Service Grid By Site

Elmcare, LLC TID # 36-3994179 P.O. Box 7759, Westchester, IL 60154 Customer Service # : 708-432-4050

SERVICES

ABORTION

Cardiac Svc/Angioplasty/CABG

HUMANA

# 312

Check Benefit

See BCBS Contracted Vendor List

Check Benefit

See ED/PR

Superior (708) 832-2000 or ANY Contracted Ambulance UIC

BARIATRIC

Medical Leadership Review

HMOI/BADV

ACUPUNCTURE

AMBULANCE

Health Plan Precert

Dr. Joseph Vitello Dr.

Carlos Galvani Dr. Subhashini Ayloo Elmhurst Memorial Hospital

Per Healthplan

Aetna (ELMO) Self-Funded Employer Plan Planned Parenthood

See ED/PR

See ED/PR

Chicago Ambulance Alliance (800) 558-6050 UIC

Dr. Joseph Vitello Dr.

Carlos Galvani Dr. Subhashini Ayloo Elmhurst Memorial Hospital

Vandenburg

Not A Covered Benefit

Elmhurst Memorial Hospital

CHEMOTHERAPY

Elmhurst Memorial Hospital Green

Elmhurst Memorial Hospital Red

Elmhurst Memorial Hospital Green

CHIROPRACTIC

Dr. Jevitz

Dr. Jevitz

Dr. Jevitz

(630) 834-3391

Consult not required

(630) 834-3391

Consult not required

(630) 834-3391

Consult not required

COLONOSCOPY SCREENING

Colonoscopy @ Hospital

COLONOSCOPY DIAGNOSTIC

Colonoscopy @ Hospital

Colonoscopy @ Hospital

Colonoscopy @ Hospital

Elmhurst Memorial Hospital

Elmhurst Memorial Hospital

Elmhurst Memorial Hospital

Consult required

Colonoscopy @ Hospital Consult required

Colonoscopy @ Hospital Consult required

CT SCAN

CT SCAN - 64 SLICE

BLOOD TRANSFUSION

DIALYSIS

DURABLE MED. EQUIPMENT/SUP.

EEG - 24 HOUR Group Allows Specialists to Request Referrals

Green Green Green Elmhurst Memorial Hospital Elmhurst Memorial Hospital Elmhurst Memorial Hospital Only if ordered Only if ordered by Only if ordered by Cardiologist Red Cardiologist Red by Cardiologist Red Green

See Appendix E

Green

Per Health Plan (800) 626-2698

The first preferred DME is: Action 630-758-7000 Walgreens Home Medical Dependicare (800) 224-7404 (800) 323-2828 Walgreens (800) 323-2828 or ANY Contracted DME Vendor

Tertiary

N/A

N:/MM/REFERRAL MANAGEMENT/Service Grid by Site

Green

Renal Care Group of Villa Park DuPage Peritoneal

Action - if not see Aetna list (Attached)

Tertiary

Tertiary

N/A

N/A

08/21/2009

GREEN REFERRAL PROCESS

GYNECOLOGICAL ONCOLOGY

Script with Elmcare stamp/sticker

Script with Elmcare stamp/sticker

Drs. Ronald Potkul and Donna Smith Drs. Ronald Potkul and Donna Smith Drs. Ronald Potkul and Donna Smith @ Loyola / Red @ Loyola / Red @ Loyola / Red Check Benefits

HEARING AIDS

Script with Elmcare stamp/sticker

Per BCBS Hearing aids may be obtained from any vendor

Check Benefits Contracted Vendor Lutheran General Providers Loyola Maternal Fetal Medicine

Not Covered Lutheran General Providers Loyola Maternal Fetal Medicine

HIGH RISK MATERNITY

Lutheran General Providers Loyola Maternal Fetal Medicine

HOME HEALTH CARE

Elmhurst Home Health (or see attached list)

IMMUNIZATIONS - TRAVEL

Loyola University Medical Center Public Health Department

INFERTILITY

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

Elmhurst Memorial Hospital

Elmhurst Memorial Hospital

Elmhurst Memorial Hospital

INPATIENT ADMISSIONS

Advocate Check Benefit Loyola University Medical Center Public Health Department

Elmhurst Home Health (or see attached list) Check Benefit Loyola University Medical Center Public Health Department

INPATIENT ADMISSIONS-PSYCH

Adult: Alexian Brothers Children: 1) Lutheran General 2) Alexian Brothers 3) Linden Oaks

IV THERAPY

Elmhurst Memorial Hospital

Elmhurst Memorial Hospital

Elmhurst Memorial Hospital

United Shockwave

United Shockwave

United Shockwave

LITHOTRIPSY

MENTAL HEALTH

See All red list Self Refer Inpt. Peds at Lutheran General

MRI'S

Elmhurst Memorial Hospital Green

Elmhurst Memorial Hospital Green

Elmhurst Memorial Hospital Green

MRI'S (OPEN)

Midwest Imaging

Midwest Imaging

Midwest Imaging

MRA

Red

(800) 331-9040

Red

Not Managed by Namm

Red

Green

Green

Green

NON-COMPLIANCE POLICY

Yes - Bring to E.D.

Yes - Bring to E.D.

Yes - Bring to E.D.

