Medical Benefits/Coverage

Is it the responsibility of IHP or my physician to understand my benefit plan?

It is your responsibility to know your benefits! You have received a Subscriber Benefit Plan Booklet from your HMO. It is important that you read it and become familiar with what is covered and what is not covered. If you are unsure of your benefits, speak with your employer or your HMO directly. IHP Customer Service may be reached at 630-942-7950 to assist you with benefit questions.

Are specialist physicians covered by my HMO plan?

Yes, Specialist services are covered when directed by your Primary Care Physician and within the scope of benefits covered in your health plan. To ensure that services are covered be sure to ask your Primary Care physician for a completed referral form.

What is a co-payment?

This is the dollar amount that you are required to pay the provider at the time of receiving services. Your HMO Plan may have co-payments for physician office visits; Physical, Occupational, Speech Therapy; Emergency Room; Outpatient Prescription Drugs, etc.

Is care in the hospital emergency room covered by my HMO?

If you feel that you have a medical emergency which means that without immediate attention would result in:

    • placing your health in serious impairment; or
    • serious impairment to bodily functions; or
    • serious dysfunction of any bodily organ or part

PROCEED TO THE NEAREST HOSPITAL EMERGENCY ROOM.

If you are unsure, contact your Primary Care Physician for advice. Your Primary Care Physician or his/her covering Physician is available 7 days per week, 24 hours per day. Under most Plans, an Emergency Room co-payment will apply and be collected at the time of service.

Why is the referral process necessary?

Your Primary Care Physician is responsible for coordinating all of your medical care. This is a distinct advantage for you. Your personal physician will have a complete medical record on your medical history and care; this ensures continuity of your care. In the event your Primary Care Physician requires the services of a Specialist Physician to meet your medical care needs at a given time, it is his/her responsibility to make this determination and to coordinate your care with this Specialist.

What must I do to obtain a referral?

1. It is your Primary Care Physician’s responsibility to determine that the services of a Specialist Physician are medically necessary.

2. The Primary Care Physician’s office will generate a Referral Form to the Specialist, indicating the specific services to be provided which may require approval from IHP or your health plan.

3. Your Primary Care Physician’s office either mail a copy of the referral to your home or contact you to let you know that your referral is ready to pick up.

4. It is your responsibility to make the appointment with the Specialist Physician and provide a copy of your referral.;

5. Read the Referral Form. Instructions for the Specialist Physician are indicated. ADDITIONAL CARE/SERVICES REQUIRE ADDITIONAL AUTHORIZATION. If this is not received, these services may not be authorized for payment.

If I have been seeing a specialist prior to becoming a member of my current HMO plan, must I obtain a referral to keep seeing this specialist?

Yes. A Referral must be in place before your visit to this Specialist after your effective date of your current HMO Plan.

Is a referral required for other services such as home health care, equipment for home, out-patient physical, occupational or speech therapy, diagnostic services, etc.?

Yes. These services require the same Referral authorization process stated above.

Do I need a referral from my primary care physician to see a Women’s Principle Health Care provider (ob/gyn)?

Female members may see a Women’s Principle Health Care Provider (WPHCP) who is in the same medical group as your Primary Care Physician without a referral. A WPHCP is an OB/GYN who has agreed to provide primary care for your OB/GYN health needs. For a list of WPHCP who are part of IHP and are accepting new members, please call IHP Member Services at 630-942-7950.

What must I do to obtain a referral for behavioral health care services?

1. It is your Primary Care Physician’s responsibility to determine that the services of a Behavioral Health Care Specialist Physician are medically necessary.

2. The Primary Care Physician’s office will generate a Referral Form to the Behavioral Health Care Specialist indicating the specific services to be provided.

3. Your Primary Care Physician’s office will contact you to let you know that your referral is ready for pick-up.

4. It is your responsibility to make the appointment with the Behavioral Health Care Specialist Physician.

For Blue Advantage and HMOI behavioral health services are a self referral process to Linden Oaks Behavioral Care Management 888-969-7874 for Humana HMO member’s self refer to the phone # on the back of their insurance card.

5. Read the Referral Form. Instructions for the Behavioral Health Care Specialist Physician are indicated. ADDITIONAL CARE/SERVICES REQUIRE ADDITIONAL AUTHORIZATION. If this is not received, these services may not be authorized for payment.

