Long Term Care

IlliniCare Health provides long term care and skilled nursing facility services for our members as part of ICP and FHP. We are committed to providing the highest quality of care for our members, wherever and whenever they access services. As part of this effort to continually pursue quality, we are implementing a Nursing Home quality improvement program for skilled and/or custodial stays. The program will manage authorizations and referrals to direct our members, whenever possible and consistent with all continuity of care obligations, to nursing facilities exhibiting better outcomes, such as those having at least three Overall Stars on the CMS Five-Star Quality Rating System for Nursing Homes (click here for info on CMS Five Star Rating system), or having inpatient admission and non-psych related emergency department visit rates comparable to Three-Star facilities.

The quality improvement program is intended to be a partnership with our providers to work alongside us to improve quality. As such, it also involves engaging nursing home ownership with lower CMS scores (2 stars and under) to focus on outcomes and quality by, for example, decreasing ER visits, improving vaccination rates, assigning participating attending physicians and coordinating census and care gap information. We thank you for your hard work in making sure our members received the best care possible.

Below are Frequently Asked Questions about long term care.

The Department of Healthcare and Family Services also have FAQs about long term care and the Integrated Care Program. These can be found by clicking here.

Physicians can contract with IlliniCare Health by calling 866-329-4701; our Provider Services team will answer questions, and help physicians through the process of becoming contracted. Ranjana Khan, Director of Network Development, can also assist. She can be reached by calling 866-329-4701. For general information on becoming a contracted physician, including applications, credentialing forms, W-9 form, etc. can be found on our website, www.IlliniCare.com, by selecting "Become a Provider" under the "For Providers" tab.

The rounding physicians in the Long Term Care Facility can continue to provide the same care they did in the past, even without a contract. While the member may receive an ID card with a new PCP’s name—the rounding physicians can continue to provide care without disruption. When billing, physicians should bill IlliniCare Health for the services they are providing the resident.

IlliniCare Health has been in close contact with many LTC facilities to explain this process to administrators. If there are further questions, or if a facility would like to set up a meeting with IlliniCare Health, please contact us at 866-329-4701.

IlliniCare Health is making great progress with our hospital network. Both emergent behavioral health and non-behavioral health hospitalizations will be covered, at participating and non-participating facilities. If a Long Term Care facility resident is hospitalized at a non-participating facility for non-urgent/emergent care, IlliniCare Health's Integrated Care coordination team can help by:

  • Assisting the facility identify participating providers/ facilities.
  • Coordinating a Single Case Agreement, when the medically necessary care is not available at a participating facility.
  • Helping the facility coordinate transportation, follow up care needs, and developing a comprehensive medical and psychosocial care plan, based on the member’s care needs/gaps identified during discharge planning and through a Health Risk Assessment.

IlliniCare Health's Integrated Care team can be reached at 866-329-4701.

Facilities interested in contracting with IlliniCare Health can call 866-329-4701, and be directed to the contracting department. There are also many resources on our website at www.IlliniCare.com including applications, forms, etc. Once contracted, IlliniCare Health's Provider Relations team will reach out to LTC facilities within 30 days of their effective date to set up orientations, and answer any questions they have about their contract.

IlliniCare Health already has contracts in place with various facilities in the 606 zip code area. If a facility is not contracted with us, they need to contact us for an authorization for the admission. These can be faxed to our prior authorization department at 1-877-401-8174. Once the stay is authorized, the facility would need to bill the member’s health plan. All claims for IlliniCare Health members can be sent here:

IlliniCare Health
Claims Department
P.O. Box 4020
Farmington, MO 63640-4402

Additional billing information can be found on our website, www.IlliniCare.com, as well as a list of all of our participating LTC facilities. For any additional questions, facilities can call IlliniCare Health Provider Services at 866-329-4701.

Yes, you must submit a claim to IlliniCare Health using a CMS 1450 (UB-04).

Any room and board revenue code can be used. A useful resource for finding appropriate revenue codes can be found by clicking here.

There are varying circumstances surrounding coverage by IlliniCare Health. Please contact our office at 866-329-4701 for specifics regarding a particular member.

IlliniCare Health is responsible for the first 90 days of a new benefit period.

IlliniCare Health will pay the per diem rate as supplied by IDPA.

Medically necessary DME is covered when provided by a state-certified durable medical equipment provider.

Yes. You are still required to submit a ‘Welcome Packet’ to IPDA for each new admission. Once that process is complete, the State will let us know by including the member in the Patient Credit File. Item of Note: It is important to note that if this process is not complete, IlliniCare Health will not pay for any claims.

Medically necessary therapy provided by an entity other than the LTC facility will be covered. The first six visits are covered without authorization; all visits thereafter require authorization to establish medically necessary.

Inpatient hospice is handled as pass-through billing by the hospice provider. IlliniCare Health will pay 95% of the LTC facility’s per diem rate, and the hospice agency is responsible for paying the facility. This arrangement must be agreed upon between the hospice agency and the LTC facility. IlliniCare Health is not part of this negotiation. Please refer to the Hospice Handbook.

In accordance with the Smart Act that went into effect on 4/1/2013, IlliniCare Health implemented the HFS change which eliminates bed holds for adults age 21 year and over in nursing homes.