NUTRITIONAL COUNSELING

Green Referral

Green Referral

Green Referral

Elmhurst Memorial Hospital

Elmhurst Memorial Hospital

Elmhurst Memorial Hospital

OBSERVATION - 23 HOUR

OPTOMETRY

Davis Vision (877)-393-8844 (effective 07/01/08)

ORTHOTIC/PROSTHETIC (See L Code List)

Scheck & Siress Hanger Prosthetic & Orthotics MD Orthotics

N:/MM/REFERRAL MANAGEMENT/Service Grid by Site

Cole Vision Self Refer (800) 334-7591

Cole Vision Self Refer (800) 334-7591

Scheck & Siress Hanger Prosthetic & Orthotics MD Orthotics

Elmhurst Clinic or Aetna provider

08/21/2009

Elmhurst Hospital

OUTPATIENT LABS

OUTPATIENT PHP/IOP

Elmhurst Clinic

Elmhurst Memorial Hospital

Elmhurst Hospital

Elmhurst Clinic

Not Managed

Elmhurst Hospital

Elmhurst Clinic

Not Managed

OUTPATIENT SURGICAL PROCS

Elmhurst Memorial Hospital Elmhurst OP Surgical Center Check Appendix B

PACEMAKER CHECKS

PODS ADE - Midwest Heart/Green PODS ADE - Midwest Heart/Green PODS B-Elmhurst Clinic/Green PODS B-Elmhurst Clinic/Green If Cross PODS, If Cross PODS, becomes a Red becomes a Red

PODS ADE - Midwest Heart/Green PODS B-Elmhurst Clinic/Green If Cross PODS, becomes a Red

PAIN MGMT

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

CORTISONE

EPIDURAL INJECTIONS PET SCANS

PULMONARY REHABILITATION

RADIATION THERAPY

Elmhurst Memorial Hospital Elmhurst OP Surgical Center

Elmhurst Memorial Hospital Elmhurst OP Surgical Center

Medical Out Sourcing @Elmhurst Memorial Hospital

Medical Out Sourcing @Elmhurst Memorial Hospital

Medical Out Sourcing @Elmhurst Memorial Hospital

Elmhurst Memorial Hospital

Elmhurst Memorial Hospital

Elmhurst Memorial Hospital

Elmhurst Memorial Hospital Green

Elmhurst Memorial Hospital Red

Elmhurst Memorial Hospital Green

SKILLED NURSING FACILITY

Elmhurst Memorial Hospital Skilled Nursing Facility Or Manor Care

SLEEP STUDY - ADULT

Elmhurst Memorial Hospital (Green Elmhurst Memorial Hospital (Green Elmhurst Memorial Hospital (Green Referral) Referral) Referral)

SLEEP STUDY - PEDS.

Loyola University Medical Center Lutheran General Hospital

STERILIZATION

Vasectomy Tubal Ligation

SUBSTANCE ABUSE

SYNAGIS

SYNVISC

TERTIARY HOSPITALS - ADULT

Elmhurst Memorial Hospital Skilled Nursing Facility Or Manor Care

Loyola University Medical Center Lutheran General Hospital

Elmhurst Extended Care

Loyola University Medical Center Lutheran General Hospital

Check benefit

Check benefit

Covered - Hospital

Check benefit

Check benefit

Covered - Hospital

Not Managed by Namm Call Health Plan

Not Managed by Namm Call Health Plan

Ultra Care

Ultra Care Ultra Care Elmhurst Mem Hosp. Infusion Elmhurst Mem Hosp. Infusion Ctr Medical review if no Ctr Medical review if no Milliman Milliman

Ortho (Green)

Ortho (Green)

Elmhurst Mem Hosp. Infusion Ctr Medical review if no Milliman

Injection (Red)

(Red)

Not Managed by Namm Call Health Plan

Injection

Ortho (Green) (Red)

Injection

Lutheran General Hospital, Loyola, Rush (See list if Ortho), or University Lutheran General Hospital, Loyola, Lutheran General Hospital, Loyola, Rush (See list if Ortho), or University Rush (See list if Ortho), or University of Illinois of Illinois of Illinois Loyola Physician Foundation- #800003 Loyola Medical Center- #200038

TERTIARY HOSPITALS - PEDS.

Lutheran Generan Hospital, Loyola, Lutheran General Hospital, Loyola, Lutheran General Hospital, Loyola, Rush, University of Illinois, Advocate Rush, University of Illinois, Advocate Rush, University of Illinois, Advocate Hope Children's Hope Children's Hope Children's

THALLIUM STRESS TEST (Red or Green referral)

Elmhurst Memorial Hospital Green

THERAPY - OCCUPATIONAL

Elmhurst Memorial Hospital Elmhurst Memorial Hospital Elmhurst Memorial Hospital Elmhurst Rehab Elmhurst Rehab Elmhurst Rehab Elmhurst Memorial Hospital /

THERAPY - PEDS. PT/OT/ST

Elmhurst Memorial Hospital Green

Loyola

University Medical Center Lutheran General Hospital

N:/MM/REFERRAL MANAGEMENT/Service Grid by Site

Elmhurst Memorial Hospital /

Elmhurst Memorial Hospital Green

Loyola

University Medical Center Lutheran General Hospital

Elmhurst Memorial Hospital /

Loyola University Medical Center Lutheran General Hospital

08/21/2009

THERAPY - PHYSICAL

Elmhurst Memorial Hospital Elmhurst Rehab

Elmhurst Memorial Hospital Elmhurst Rehab

Elmhurst Memorial Hospital Elmhurst Rehab

THERAPY - SPEECH

Elmhurst Memorial Hospital Elmhurst Rehab

Elmhurst Memorial Hospital Elmhurst Rehab

Elmhurst Memorial Hospital Elmhurst Rehab

TRANSPLANTS

See Scope of Benefits Audrey Johnson-Tarver Per Healthplan (312) 997-6615 Fax (312) 938(800) 626-2698 4682

TRANSPORTATION

N/A

Per Aetna Network (877) 212-8811

N/A

N/A

X-rays Allowed in Ortho Office (Fracture Care)

Yes

Yes

Yes

X-rays Allowed in Ortho. Office

Yes

Yes

Yes

XOLAIR

Care Mark Therapeutics

Care Mark Therapeutics

Care Mark Therapeutics

Loyola University Physician Foundation - #800003 Loyola University Medical Center - #200038 Durable Medical Equipment - Aetna Website: www.aetna.com/docfind/home.do ESWT for Podiatry is a Non-Covered Benefit for ELMO ***THIS IS NOT AN ALL-INCLUSIVE LISTING

