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YouthCareProvider ManualYOUTHCARE HEALTHCHOICE ILLINOISUpdated 2/1/20201
We thank you for being part of YouthCare’s network ofparticipating physicians, hospitals, and other healthcareprofessionals. Our number one priority is the promotionof healthy lifestyles through preventive healthcare.YouthCare works to accomplish this goal by partneringwith the providers who oversee the healthcare of ourmembers.ABOUT USMISSIONYouthCare HealthChoice Illinois was designed bythe Illinois Department of Healthcare and FamilyServices (HFS) and Department of Children and FamilyServices (DCFS) to serve Illinois members through theHealthChoice Illinois plan. It builds on the local servicesystem, consent process, comprehensive assessmentsand consent requirements to help improve the safety,well-being and permanency of children who are, orhave been in DCFS custody.YouthCare focuses on improving members’ healthstatus, encouraging successful outcomes, andstriving for member and provider satisfaction ina coordinated care environment. YouthCare wasdesigned to achieve the following goals:The YouthCare program will deliver tailored programsthat support health and stability for those in out-ofhome placement. Additionally, the program offers longterm support for adoptive families and children,transitional health and social support for youth who ageout of the system. Improve access to all necessary healthcare services. Encourage quality, continuity, and appropriateness ofYouthCare has the expertise to improvemembers’ health status and quality of life. Ourparent company, Centene Corporation, has beenproviding comprehensive managed care services toindividuals receiving benefits under Medicaid and othergovernment-sponsored healthcare programs for morethan 30 years. Centene operates local health plansin multiple states and offers a wide range of healthinsurance solutions to a variety of individuals. Centenealso contracts with other healthcare and commercialorganizations to provide specialty services. For moreinformation about Centene, visit centene.com.YouthCare is a physician-driven program that iscommitted to building collaborative partnershipswith providers. YouthCare will serve our membersconsistently with our core philosophy that qualityhealthcare is best delivered locally.2 Ensure access to primary and preventive careservices. Ensure care is delivered in the best setting to achievean optimal outcome.medical care. Provide medical coverage in a cost-effective manner.HOW TO USE THIS MANUALYouthCare is committed to working with our networkof providers to achieve a high level of satisfaction indelivering quality healthcare benefits. The ProviderManual contains a comprehensive overview ofYouthCare operations, benefits, policies, andprocedures.Please contact the Provider Services department ifyou need further explanation on any topics coveredin the Provider Manual.
Contact InformationThe following chart contains contact information for YouthCare. When contacting anydepartment, please have the following information on hand: National Provider Identifier (NPI); Tax ID Number (TIN); and If calling about a member-related issue, please know the member’s ID Number.YouthCare’s hours of operation are Monday – Friday 8:00 a.m. to 6 p.m. (CST)YouthCare HealthChoice Illinois Member and Provider ServicesWebsite844-289-2264TTY: 711ILYouthCare.com3
Claims Contact InformationUse the below contact information when submitting claims-related requests to YouthCare.CLAIMS TYPEFIRST SUBMISSION OF CLAIMS(MEDICAL AND BEHAVIORAL HEALTH)YouthCareAttn: ClaimsPO Box 4020Farmington, MO 63640-4402MEDICAL REQUESTS FOR RECONSIDERATION ANDCORRECTED CLAIMSYouthCareAttn: ReconsiderationPO Box 4020Farmington, MO 63640-4402MEDICAL CLAIM DISPUTEYouthCareAttn: Claim DisputePO Box 4020Farmington, MO 63640-3800BEHAVIORAL HEALTH REQUESTS FOR RECONSIDERATIONAND CORRECTED CLAIMSYouthCareAttn: BH ReconsiderationPO Box 7300Farmington, MO 63640-3828BEHAVIORAL HEALTH CLAIM DISPUTEYouthCareAttn: BH DisputePO Box 7300Farmington, MO 63640-3809PHARMACY CLAIMS4ADDRESSEnvolve Pharmacy Solutions5 River Park Place EastSuite 210Fresno, CA 93720
Payer IDs For ClearinghousesIf you would like to submit your claims through a clearinghouse, please use YouthCare’sPayer ID #: 68069If you have any questions about submitting claims through clearinghouses, please contact:YouthCare c/o Centene EDI Department800-225-2573, ext. 6075525EDIBA@centene.com5
YouthCare HealthChoice Illinois plan is availablein all Illinois allRock lMcMasonSchuylerDe ankakeeMarshallKnoxWarrenHendersonStarkckWillLa JacksononmslliaWiUnionerdxanAle6nd ClarkerlarygomeMontSalineon abashSc
