Office (Fracture Care)

Page 26: Service Grid by Site

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Oak West Primary Physician Assoc. TID # 36-4008699

P.O. Box 7820, Westchester, IL 60154

Customer Service # : 708-432-1287

Health Plan Precert

Medical Leadership Review

SERVICES UNICARE

ABORTION

ACUPUNCTURE No Coverage

AMBULANCE Superior (708) 832-2000

BLOOD TRANSFUSION

Cardiac Svc/Angioplasty/CABG Westlake

CHEMOTHERAPY

CHIROPRACTIC

COLONOSCOPY SCREENINGConsult not required Consult not required Consult not required

Colonoscopy @ Hospital Colonoscopy @ Hospital Colonoscopy @ Hospital

COLONOSCOPY DIAGNOSTICColonoscopy @ Hospital Colonoscopy @ Hospital Colonoscopy @ Hospital

CT SCAN Westlake

CT SCAN - 64 SLICE Westlake

DIALYSIS Per Appendix E

DURABLE MED. EQUIPMENT/SUP.

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

Superior (708) 832-2000 or ANY Contracted Ambulance

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.

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

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

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

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

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

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

Red

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

Red

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

Red

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

Red

Per Healthplan (312) 234-8800

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

Page 27: Service Grid by Site

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Oak West Primary Physician Assoc. TID # 36-4008699

P.O. Box 7820, Westchester, IL 60154

Customer Service # : 708-432-1287

Health Plan Precert

Medical Leadership Review

SERVICES UNICARE

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

EEG - 24 HOUR Westlake

Yes Yes

GREEN REFERRAL PROCESS

GYNECOLOGICAL ONCOLOGY

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

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

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

Group Allows Specialists to Request Referrals and Imaging

Schwab Rehab Hospital Audiology Dept.

(773) 522-5870

Patient obtains Green Referral and Script from PCP

Patient obtains Green Referral and Script from PCP

Patient obtains Green Referral and Script from PCP

Dr. Donna Smith @ Loyola Red

Dr. Donna Smith @ Loyola Red

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 Benefits Contracted Vendor

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

INFUSION SERVICES - IVIG AND REMICADE

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

PCP to determine care setting.

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

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

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

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

Procare Dr. Piyaka

Wellpoint Self Refer

(800) 746-6294

Self Refer PsycHealth (800) 753-5456

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

Red

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

Red

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Oak West Primary Physician Assoc. TID # 36-4008699

P.O. Box 7820, Westchester, IL 60154

Customer Service # : 708-432-1287

Health Plan Precert

Medical Leadership Review

SERVICES UNICARE

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

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

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

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

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

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

Davis Vision (877) 393-8844

(effective 07/01/08)

Self Refer Per Plan Vision Rider

Adult - No Coverage Under 21 - Self Refer

(800) 424-1155

ORTHOTIC/PROSTHETIC (See L Code List)

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

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

Check Appendix B

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

Westlake Community Hospital or Our Lady of the Res.

Red

Westlake Community Hospital or Our Lady of the Res.

Red

Westlake Community Hospital or Our Lady of the Res.

Red

In the office of ORS Red

In the office of ORS Red

In the office of AN Red

In the office of AN Red

In the office of AN 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.

Page 29: Service Grid by Site

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Oak West Primary Physician Assoc. TID # 36-4008699

P.O. Box 7820, Westchester, IL 60154

Customer Service # : 708-432-1287

Health Plan Precert

Medical Leadership Review

SERVICES UNICARE

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

RADIATION THERAPY

SKILLED NURSING FACILITY

SLEEP STUDY - ADULT

SLEEP STUDY - PEDS University of Chicago Hospital

STERILIZATION Vasectomy

Tubal Ligation

SUBSTANCE ABUSE

SYNAGIS

SYNVISC Ortho Office Ortho Office

TERTIARY HOSPITALS - ADULT

TERTIARY HOSPITALS - PEDS.

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

Merit Sleep Management (888) 637-4848

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

Loyola University Medical Ctr. University of Chicago

Mt. Sinai Hospital

Loyola University Medical Ctr. University of Chicago

Loyola University Medical Ctr. University of Chicago

Mt. Sinai Hospital Rush Medical Center

THALLIUM STRESS TEST

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

Green

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

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

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

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

Westlake UNLIMITED

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

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

Westlake UNLIMITED

See Scope of Benefits Audrey Johnson-Tarver

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

Per Healthplan (866) 694-0724

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

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Oak West Primary Physician Assoc. TID # 36-4008699

P.O. Box 7820, Westchester, IL 60154

Customer Service # : 708-432-1287

Health Plan Precert

Medical Leadership Review

SERVICES UNICARE

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

Transportation N/A N/A

Yes Yes Yes

X-rays Allowed in Ortho. Office No No No

XOLAIR Care Mark Care Mark Care Mark

***THIS IS NOT AN ALL-INCLUSIVE LISTING

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

X-rays Allowed in ortho office (Fracture Care)