N:/MM/REFERRAL MANAGEMENT/Service Grid by Site

08/21/2009

Health Options of Illinois TID # 36-3680139 P.O. Box 7760, Westchester, IL 60154 Customer Service # : 847-656-0013 SERVICES

Health Plan Precert Medical Leadership Review

HMOI/BADV

# 275

ABORTION

Check Benefit See BCBS Contracted Vendor List

ACUPUNCTURE

Lewis Chiropractic Center

AMBULANCE

Any contracted ambulance

BARIATRIC - MUST MEET MILLIMAN SURGICAL CRITERIA AND HOI GUIDELINES PRIOR TO CONSULT (CONSULT-RED REFERRAL)

Dr. Michael Scheer @ Vista East

BLOOD TRANSFUSION

Red

Cardiac Svc/Angioplasty/CABG

CHEMOTHERAPY

CHIROPRACTIC

(847) 336-3400

Vista East

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 SCREENING

COLONOSCOPY DIAGNOSTIC

Hospital

Consult required (Red) Colonoscopy at Hospital (HP Pre-cert not required) Vista East or Vista West Green

CT SCAN

CT SCAN 64 SLICE

Vista East

DIALYSIS

See Appendix E

DURABLE MED. EQUIPMENT/SUP.

Any contracted DME vendor

EEG - 24 HOUR

Group Allows Specialists to Request Referrals

Colonoscopy @ (HP Precert not required)

Vista East OB/GYN Only (May only refer to selected specialties--See Attached)

N:/MM/REFERRAL MANAGEMENT/Service Grid by Site

08/21/2009

GREEN REFERRAL PROCESS

GYNECOLOGICAL ONCOLOGY

HEARING AIDS

NorthShore University / Red Check Benefits Per BCBS - Hearing aids may be obtained from any vendor

HIGH RISK MATERNITY

NorthShore University HealthSystem

HOME HEALTH CARE

Per BCBS List

IMMUNIZATIONS - TRAVEL

Passport Health - Gurnee (888) 499-7277

INFERTILITY

Check Scope of Benefits Call for Benefits See Health Plan Prov. List

INPATIENT ADMISSIONS

Vista East / Vista West

IV THERAPY

LITHOTRIPSY

Vista East United Shockwave (Has a unit at Condell Hospital that bills under United Shockwave) Outpatient - See Red List

MENTAL HEALTH

Inpt-Vista East and Vista West

MRI'S

MRI Institute

MRI'S (OPEN)

Vista MRI Institute

Only if criteria not met

Only if criteria not met

MRA

Red

NON-COMPLIANCE POLICY

Yes

NUTRITIONAL COUNSELING

Red Referral

OBSERVATION - 23 HOUR

OPTOMETRY

Vista East Davis Vision (877) 393-8844

ORTHOTIC/PROSTHETIC (See L code List) INPATIENT LABS

(effective 07/01/08)

Any contracted vendor Quest

N:/MM/REFERRAL MANAGEMENT/Service Grid by Site

STAT only

Vista East -

08/21/2009

OUTPATIENT PHP/IOP

N/A

OUTPATIENT SURGICAL PROCS

Vista East (Victory) or Vista Surgical & Tx Ctr. Only if criteria not met check Appendix B

PACEMAKER CHECKS

Cardiac E.P. Consultants, SC

PAIN MANAGEMENT

CORTISONE EPIDURAL INJECTIONS

In the office of ORS

Vista East

Dr. Kurup

Dr. Mehta

SKILLED NURSING FACILITY

Per BCBS List

SLEEP STUDY - ADULT

Vista East

SLEEP STUDY - PEDS.

STERILIZATION

Red

Vista West MRI

PULMONARY REHABILITATION

RADIATION THERAPY

Red

In the office of Dr. Arber

PET SCANS

Red

Children's Hospital of Wisconsin Check Benefit

In the office of Dr. Khan Vasectomy Tubal Ligation Check Benefit Vista East

SUBSTANCE ABUSE

Not Managed by NAMM

Contact Healthplan

SYNAGIS

Ultra Care or Peds Office

SYNVISC

Ortho Office

TERTIARY HOSPITALS - ADULT

TERTIARY HOSPITALS - PEDS. THALLIUM STRESS TEST (Red or Green referral)

Northshore University Health System

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

Green

THERAPY - OCCUPATIONAL

Vista Physical Medicine

THERAPY - PEDS. PT/OT/ST

Vista Physical Medicine

THERAPY - PHYSICAL

Vista Physical Medicine

N:/MM/REFERRAL MANAGEMENT/Service Grid by Site

08/21/2009

THERAPY - SPEECH

TRANSPLANTS

Vista Physical Medicine See Scope of benefits Audrey Johnson-Tarver 312-997-6615 Fax 312-938-4682

TRANSPORTATION

N/A

X-rays Allowed in Ortho Office (Fracture Care)

Yes

X-rays Allowed in Ortho. Office

No

XOLAIR

Walgreens

***THIS IS NOT AN ALL-INCLUSIVE LISTING

N:/MM/REFERRAL MANAGEMENT/Service Grid by Site

08/21/2009

Hinsdale Physicians Healthcare TID # 36-3851702 P.O. Box 7789, Westchester, IL 60154 Customer Service # : 708-432-4053 SERVICES ABORTION