Member EligibilityMEMBER ID CARDAll YouthCare members receive an ID card (see sample below). Members should presenttheir ID card at the time of service, but an ID card in and of itself is not a guarantee of eligibility; therefore,providers must verify a member’s eligibility on each date of service.The member ID number, effective date, contact information for YouthCare, and PCP information areincluded on the ID card. If you are not familiar with the member seeking care, please ask to see photoidentification for confirmation. If you suspect fraud, please contact Provider Services immediately.YouthCare HealthChoice Illinois ID card:YouthCareHealthChoice IllinoisMember Name:Medicaid ID #:Effective Date:PCP Name:PCP Number:YouthCareRXBIN: 020545RXPCN: RXA383RXGROUP: RXGMCIL01MEMBERSMember Services, Behavioral Health, Dental,Transportation, 24/7 Nurse Advice Line:844-289-2264TTY: 711ILYouthCare.comMailing AddressYouthCareHealthChoice IllinoisPO Box 92050Elk Grove Village, IL 60009-2050PROVIDERS24/7 Eligibility and Prior Auth Check:844-289-2264Envolve Pharmacy Solutions Help Desk:800-678-6237Paper ClaimsYouthCareHealthChoice IllinoisAttn: ClaimsPO Box 4020Farmington, MO 63640-4402Payer ID #: 68069Claim and EFT/ERA information on ILYouthCare.com7
VERIFYING ELIGIBILITYUse one of the following methods to verify a member’s eligibility:Log on to the Provider Portalat Provider.IlliniCare.com.Providers can search by dateof service plus any of thefollowing: member nameand date of birth, or memberID number. You can submitmultiple member ID numbersin a single request.8Call our automated membereligibility Interactive VoiceResponse (IVR) system.Call Provider Services from anytouch tone phone and followthe appropriate menu optionsto reach our automatedmember eligibility-verificationsystem 24 hours a day. Theautomated system will promptyou to enter the member IDnumber, the member date ofbirth, and the month of serviceto check eligibility.Call Provider Services.If you cannot confirm amember’s eligibility usingthe first two methods, callProvider Services. Followthe menu prompts to speakto a representative to verifyeligibility before renderingservices. Provider Serviceswill need the member nameor member ID number andthe member date of birth toverify eligibility.
Benefit Explanation & LimitationsYouthCare providers supply a varietyof medical benefits and services, some ofwhich are outlined on the following pages. Allservices must be medically necessary andsome services require prior authorization. Seepage 16 for information regarding the priorauthorization process.Please note we will NOT authorize servicesfor out of network or non-participatingproviders, unless the services are necessaryfor continuity of care reasons. We may alsoauthorize services for out of network providersat our discretion if the services are notavailable through our in-network providers.For specific benefit information not covered inthis Manual, please contact Provider Services.Providers can also reference ILYouthCare.com forthe most recent benefit updates.9
COVERED SERVICESNote: Some services require prior authorization.Always check if services need prior authorizationbefore completing. See page 16 for informationregarding the prior authorization process. Abortion services in limited situations Advanced Practice Nurse services Ambulatory Surgical Treatment Center services Assisted living Audiology services Behavioral health outpatient services Community case services Crisis services Inpatient psychiatric services Intensive outpatient services Partial hospitalization services Residential rehabilitation services Chiropractic services Clinic services Dental services Durable medical equipment Early and Periodic Screening, Diagnostics, and Family Planning services and supplies Pharmacy servicesHome Health Agency visitsHospital ambulatory (outpatient) servicesHospital inpatient servicesHospital emergency department servicesImaging servicesLaboratory servicesMedical supplies, equipment, prostheses, andorthosesPhysician servicesPodiatric servicesRenal dialysis servicesSub-acute alcohol and substance abuse servicesTransportation to secure covered medical servicesTreatment (EPSDT) services to members under theage of twenty-one (21)ADDITIONAL BENEFITSYOUTHCARE HEALTHCHOICE ILLINOIS10No CopaysNo copays for medical visits or prescriptions.PrescriptionsOption for 90-day supply mailed to member’s home.Dental ServicesServices provided in school dental programs.Practice Visits“Practice visits” to the dentist or certain specialists if needed.My Health Pays Rewards program that provides prepaid debit card with funds added whenmembers utilize certain screenings and preventive care.Connections PlusCell phones provided to eligible members who don’t have access to a phoneto call providers, 911, or care coordinators.Vision Services 100 credit for eyeglass frames or an 80 credit for contact lenses. Replacement Glasses: Eyeglasses may be replaced as needed, withoutpre-authorizationNurse Advice LineMembers can call a nurse for advice 24 hours a day, 7 days a week.