Page 31: Service Grid by Site

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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 @ Hospital Colonoscopy @ Hospital

COLONOSCOPY DIAGNOSTICConsult required (Red) Consult required (Red)

Colonoscopy @ Hospital Colonoscopy @ Hospital

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

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

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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 HealthSpring 847-993-1928

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

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

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

Page 33: Service Grid by Site

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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 HealthSpring 847-993-1928

HealthSpring 847-993-1928

NON-COMPLIANCE POLICY Yes Yes

NUTRITIONAL COUNSELING

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

Self Refer MHN (800) 511-6946

Self Refer MHN (800) 511-6946

Heart Care Centers of Illinois Red

Will County Medical Associates (815) 725-2121

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

Will County Medical Associates (815) 725-2121

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

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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 HealthSpring 847-993-1928

HealthSpring 847-993-1928

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

THALLIUM STRESS TEST

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

***THIS IS NOT AN ALL-INCLUSIVE LISTING

Office-no precert Hospital-Precert

Office-no precert Hospital-Precert

Call HealthSpring for benefit determination

Call HealthSpring for benefit determination

Self Refer MHN (800) 511-6946

Self Refer MHN (800) 511-6946

Metro South Medical Center Green

Provena St. Joseph Hospital Green

Metro South Medical Center

Metro South Medical Center

Metro South Medical Center

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)

Page 35: Service Grid by Site

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Silver Cross MCO TID # 36-3876019

P.O. Box 7849, Westchester, IL 60154 Health Plan Precert

Customer Service # : 815-727-1998 Medical Leadership Review

SERVICES HUMANA UNICARE

ABORTION

ACUPUNCTURE

AMBULANCE Superior (708) 832-2000

BARIATRIC

BLOOD TRANSFUSION Green Green Green

CARDIAC STRESS TEST

Cardiac Svc/Angioplasty/CABG

CHEMOTHERAPY

CHIROPRACTIC Davidson Chiropractic Davidson Chiropractic Davidson Chiropractic

COLONOSCOPY SCREENINGConsult not required Consult not required Consult not required

Colonoscopy @ Hospital Colonoscopy @ Hospital Colonoscopy @ Hospital

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

Colonoscopy @ Hospital Colonoscopy @ Hospital Colonoscopy @ Hospital

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

Check Benefit Per Healthplan

Check Benefit Per Healthplan

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

4358

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

4359

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

4360

Superior (708) 832-2000 or ANY Contracted Ambulance

Chicago Ambulance Alliance (800) 558-6050

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

Per Dr. Hindo

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

Per Dr. Hindo

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

Per Dr. Hindo

Silver Cross Hospital Green

Silver Cross Hospital Red

Silver Cross Hospital Green

Silver Cross Hospital Provena St. Joseph

Silver Cross Hospital Provena St. Joseph

Silver Cross Hospital Provena St. Joseph

Joliet Oncology/Hem Midwest Center for Hen/Onc.

Green

Joliet Oncology/Hem Midwest Center for Hen/Onc.

Red

Joliet Oncology/Hem Midwest Center for Hen/Onc.

Green

Silver Cross Hospital Homer Glen Facility-Non contrast Imaging

Green

Silver Cross Hospital Homer Glen Facility-Non contrast Imaging

Green

Silver Cross Hospital Homer Glen Facility-Non contrast Imaging

Green

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

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

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.)

Silver Cross Hospital Homer Glen Facility

CPT 0144T Facility ID 10031

(PA Review Mandatory-Red Ref.)

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

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

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

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Silver Cross MCO TID # 36-3876019

P.O. Box 7849, Westchester, IL 60154 Health Plan Precert

Customer Service # : 815-727-1998 Medical Leadership Review

SERVICES HUMANA UNICAREHMOI/BADV # 266

EKG

GREEN REFERRAL PROCESS Stamp Script Stamp Script Stamp Script

GYNECOLOGICAL ONCOLOGY

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

Silver Cross Hospital Homer Glen Facility

Silver Cross Hospital Homer Glen Facility

Silver Cross Hospital Homer Glen Facility

Group Allows Specialists to Request Referrals

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

Gloval OB referral not required for global OB care

Gloval OB referral not required for global OB care

Check Benefits Per BCBS - Hearing aids may

be obtained from any vendor

Check Benefits Contracted Vendor

Check Benefits Contracted Vendor

Women's Health Consultants/RUMC (Level II

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

Loyola University Medical Center

Women's Health Consultants/RUMC (Level II

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

Loyola University Medical Center

Call for Benefits Any contracted BCBS infertility provider

Fax the completed Humana Form Fertility Centers of Illinois

INFUSION SERVICES - IVIG AND REMICADE

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)

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)

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.