Health Plan Precert Medical Leadership Review

HMOI/BADV

HUMANA

# 257

Check Benefit

See BCBS Contracted Vendor List

UNICARE

Check Benefit Per Healthplan

Check Benefit Per Healthplan Check Benefit Dr. Xlaoping Xu (630) 655-9988

ACUPUNCTURE

Dr. Xlaoping Xu (630) 655-9988

Check Benefit Dr. Xlaoping Xu (630) 655-9988

AMBULANCE

Superior (708-832-2000) or ANY Contracted Ambulance

Chicago Ambulance Alliance (800) 558-6050

BARIATRIC

Loyola University Medical Center

Superior (708) 832-2000

Loyola University Medical Center

Loyola University Medical Center

Cardiac Svc/Angioplasty/CABG

Hinsdale Hospital LaGrange Hospital

Hinsdale Hospital LaGrange Hospital

Hinsdale Hospital LaGrange Hospital

CHEMOTHERAPY

HPH Hematology/Onc Specialist

HPH Hematology/Onc Specialist

HPH Hematology/Onc Specialist

CHIROPRACTIC

COLONOSCOPY SCREENING

COLONOSCOPY DIAGNOSTIC

Green

See Red List Consult Required (Green)

Check Benefit

Green

See Red List

Consult Required (Green)

Check Benefit

Green

See Red List

Consult Required (Green)

Colonoscopy @ Hospital

Colonoscopy @ Hospital

Colonoscopy @ Hospital

Consult Required (Green)

Consult Required (Green)

Consult Required (Green)

Colonoscopy @ Hospital

Colonoscopy @ Hospital

Colonoscopy @ Hospital

CT SCAN

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)

CT SCAN - 64 SLICE

Cardiologist or contracted Hospital Green

Cardiologist or contracted Hospital Green

Cardiologist or contracted Hospital Green

BLOOD TRANSFUSION

DIALYSIS

Red

Red

Red

See Appendix E

Per Health Plan

Per Health Plan

DURABLE MED. EQUIPMENT/SUP.

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

EEG - 24 HOUR

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

GREEN REFERRAL PROCESS

Patient obtains Green Referral

N:/MM/REFERRAL MANAGEMENT//Service Grid by Site

Patient obtains Green Referral

Patient obtains Green Referral

08/21/2009

GYNECOLOGICAL ONCOLOGY

HEARING AIDS

Drs. Sameer Sharma and Sudarshan Sharma @ Hinsdale / Red Check Benefits

Per BCBS - Hearing aids may be obtained from any vendor

Drs. Sameer Sharma and Sudarshan Sharma @ Hinsdale / Red Check Benefits Contracted Vendor

Drs. Sameer Sharma and Sudarshan Sharma @ Hinsdale / Red Check Benefits Contracted Vendor

HIGH RISK MATERNITY

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

HOME HEALTH CARE

Health Care at Home (630) 856-6901 Orsini (847) 734-7373

IMMUNIZATIONS - TRAVEL

INFERTILITY

Loyola University Medical Center Check Scope of Benefits Call for Benefits See Health Plan Prov. List

Advocate HHC (800) 564-2025

Check Benefit Check Benefit Loyola University Medical Center Loyola University Medical Center Fax the completed Humana Form Fertility Centers of Illinois

Contact Unicare - HPH does not manage Coram Specialty Infusion Services (Effective May 13th). Coram nurse / PCP to determine care setting.

INFUSION SERVICES - IVIG AND REMICADE

INPATIENT ADMISSIONS

Orsini (847) 734-7373 Chartwell (infusion) (800) 551-9355 Ultracare (800) 222-9444

Hinsdale Hospital Hinsdale Hospital Hinsdale Hospital LaGrange Hospital LaGrange Hospital LaGrange Hospital Glen Oaks Medical Center Glen Oaks Medical Center Glen Oaks Medical Center Adventist Bolingbrook Hospital Adventist Bolingbrook Hospital Adventist Bolingbrook Hospital

IV THERAPY

LITHOTRIPSY

MENTAL HEALTH

MRI'S

MRI'S (OPEN)

United Shockwave PsycHealth Self Refer

United Shockwave Mental Health Specialty Services Self Refer (800) 331-9040

(800) 753-5456

United Shockwave 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

Green

Green

Green

Yes

Yes

Yes

MRA

NON-COMPLIANCE POLICY

NUTRITIONAL COUNSELING

Oakbrook Health and Nutrition Oakbrook Health and Nutrition Oakbrook Health and Nutrition Dr. Ghani or Dr. Auriemma Dr. Ghani or Dr. Auriemma Dr. Ghani or Dr. Auriemma

OBSERVATION - 23 HOUR

Hinsdale Hospital Hinsdale Hospital Hinsdale Hospital LaGrange Hospital LaGrange Hospital LaGrange Hospital Glen Oaks Medical Center Glen Oaks Medical Center Glen Oaks Medical Center Adventist Bolingbrook Hospital Adventist Bolingbrook Hospital Adventist Bolingbrook Hospital Davis Vision

OPTOMETRY ORTHOTIC/PROSTHETIC (See L Code List)

(877) 393-8844 (effective 07/01/08)

Scheck & Siress Hanger Prosthetics & Orthotics MD Orthotics

N:/MM/REFERRAL MANAGEMENT//Service Grid by Site

Cole Vision Self Refer

(800) 334-7591

Scheck & Siress

Cole Vision Self Refer

(800) 334-7591

Scheck & Siress Hanger Prosthetics & Orthotics

08/21/2009

Quest Diagnostics Quest Diagnostics Quest Diagnostics Hinsdale Hospital Hinsdale Hospital Hinsdale Hospital LaGrange Hospital LaGrange Hospital LaGrange Hospital Glen Oaks Medical Center Glen Oaks Medical Center Glen Oaks Medical Center Bolingbrook Hospital Bolingbrook Hospital Bolingbrook Hospital

OUTPATIENT LABS

OUTPATIENT PHP/IOP

OUTPATIENT SURGICAL PROCS

Hinsdale Hospital Hinsdale Hospital Hinsdale Hospital LaGrange Hospital LaGrange Hospital LaGrange Hospital Glen Oaks Medical Center Glen Oaks Medical Center Glen Oaks Medical Center Bolingbrook Med. Ctr Bolingbrook Med. Ctr Bolingbrook Med. Ctr Hinsdale Surgical Ctr. Hinsdale Surgical Ctr. Hinsdale Surgical Ctr. Westmont Surgical Ctr. (Can only Westmont Surgical Ctr. (Can only Westmont Surgical Ctr. (Can only be be used by Hinsdale Ortho) be used by Hinsdale Ortho) used by Hinsdale Ortho) Check Appendix B

PACEMAKER CHECKS

Highland Pacemaker Clinic Red

Highland Pacemaker Clinic Red

Highland Pacemaker Clinic Red

PAIN MGMT

In the office of ORS

In the office of ORS

In the office of ORS

CORTISONE

EPIDURAL INJECTIONS

Red Referral

Red Referral

Any Adventist facility In the office of Pain Spec. Red Referral, review after Red Referral 3rd inj.