If I have questions on referrals or other HMO procedures, who should I call?

You may contact IHP Customer Service at 630-942-7950 with questions on referrals or HMO guidelines.

What if I require hospital care?

If you require hospitalization, your IHP Primary Care Physician will arrange this for you. This will require prior authorization by the IHP Utilization Management Department..

If I need to report an emergency inpatient admission who should I call?

You may contact IHP Customer Service at 630-942-7950 with admission information.

What is the utilization management process?

Pre-Admission Certification and Concurrent Review are two programs established to ensure that you receive the most appropriate and cost effective health care. Your PCP must obtain approval from your participating MG/IPA prior to inpatient hospital admission other than emergency situations. Your participating MG/IPA may recommend other courses of treatment that could help you avoid an inpatient stay. It is your responsibility to cooperate with the recommendations made by your PCP. Concurrent Review ensures that your length of stay is appropriate given your diagnosis and treatment.

How are utilization management decisions made?

Utilization Management decisions are based only on the appropriateness of care and services, and the existence of coverage. NHCA does not specifically reward practitioners or other individuals for issuing denials of coverage or services. Financial incentives for Utilization Management decision-makers do not encourage decisions that result in under-utilization. IHP affirms that there is no conflict of interest between IHPand its decision-makers.

How can I get questions answered regarding utilization management issues?

Utilization Management (UM) staff are available to receive inbound telephone calls from providers and members regarding UM inquiries and questions Monday-Friday, 8:00 a.m.-5:00 p.m., except holidays..

Each staff member has a confidential voice mail system for incoming calls. For urgent issues, the voice mail instructions for each staff member provides directions on how to contact the on-call UM representative. After business hours, callers may also leave a message with IHP’s answering service or request that the answering service contact the on-call UM representative. On-call coverage by a UM staff member is provided 24 hours/day, 7 days/week. Whenever initiating or returning telephone calls, UM staff provide their name, title, and organization. Telephone calls are returned within one business day of receiving a message.

How are outpatient prescription drugs handled?

If your prescriptions have been ordered by your previous physician, your IHP physician (either Primary Care or Specialist) will refill prescriptions only after he/she has seen you. This is one reason why it is important to become established with your Primary Care Physician as soon as possible after your effective date of coverage. As always, please discuss any questions about your medications with your physician

The use of generic drugs may save you money. The next time your physician writes you a prescription, ask if a generic is right for you.

What should I do if I prefer specific cultural practices to be included in my health care?

Your cultural heritage is important to your Primary Care Physician. If you have specific requests or concerns, please discuss these with your doctor.

Can I be assured that my medical care and information will be held in strict confidence?

Yes, IHP participating physicians, other contracted providers, as well as staff of IHP are all committed to and bound by the mandates of confidentiality.

If my HMO is a secondary payor (another medical insurance is paying first) , do I still need to turn in my primary insurance explanation of benefits to IHP?

Yes claims information from your primary insurance is important in order to allow for accurate coordination of benefits. Forward to,

Illinois Health Partners
C/O Boncura Health Solutions
P.O. Box 7050
Downers, IL 60515

What do I need to do if I disagree with a denial of payment or referral for services? How do I appeal this?

If you feel your claim has been wrongfully denied or a Referral for services has been wrongfully denied, please submit a request for reconsideration and the reasons to:

Illinois Health Partners
Attn: Claims Department
1100 W 31st Street- Suite 400
Downers Grove, Il 60515  

What is the appeal process?

Communication with your physician is an important part of your health care. If you do not understand any course of your care, please discuss this with your PCP. You can also contact our Member Services Dept. at 630-942-7950

The role of Member Services is to help with Member issues or concerns that cannot be resolved through normal channels. As an HMO member, you have the right to appeal any payment or denial of covered services by contacting our office at 630-942-7950, or in writing at

Illinois Health Partners
Attn: Claims Department
1100 W 31st Street- Suite 400
Downers Grove, Il 60515

Or this can be initiated by contacting the HMO of Blue Cross/Blue Shield of Illinois Blue Shield of Illinois at 312-653-6600, or in writing at:

HMO Appeal Committee
300 East Randolph
Chicago, IL 60601

Following an adverse determination for a clinical service, procedure or treatment that is not reviewed as medically necessary, any involved party may request an external independent review.