General Preventive Care ServicesPregnancy and Maternity Services Eye exams. We cover an eye exam every once a year Outpatient services including routine prenatal(more if member’s eyesight changes a lot). We coverrefractions to determine a prescription for glasses.care before and after delivery for problems orcomplications resulting from pregnancyor childbirth. Health education programs including: diabeteseducation, heart health education, nutritionaleducation, etc. Child and youth immunizations. Immunizations are covered according to theAdvisory Committee on Immunization Practices(ACIP), and the United States Preventive ServicesTask Force recommendations. Periodic check-ups. A complete history and physicalexam every one to three years. Cancer screening for cervical, breast, colorectal,prostate, and skin.Well-Child CareThe Child Health & Disability Prevention (CHDP)program offers: Health history. Medical, dental, nutritional assessment as well asphysical and mental developmental assessments. Administration of immunizations. Vision and hearing testing. Some laboratory tests (e.g., tuberculin,sickle cell, blood and urine tests, pap smears). Inpatient hospital services in participatinghospitals and out-of-network emergency laborand delivery services. Care from the Comprehensive Perinatal ServicesProgram (CPSP), including a medical/obstetrical,nutritional, psychosocial, and health educationassessment at the first prenatal visit, one visitduring each trimester thereafter, and at thepostpartum visit. The newborn child’s healthcare for themonth of delivery and the month after delivery.By that time, the newborn should be enrolledseparately.Voluntary Contraception ServicesYouthCare covers the cost of contraceptives,including the birth control device, and fitting orinserting the device (such as diaphragms, IUDs,Norplant). Members can get services from anyqualified family planning provider. He/she does nothave to be a participating provider.Our members do not need a referral from a PCP anddo not have to get permission from YouthCare to getthese services. Health education, anticipatory guidance includingsmoking and information on second-hand smoke. Coverage of any test recommended by YouthCareand medical professionals, and that meets medicalnecessity criteria.Screening and Brief Intervention, Referralfor Treatment (SBIRT)This is a billable service for primary care providersas a way to screen members and refer them toappropriate behavioral health services. YouthCarealso offers training for PCPs on the use of thisscreening tool.11
NON-COVERED SERVICESHere is a list of some of the medical services andbenefits that YouthCare does not cover: Services that are experimental or investigational innature Services that are provided by an out-of-network provider and not authorized by YouthCareServices that are provided without a requiredreferral or required prior authorizationElective cosmetic surgeryInfertility careAny service that is not medically necessaryServices provided through local educationagenciesTHIRD PARTY LIABILITY (TPL) SERVICESProviders that have identified changes in theirpatient’s private health insurance information cannotify the Department of Healthcare and FamilyServices of the change in health insurance status by: Calling the Third Party Liability (TPL) Inquiry Line at 217-524-2490 and speaking with a CustomerService Representative; orFaxing the information to the TPL unit at 217-5571174. (Provided upon request, is a preferred faxform TPL can either fax or email, which includes allnecessary information); or Scanning and sending the information by email tothe TPL unit at HFS.TPL.1442@illinois.gov.Providers should also advise their patients to contactthe TPL unit directly to report the changes in theirprivate health insurance information. Clients cancall, fax or email the TPL unit as outlined above.12When contacting TPL, providers or clients will needto provide the following information: Provider name, phone number, and provider # ortax id; Patient’s RIN (recipient number);Patient’s Name;Patient’s DOB;Policy holder Name, DOB, & SSN;Complete insurance company name andaddress; Policy group # & policy number; and Coverage dates.Please note the above mentioned phone numbersand email address are ONLY for adding or updatingprivate health insurance information. The TPLInquiry Line will not be able to assist clients withquestions that are not related to TPL. Clientsshould use the following resources, for assistancewith other questions: Medicare - send an email to DHS.SSAPC@illinois.gov or fax the information to 217-527-7554; or Managed Care Program - refer to the ManagedCare options listed on this website at dCare/Pages/default.aspx Cash or medical eligibility - find or visit the LocalDHS office at http://www.dhs.state.il.us/page.aspx?, or call the HFS Client Healthcare Hotlineat 800-226-0768, or the DHS Helpline at800-843-6154.
