Section 140.400  Payment to Practitioners

a)         This Section applies to physicians, dentists, Advanced Practice Nurses (APN) (see Section 140.435), optometrists, podiatrists and chiropractors.

1)         Practitioners are required to bill the Medical Assistance Program at the same rate they charge patients paying their own bills and patients covered by other third party payers.

2)         A practitioner may bill only for services he or she personally provides or which are provided under his or her direct supervision in his or her office by his or her staff.  An APN, as described in Section 140.435, may bill only for the services personally provided by the individual APN.

3)         Payment will be made only in the practitioner's name or a Department approved alternate payee.

4)         Payments will be made according to a schedule of statewide pricing screens established by the Department.  Covered services provided by qualifying providers under the Maternal and Child Health Program will be reimbursed at enhanced rates as described in subsection (b) of this Section.  The pricing screens are to be established based on consideration of the market value of the service.  In considering the market value, the Department will examine the costs of operations and material.  Input from advisory groups designated by statute, generally recognized provider interest groups and the general  public will be taken into consideration in determining the allocation of available funds to rate adjustments.  Increases in rates are contingent upon funds appropriated by the General Assembly.  Reductions or increases may be affected by changes in the market place or changes in funding available for the Medical Assistance Program.  Screens will be related to the average statewide charge.  The upper limit for services shall not exceed the lowest Medicare charge levels.

b)         Practitioners who meet the qualifications for and enter into a Primary Care Provider Agreement for participation in the Maternal and Child Health Program, as described in Subpart G, will receive enhanced reimbursement in accordance with Section 140.930(a)(1).

c)         The Department will distribute (initially and upon revision of the amounts) to practitioners the maximum allowable amounts for the most commonly billed procedures codes.  Interested individuals may request a copy of the maximum allowable amounts from the Department by directing the request to the Bureau of Comprehensive Health Services, Prescott E. Bloom Building, 201 South Grand Avenue East, Springfield, Illinois 62763-0001.  In addition, a participating individual practitioner may request the maximum allowable amounts for less commonly billed specific procedures that relate to the individual's practice.  This request must be in writing and identify specific procedure codes and associated descriptions.

(Source:  Amended at 30 Ill. Reg. 796, effective January 1, 2006)