Red Referral

In the office of Pain Spec. Red Referral

PEDIATRIC PT/OT/ST

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

PET SCANS

Molecular Imag., Regional PET Molecular Imag., Regional PET Molecular Imag., Regional PET Imaging, DBA-Hinsdale PET Scan, Imaging, DBA-Hinsdale PET Scan, Imaging, DBA-Hinsdale PET Scan, LLC If no Milliman, LLC If no Milliman, LLC If no Milliman, needs review needs review needs review

PULMONARY REHABILITATION

Hinsdale Hospital

Hinsdale Hospital

Hinsdale Hospital

RADIATION THERAPY

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

SKILLED NURSING FACILITY

Manor Care Hinsdale(630) 325-9630 Manor Care Westmont(630)323-4400 Burgess Sq. Westmont(630) 9712645

Manor Care Hinsdale(630) 325-9630 Manor Care Westmont(630)323-4400

Multiple Vendors including the Manor Care Facilities Call Case Management

SLEEP STUDY - ADULT

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

SLEEP STUDY - PEDS.

STERILIZATION:

Rush University Medical Center

Check Benefit

Vasectomy Tubal Ligation

SUBSTANCE ABUSE

SYNAGIS

SYNVISC

Check Benefit Not managed by Namm Call (800) 3463986 McKesson

Ultra Care

Rush University Medical Center Check Benefit Check Benefit

Per Healthplan

Not managed by Namm Call Healthplan McKesson

Green

Per Healthplan

Ultra Care

Loyola University Medical Center University of Chicago Hospital Check Benefit Check Benefit

Per Healthplan Per Healthplan

Not managed by Namm Call Healthplan

Green

McKesson Ultra Care

Green

Ortho Office or PCP Office Ortho Office or PCP Office Ortho Office or PCP Office Injection ordered through Injection ordered through Injection ordered through Ultracare Ultracare Ultracare Loyola University Medical Center

TERTIARY HOSPITALS - ADULT

TERTIARY HOSPITALS - PEDS.

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

N:/MM/REFERRAL MANAGEMENT//Service Grid by Site

08/21/2009

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

THERAPY - PHYSICAL

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

THERAPY - SPEECH

Westbrook - Bolingbrook

TRANSPLANTS

See Scope of Benefits Audrey Johnson-Tarver Per Healthplan (312) 997-6615 Fax (312) 938(800) 626-2698 4682

THERAPY - OCCUPATIONAL

TRANSPORTATION X-Rays Allowed in Ortho Office (Fracture Care) X-rays Allowed in Ortho. Office

XOLAIR

Glen Oaks Sports & Spine

N/A Yes

(3 visits, 1 xray and casting) Hinsadale Ortho Only

McKesson Walgreens Ultracare

LaGrange -

Per Healthplan

N/A Yes

(3 visits, 1 xray and casting) Hinsadale Ortho Only

McKesson Walgreens Ultracare

(866) 694-0724

N/A Yes

(3 visits, 1 x-ray and casting) Hinsadale Ortho Only

McKesson Walgreens Ultracare

***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.

N:/MM/REFERRAL MANAGEMENT//Service Grid by Site

08/21/2009

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

ABORTION

ACUPUNCTURE

AMBULANCE

BARIATRIC

HMOI/BADV

Self Refer

# 334

(312) 653-6600

See PR for Letter of Agreement

Superior (708-832-2000) or Any Contracted Ambulance

Dr. Ayloo @ U IC

BLOOD TRANSFUSION

UNICARE

Must call Unicare for Auth (888) 234-8855

See PR for Letter of Agreement

Superior (708) 832-2000

Dr. Ayloo @ U IC

Red

Red

Cardiac Svc/Angioplasty/CABG

Advocate Ill. Masonic Med. Ctr. U of C and UIC

Advocate Ill. Masonic Med. Ctr. U of C and UIC

CHEMOTHERAPY

HCHP Physician's Office (Green) Holy Cross Hospital (Red)

HCHP Physician's Office (Green) Holy Cross Hospital (Red)

CHIROPRACTIC

COLONOSCOPY SCREENING

COLONSCOPY DIAGNOSTIC

CT SCAN

CT SCAN - 64 SLICE

DIALYSIS

DURABLE MED EQUIPMENT/SUP

See PR for Letter of Agreement

See PR for Letter of Agreement

Consult required (Green)

Consult required (Green)

Colonoscopy @ Hospital

Colonoscopy @ Hospital

Consult required (Green)

Consult required (Green)

Colonoscopy @ Hospital

Colonoscopy @ Hospital

Holy Cross Hospital

Group Allows Specialists to Request Referrals

Holy Cross Hospital

Green

Advocate Illinois Masonic

Advocate Illinois Masonic

See Appendix E

Per Health Plan

Integrated Check Benefit, <$1000 Dependicare(800) 224-7404 No precert needed Walgreens (800) 323-2828 Dependicare/Walgreens or Any Contracted DME

EEG - 24 HOUR ENDOSCOPIES (INCLUDING CAPSULE ENDOSCOPIES)

Green

U of C

Office or Hospital Setting (Red Referral)

U of C Office Setting (Red Referral) Hospital Setting (Red Referral)