United Shockwave "O" note-Ingalls Surg Ct.

United Shockwave "O" note-Ingalls Surg Ct.

Central Professional Group Green

Self Refer (800) 331-9040

Wellpoint Self Refer

(800) 746-6294

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

Silver Cross MCO TID # 36-3876019

P.O. Box 7849, Westchester, IL 60154 Health Plan Precert

Customer Service # : 815-727-1998 Medical Leadership Review

SERVICES HUMANA UNICAREHMOI/BADV # 266

MRI'S

MRI'S (OPEN)

MRA Green Green Green

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

NUTRITIONAL COUNSELING

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

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

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

Open Advanced MRI Red

Open Advanced MRI Red

Open Advanced MRI Red

Silver Cross Hospital Green Referral

Silver Cross Hospital Green Referral

Silver Cross Hospital Green Referral

Davis Vision (877) 393-8844

(effective 07/01/08)

Eye Med Self Refer

(866) 273-0817

Self Refer Per Plan Vision Rider

ORTHOTIC/PROSTHETIC (See L Code List)

Scheck & Siress Hanger Prosthetic & Orthotics

MD Orthotics

Scheck & Siress MD Orthotics

Scheck & Siress Hanger Prosthetic & Orthotics

MD Orthotics

Silver Cross Hospital Homer Glen Facility

Silver Cross Hospital Homer Glen Facility

Silver Cross Hospital Homer Glen Facility

Silver Cross Hospital Check Appendix B

Alliance Healthcare Services, Inc (866) 667-7226

Provider ID # 1235282344

Alliance Healthcare Services, Inc (866) 667-7226

Provider ID # 1235282344

Alliance Healthcare Services, Inc (866) 667-7226

Provider ID # 1235282344

Silver Cross Hospital Green

Silver Cross Hospital Red

Silver Cross Hospital Green

Silver Cross Hospital Green

Silver Cross Hospital Green

Silver Cross Hospital Green

Dr. Asaad@Hoffman Center Green

Dr. Asaad@Hoffman Center Red

Dr. Asaad@Hoffman Center Green

Page 38: Service Grid by Site

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

Silver Cross MCO TID # 36-3876019

P.O. Box 7849, Westchester, IL 60154 Health Plan Precert

Customer Service # : 815-727-1998 Medical Leadership Review

SERVICES HUMANA UNICAREHMOI/BADV # 266

SKILLED NURSING FACILITY

SLEEP STUDY ADULT

SLEEP STUDY PEDS.

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

Tubal Ligation Check Benefit

SUBSTANCE ABUSE

SYNAGIS

SYNVISC

TERTIARY HOSPITALS - ADULT

TERTIARY HOSPITALS - PEDS.

THERAPY - OCCUPATIONAL

THERAPY - PEDS. PT/OT/ST

THERAPY - PHYSICAL

THERAPY - SPEECH

TRANSPLANTS

Cardinal Sleep Center Green

Cardinal Sleep Center Green

Cardinal Sleep Center Green

Cardinal Sleep Center Green

Cardinal Sleep Center Green

Cardinal Sleep Center Green

Check Benefit

Check Benefit

Not managed by NAMM Patients need to call Healthplan

Not managed by NAMM Patients need to call Healthplan

Not managed by NAMM Patients need to call Healthplan

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

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

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.

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

relations.

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

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

THALLIUM STRESS TEST

Silver Cross Hospital Green

Silver Cross Hospital Green

Silver Cross Hospital Green

Silver Cross Hospital Green

Silver Cross Hospital Green

Silver Cross Hospital Green

Silver Cross Hospital Green

Silver Cross Hospital Green

Silver Cross Hospital Green

Silver Cross Hospital Green

Silver Cross Hospital Green

Silver Cross Hospital Green

Silver Cross Hospital Green

Silver Cross Hospital Green

Silver Cross Hospital Green

See Scope of Benefits Audrey Johnson-Tarver

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

Per Healthplan (800) 626-2698

Per Healthplan (866) 694-0724

Page 39: Service Grid by Site

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

Silver Cross MCO TID # 36-3876019

P.O. Box 7849, Westchester, IL 60154 Health Plan Precert

Customer Service # : 815-727-1998 Medical Leadership Review

SERVICES HUMANA UNICAREHMOI/BADV # 266

TRANSPORTATION N/A N/A N/A

Yes Yes Yes

X-rays Allowed in Ortho. Office Yes Yes Yes

X-RAYS

XOLAIR Red Red Red

***THIS IS NOT AN ALL-INCLUSIVE LISTING

X-Rays Allowed in Ortho Office (Fracture Care)

Silver Cross Hospital Homer Glen Facility

Silver Cross Hospital Homer Glen Facility

Silver Cross Hospital Homer Glen Facility

Page 40: Service Grid by Site

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

Swedish Covenant Managed Care TID # 36-4118659

P.O. Box 7850, Westchester, IL 60154 Health Plan Precert

Customer Service # : 708-432-4055 Medical Leadership Review

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 SCREENINGConsult not required Consult not required Consult not required

Colonoscopy @ Hospital Colonoscopy @ Hospital Colonoscopy @ Hospital

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

Colonoscopy @ Hospital Colonoscopy @ Hospital Colonoscopy @ Hospital

CT SCAN

CT SCAN - 64 SLICE

DIALYSIS Swedish Swedish Swedish

DURABLE MED. EQUIPMENT/SUP.