Preventive ScreeningsYouthCare encourages our members to undergoroutine preventive screenings to diagnose and treatconditions in a timely fashion. Below is an overviewof the preventive screenings covered by YouthCare.EARLY AND PERIODIC SCREENING,DIAGNOSTIC AND TREATMENTThe Early and Periodic Screening, Diagnosticand Treatment (EPSDT) benefit is Medicaid’scomprehensive and preventive child healthprogram for individuals under the age of 21, which ismandated by state and federal law.YouthCare provides coverage for the full range ofEPSDT services in accordance with HFS policiesand procedures. These services include periodichealth screenings and appropriate up-to-dateimmunizations using the Advisory Committeeon Immunization Practices (ACIP) recommendedimmunization schedule and the American Academyof Pediatrics (AAP) periodicity schedule for pediatricpreventative care.The following services are included in the EPSDTbenefit: Comprehensive health history Developmental history – including assessment ofboth physical and mental health development Comprehensive physical exam (with clothes offwhen clinically appropriate) Laboratory tests (including blood lead levelassessment) Health education. Vision screening and necessary follow-up services Dental screening and necessary follow-upservices Hearing screening and necessary follow-upservices Other necessary healthcare, diagnostic services,treatment, and other measures to amelioratedefects, physical, and mental illnesses andconditions identified. PCPs should provideinter-periodic screenings, which are MedicallyNecessary to determine the existence ofsuspected physical or mental illnesses orconditions. This includes at a minimum visionand hearing screening services. An inter-periodicvisit may be performed only for vision or hearingscreening services. Appropriate children’s immunizationsAll components of the EPSDT exam must be clearlydocumented in the PCP’s medical record for eachmember. Minimum record requirements areas stated in the Illinois Handbook for Providersof Healthy Kids Services and must include thefollowing: Problem listMedication listPersonal health, social history and family historyPeriodic examination recordsGrowth chartsObjective developmental screening tools or riskassessment screening tools, as applicable Health education and anticipatory guidance Nutritional assessment, including documentationand interpretation of BMI for children starting at 2years of age Relevant history of current illness or injury, if any,and physical findings Immunization records Reports of procedures, tests, and results,including findings and clinical impression fromscreening or assessments Allergy history Diagnostic and therapeutic orders, includingmedication lists Clinical observations, including results oftreatment Diagnostic impressions13
Hospital admissions and discharges, if any Referral information and specialty consultationreports, if anyYouthCare requires that providers cooperateto the maximum extent possible with efforts toimprove the health status of Illinois citizens, and toactively participate in the increase of percentageof eligible members obtaining EPSDT services inaccordance with the adopted periodicity schedules.YouthCare will cooperate and assist providers toidentify all members that are not up-to-date withtheir immunizations.All PCPs should ensure that appropriateimmunizations are available for child members.Vaccines are available at no charge to public andprivate providers for eligible children ages newbornthrough 18 years through the federal Vaccinefor Children (VFC) program. To enroll in the VFCprogram or receive more information, visit the IllinoisDepartment of Public Health website.YouthCare providers shall participate in the Vaccinesfor Children (VFC) program. Vaccines from VFCshould be billed with the specific antigen codes forreimbursement of administration of the vaccine. Nopayment will be made on the administration codesalone.14PREVENTIVE CAREThe below guides are the recommendedpreventive care schedules for youth. Membersshould consult with their PCP to determine whichscreenings are right for them and when to undergoeach screening.Wellness VisitsAgeUnder age 21FrequencyAnnuallyWellness visits include: Complete health history Comprehensive physical exam Preventive screenings (as needed)
Recommended Preventive ScreeningsScreeningRecommendationAlcohol misuse: screening andcounselingMembers age 18 and older.Bacteriuria screeningYouth 12-16 weeks pregnant.Blood pressure screeningAnnually for members age 18 and older.BRCA risk assessment and geneticcounseling/testingYouth with family members with breast,
Log on to the Provider Portal at Provider.IlliniCare.com. Providers can search by date of service plus any of the following: member name and date of birth, or member ID number. You can submit multiple member ID numbers in a single request. Call our automated member eligibility Interactive Voice Response (IVR)