Yes, In-network providers and home hospital only

N:MM/REFERRAL MANAGEMENT/Service Grid by Site

Yes, In-network providers and home hospital only

08/21/2009

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

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

Check Benefits Contracted Vendor

HIGH RISK MATERNITY

University of Chicago

University of Chicago

HOME HEALTH CARE

Refer to HMOI Contracted Providers

HEARING AIDS

IMMUNIZATIONS - TRAVEL

INFERTILITY

University of Illinois

Must call Unicare for Auth (888) 234-8855 Check Benefit

UIC Travel Clinic Check Scope of Benefits for Benefits See Health Plan Prov. List

Call

Ultracare

LITHOTRIPSY

MRI'S

MRI'S (OPEN)

Check Benefit

Holy Cross Hospital (Dr. Alston can deliver babies @ St. Bernard and/or Trinity Hospital - Red Referral)

IV THERAPY

MENTAL HEALTH

UIC Travel Clinic

Per Healthplan

Coram Specialty Infusion Services (Effective May 13th). Coram nurse / PCP to determine care setting.

INFUSION SERVICES - IVIG AND REMICADE INPATIENT ADMISSIONS

University of Illinois

Holy Cross Hospital

Per Healthplan

United Shockwave PsycHealth Self Refer

(800) 753-5456

Holy Cross Hospital Green Regional MRI

Preferred Open MRI

MRA

(888) 234-8855

United Shockwave Wellpoint Self Refer

(800) 746-6294

Holy Cross Hospital Green Regional MRI

Preferred Open MRI

Green

Green

NON-COMPLIANCE POLICY

Yes

Yes

NUTRITIONAL COUNSELING

Red Referral

Red Referral

Holy Cross Hospital

Holy Cross Hospital

OBSERVATION - 23 HOUR

OPTOMETRY

Davis Vision (877) 393-8844 (effective 07/01/08)

ORTHOTIC/PROSTHETIC (See L code list)

Scheck & Siress Hanger Prosthetic & Orthotics, MD Orthotics, Contracted physicians

OUTPATIENT LABS

Holy Cross Hospital

N:MM/REFERRAL MANAGEMENT/Service Grid by Site

(Green)

Self Refer

Per Plan Vision Rider

Must call Unicare for Auth

Holy Cross Hospital

(888) 234-8855

(Green)

08/21/2009

OUTPATIENT PHP/IOP

OUTPATIENT SURGICAL PROCS

Holy Cross Hospital

PACEMAKER CHECKS

Holy Cross Hospital

PAIN MGMT

CORTISONE

EPIDURAL INJECTIONS PET SCANS

(Green)

Holy Cross Hospital

(Green)

In the Office of ORS/POD/AN

In the Office of ORS/POD/AN

In the Office of Dr. Singa/AN

In the Office of Dr. Singa/AN

Lake Shore PET Imaging or Life Scan Chicago Lake Shore PET Imaging or Life Scan Chicago

PULMONARY REHABILITATION

RADIATION THERAPY

SKILLED NURSING FACILITY

U of C

Radiation Therapy

Consultants, Ltd.

Refer to HMOI

Contracted Providers: Renaissance of Midway

SLEEP STUDY - ADULT

Vasectomy Tubal Ligation

U of C

Radiation Therapy

Consultants, Ltd.

Must call Unicare for Auth 234-8855

Southwest Sleep Center

Southwest Sleep Center

U of C

U of C

Check Benefit

Check Benefit

Check Benefit

Check Benefit

SLEEP STUDY - PEDS

STERILIZATION

Holy Cross Hospital

Check Appendix B

(888)

SUBSTANCE ABUSE

Not Managed by NAMM Call Health Plan

No Managed by NAMM Call Health Plan

SYNAGIS

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

SYNVISC

TERTIARY HOSPITALS - ADULT

TERTIARY HOSPITALS - PEDS.

Provider is Ultracare or Walgreens Home Care

Provider is Ultracare or Walgreens Home Care

U of C UIC

U of C UIC

Advocate Illinois Masonic Advocate Illinois Masonic Medical Center (Christ Hospital-Wound Clinic Medical Center (Christ Hospital-Wound Clinic ONLY) ONLY) University of Illinois at Chicago

University of Illinois at Chicago

THALLIUM STRESS TEST

Holy Cross Hospital

THERAPY - PEDS. PT/OT/ST

Holy Cross Hospital (PT & ST) Holy Cross Hospital (PT & ST) University of Chgo (OT) University of Chgo (OT)

THERAPY - OCCUPATIONAL

THERAPY - PHYSICAL

Green Referral

Maximum Rehab Services, Ltd.

Holy Cross Hospital

Green Referral

Maximum Rehab Services, Ltd.

Holy Cross Hospital Holy Cross Hospital Maximum Rehab Services, Ltd. Maximum Rehab Services, Ltd. Therapy Providers (Dr. LabanauskasTherapy Providers (Dr. LabanauskasSurgical Only) (Green for Holy Cross Only) Surgical Only) (Green for Holy Cross Only)

N:MM/REFERRAL MANAGEMENT/Service Grid by Site

08/21/2009

THERAPY - SPEECH

Holy Cross Hospital Maximum Rehab Services, Ltd. (Green for Holy Cross only)

Holy Cross Hospital Maximum Rehab Services, Ltd. (Green for Holy Cross only)

TRANSPLANTS

See Scope of Benefits Per Healthplan Audrey Johnson-Tarver 312-997-6615 Fax (866) 694-0724 312-938-4682

TRANSPORTATION

N/A

N/A

X-Rays Allowed in Ortho Office (Fracture Care)

Yes

Yes

X-rays Allowed in Ortho. Office

XOLAIR

No

No

(Unless Urgent)

Walgreens

Urgent)

(Unless

Walgreens

***THIS IS NOT AN ALL-INCLUSIVE LISTING

N:MM/REFERRAL MANAGEMENT/Service Grid by Site

08/21/2009

Ingalls Provider Group TID # 36-3485578 P.O. Box 7790, Westchester, IL 60154 Customer Service # : 708-432-4052 SERVICES

Medical Leadership Review

HMOI/BADV

UNICARE

# 213

Check Benefit Check Benefit See BCBS Contracted Vender Per Healthplan List

ABORTION

ACUPUNCTURE

Vaught Chiropractic

Check benefits

Superior (708-832-2000) or ANY Contracted Ambulance

AMBULANCE

BARIATRIC

Health Plan Precert

Gastric Bypass Lap Band

BLOOD TRANSFUSION

Ingalls

IPG Hematology/Onc Specialist

COLONOSCOPY DIAGNOSTIC

DIALYSIS

DURABLE MED. EQUIPMENT/SUP.