EEG - 24 HOUR Swedish Swedish Swedish

No No No

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

Check Benefit Per Healthplan

Check Benefit Per Healthplan

Swedish - After all conservative treatments have been exhausted

Swedish - After all conservative treatments have been exhausted

Swedish - After all conservative treatments have been exhausted

Chicago Ambulance Alliance (800) 558-6050

Chicago Ambulance Alliance (800) 558-6050

Chicago Ambulance Alliance (800) 558-6050

Swedish - After all conservative treatments have been exhausted

Swedish - After all conservative treatments have been exhausted

Swedish - After all conservative treatments have been exhausted

Swedish Red

Swedish Red

Swedish Red

Swedish Evanston Hospital

Red

Swedish Evanston Hospital

Red

Swedish Evanston Hospital

Red

Walgreens Dependicare

Integrated Walgreens

Dependicare

Integrated Walgreens

Dependicare

Group Allows Specialists to Request Referrals

Page 41: Service Grid by Site

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

Swedish Covenant Managed Care TID # 36-4118659

P.O. Box 7850, Westchester, IL 60154 Health Plan Precert

Customer Service # : 708-432-4055 Medical Leadership Review

HUMANA

SERVICES Commercial Medicare HealthSpring

GYNECOLOGICAL ONCOLOGY

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

Drs. Gustavo Rodriquez and Herbert Beck @ ENH

Red

Drs. Gustavo Rodriquez and Herbert Beck @ ENH

Red

Check Benefits Contracted Vendor

Check Benefits Contracted Vendor

Check Benefits Contracted Vendor

Swedish HRS Home Health

Call for Benefits Fertility Centers of Illinois

Not managed by NAMM Patients need to call Healthplan

Not managed by NAMM Patients need to call Healthplan

Not managed by NAMM Self refer to Mental

Health Network (800) 511-6946

Swedish Red

Swedish Red

Swedish Red

Swedish MRI Lincoln Imaging

Red

Swedish MRI Lincoln Imaging

Red

Swedish MRI Lincoln Imaging

Red

Page 42: Service Grid by Site

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

Swedish Covenant Managed Care TID # 36-4118659

P.O. Box 7850, Westchester, IL 60154 Health Plan Precert

Customer Service # : 708-432-4055 Medical Leadership Review

HUMANA

SERVICES Commercial Medicare HealthSpring

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)

Scheck & Siress MD Orthotics

Scheck & Siress MD Orthotics

Scheck & Siress MD Orthotics

Not managed by NAMM Patients need to call Healthplan

Not managed by NAMM Patients need to call Healthplan

Not managed by NAMM Patients need to call Healthplan

Swedish Covenant Hospital - Red "O" note Pacemaker Clinic

Swedish Covenant Hospital - Red "O" note Pacemaker Clinic

Swedish Covenant Hospital - Red "O" note Pacemaker Clinic

DRW & Associates (773) 805-1871

DRW & Associates (773) 805-1871

DRW & Associates (773) 805-1871

DRW & Associates (773) 805-1871

DRW & Associates (773) 805-1871

Not managed by NAMM Patients need to call Healthplan

Not managed by NAMM Patients need to call Healthplan

Not managed by NAMM Patients need to call Healthplan

Red Referral made out to Walgreen's Home Medical Supply

Red Referral made out to Walgreen's Home Medical Supply

Red Referral made out to Walgreen's Home Medical Supply

Page 43: Service Grid by Site

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

Swedish Covenant Managed Care TID # 36-4118659

P.O. Box 7850, Westchester, IL 60154 Health Plan Precert

Customer Service # : 708-432-4055 Medical Leadership Review

HUMANA

SERVICES Commercial Medicare HealthSpring

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

TRANSPORTATION N/A N/A N/A

Yes Yes Yes

X-rays Allowed in Ortho. Office No No No

XOLAIR Walgreens Home Care Walgreens Home Care Walgreens Home Care

***THIS IS NOT AN ALL-INCLUSIVE LISTING

THALLIUM STRESS TEST

Swedish Green

Swedish Green

Swedish Green

X-rays Allowed in Ortho office (Fracture Care)