EEG- 24 HOUR Group Allows Specialists to Request Referrals

Ingalls

Green

Ingalls

Green

Vaught Chiropractic

COLONOSCOPY SCREENING

CT SCAN - 64 SLICE

Green

Ingalls

CHIROPRACTIC

CT SCAN

Superior (708) 832-2000

Dr. James Madura/RUSH or Dr. John Alverdy/U of C only Dr. John Alverdy/U of C Must complete Must complete solutions solutions program at Ingalls Wellness program at Ingalls Wellness Center prior to Center prior to consult consult Dr. Jonathan Myers/Rush or Dr. Vivek Prachand only Dr. Vivek Prachand/U of C Must complete solutions program at Ingalls Must Wellness Center prior to consult complete solutions program at Ingalls Wellness Center prior to consult

Cardiac Svc/Angioplasty/CABG

CHEMOTHERAPY

Vaught Chiropractic

IPG Hematology/Onc Specialist

Check benefits

Green

Vaught Chiropractic

Consult required (Green)

Consult required (Green)

Colonoscopy @ Hospital

Colonoscopy @ Hospital

Consult required (Green)

Consult required (Green)

Colonoscopy @ Hospital

Colonoscopy @ Hospital

Ingalls

Green

Ingalls

Green

Not a covered benefit

Not a covered benefit

See Appendix E

Per Health Plan

Dependicare (800) 224-7404 Walgreens (800) 323-2828 Any Contracted DME Vendor

Check Benefit <$1000 No precert needed Dependicare/Walgreens

Ingalls

Ingalls

Only general surgeons, ortho for surgery, oncology

Only general surgeons, ortho for surgery, oncology

N:/MM/REFERRAL MANAGEMENT/Service Grid by Site

08/21/2009

GREEN REFERRAL PROCESS

GYNECOLOGICAL ONCOLOGY

HEARING AIDS

HIGH RISK MATERNITY

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 University of Chicago Hospital

Dr. Yamada @ U of C / Red

Check Benefits Contracted Vendor

University of Chicago Hospital

HOME HEALTH CARE

Refer to HMOI Contracted Vendor

Call Unicare for Authorization 888-234-8855

IMMUNIZATIONS - TRAVEL

University of Chicago Travel Clinic

Check Benefit University of Chicago Travel Clinic

INFERTILITY Semen Analysis Referrals to Fertility Check Scope of Benefits Call for Benefits Centers of Illinois--Orland Park (Red See Health Plan Prov. List Referral)

Check benefits - IPG Risk No Precert needed from Unicare

Coram Specialty Infusion Services (Effective May 13th). Coram nurse / PCP to determine care setting.

INFUSION SERVICES - IVIG AND REMICADE INPATIENT ADMISSIONS

Ingalls

IV THERAPY

Ultracare

Ingalls

Per Healthplan

888-234-8855

LITHOTRIPSY

United Shockwave Ingalls T.P.

United Shockwave Ingalls T.P.

MENTAL HEALTH

PsycHealth Self Refer

Wellpoint Self Refer 800-746-6294

MRI'S

MRI'S (OPEN)

MRA

800-753-5456

Ingalls

Green

Ingalls Memorial Hospital Green Referral Ingalls

Green

NON-COMPLIANCE POLICY (Sanction) NUTRITIONAL COUNSELING

Ingalls Memorial Hospital Dietician Red Referral

ORTHOTIC/PROSTHETIC (See L Code List)

Ingalls

(877) 393-8844 (effective 07/01/08)

Scheck & Siress Hanger Prosthetic & Orthotics MD Orthotics

N:/MM/REFERRAL MANAGEMENT/Service Grid by Site

Green

Yes

Ingalls Memorial Hospital Dietician Red Referral

Ingalls Davis Vision

Green

Ingalls Memorial Hospital Green Referral

Yes

OBSERVATION- 23 HOUR

OPTOMETRY

Ingalls

Ingalls Cole Vision Self Refer

800-334-7591

Scheck & Siress Hanger Prosthetic & Orthotics MD Orthotics

08/21/2009

OUTPATIENT LABS

Ingalls Memorial Hopsital

Ingalls Memorial Hopsital

OUTPATIENT PHP/IOP

OUTPATIENT SURGICAL PROCS

Ingalls Harvey or Tinley Park Midwest Eye Surgical Ingalls Harvey or Tinley Park Center Check Appendix B

PACEMAKER CHECKS

Ingalls

PAIN MGMT

In the office of ORS Red

CORTISONE

EPIDURAL INJECTIONS PET SCANS

Ingalls

Red

In the office of ORS Red

Green

Ingalls

Green

Ingalls

Ingalls Cancer Care Ctr. Tx Only-Red

SKILLED NURSING FACILITY

HMOI Contracted Providers

SLEEP STUDY - ADULT

Ingalls

SLEEP STUDY - PEDS.

Ingalls

STERILIZATION: Vasectomy Semen Analysis Referrals to Fertility Centers of Illinois--Orland Park (Red Referral) Tubal Ligation

SUBSTANCE ABUSE

Ingalls

Drs. Holly Carobene, Howard Robinson & Drs. Holly Carobene, Howard Robinson & John Hong / Red John Hong / Red

PULMONARY REHABILITATION

RADIATION THERAPY

Red

Green

Green

Check Benefit

Check Benefit Not Managed by NAMM Call Healthplan

Ingalls

Ingalls Cancer Care Ctr. Tx Only-Red Must call Unicare for Authorization 888-234-8855 Ingalls

Green

Ingalls

Green

Check Benefit

Check Benefit

Per Healthplan

Per Healthplan

Not Managed by NAMM Call Healthplan

SYNAGIS

Dependicare from PCP Office

Dependicare from PCP Office

SYNVISC

Ultracare

Ultracare

TERTIARY HOSPITALS - ADULT

TERTIARY HOSPITALS - PEDS THALLIUM STRESS TEST (Red or Green referral)

Rush Presbyterian

University of Chicago

University of Chicago

University of Chicago Children's Memorial Hospital Hope Children's Hospital

University of Chicago Children's Memorial Hospital

Ingalls

Ingalls

Green

Green

THERAPY - OCCUPATIONAL

Ingalls

Ingalls

THERAPY - PEDS. PT/OT/ST

Ingalls

Ingalls

N:/MM/REFERRAL MANAGEMENT/Service Grid by Site

08/21/2009

THERAPY - PHYSICAL

THERAPY - SPEECH

TRANSPLANTS

Ingalls or ICOR (Ingalls Center for Outpatient Rehab.)

Ingalls or ICOR (Ingalls Center for Outpatient Rehab.)

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

Ingalls

Per Healthplan

(866) 694-0724

TRANSPORTATION

N/A

N/A

X-rays Allowed in Ortho office (Fracture Care)

Yes

Yes

X-rays Allowed in Ortho. Office

No

No

Walgreens

Walgreens

XOLAIR ***THIS IS NOT AN ALL-INCLUSIVE LISTING

N:/MM/REFERRAL MANAGEMENT/Service Grid by Site

08/21/2009

Northwest Community Health Partners TID # 36-2340313 P.O. Box 7819, Westchester, IL 60154 Customer Service # : 708-432-4054 SERVICES

Health Plan Precert Medical Leadership Review

HMOI/BADV

HUMANA

# 336

ABORTION

Check Benefit Check Benefit See BCBS Contracted Vender Per Healthplan List

ACUPUNCTURE

Des Plaines Chiropractic Center (847) 299-3440

AMBULANCE BARIATRIC

Any contracted ambulance

Gastric Bypass Lap Band

Des Plaines Chiropractic Center (847) 299-3440 Chicago Ambulance Alliance (800) 558-6050

Dr. Joyce @ Silver Cross

Dr. Joyce @ Silver Cross

Dr. S. Sarker @ Loyola

Dr. S. Sarker @ Loyola

BLOOD TRANSFUSION

Red

Cardiac Svc/Angioplasty/CABG

Northwest Community Hospital (EP Study--Dr. Lin)

Northwest Community Hospital

CHEMOTHERAPY

Office of NWC Hematology/Onc Specialist Tx only Red

Office of NWC Hematology/Onc Specialist Tx only Red

CHIROPRACTIC

Des Plaines Chiropractic Ctr. Des Plaines Chiropractic Ctr. (847) 299-3440 (847) 299-3440 Clark Chiro & Rehab, PC Clark Chiro & Rehab, PC (847) 259-9864 (847) 259-9864

(Including Type & Cross)

Red

(Including Type & Cross)

COLONOSCOPY SCREENING

Colonoscopy @ Hospital

Colonoscopy @ Hospital

COLONOSCOPY DIAGNOSTIC

Colonoscopy @ Hospital

Colonoscopy @ Hospital

Northwest Community Hospital Green

Northwest Community Hospital Green

CT SCAN

CT SCAN - 64 SLICE

DIALYSIS

DURABLE MED. EQUIPMENT/SUP.

EEG - 24 HOUR Group Allows Specialists to Request Referrals GREEN REFERRAL PROCESS

Medical Director conversation with the Cardiologist is required

Medical Director conversation with the Cardiologist is required

See Appendix E

Per Health Plan

Dependicare(800) 224-7404 Walgreens (800) 323-2828 Northwest Community Hospital Green

Walgreens Home Medical (800) 323-2828 Northwest Community Hospital Green

Yes--All Specialists performing surgery Yes--All Specialists performing surgery (Submitted on a (Submitted on a Surgical Request Form rather than a Red Surgical Request Form rather than a Red Referral) Referral) A short referral form needs to be completed in order to refer to a green list physician

N:/MM/REFERRAL MANAGEMENT/Service Grid by Site

A short referral form needs to be completed in order to refer to a green list physician

08/21/2009

GYNECOLOGICAL ONCOLOGY

Drs. J. Tunca, R. Weiss and S. Kwon @ NWC / Red

HEARING AIDS

Check Benefit Northwest Community Hospital

HIGH RISK MATERNITY

HOME HEALTH CARE

Drs. J. Tunca, R. Weiss and S. Kwon @ NWC / Red Check Benefits Contracted Vendor

St. Alexius Group St. Alexius Group Suburban Maternal Fetal Medicine Suburban Maternal Fetal Medicine (Dr.Smith's High Risk OB Pt's (Dr.Smith's High Risk OB Pt's NorthShore University HealthSystem) NorthShore University HealthSystem)

Northwest Community Hospital Home Health Care

Northwest Community Hospital Home Health Care

IMMUNIZATIONS - TRAVEL

NWCH Occupational Health Dept. Provider ID # 800003 Red

Check Benefit NWCH Occupational Health Dept.

IMMUNIZATIONS - ROUTINE

NWCH Occupational Health Dept. Provider ID # 800003 Red Copy to ED/PR Rep

Check Benefit NWCH Occupational Health Dept.

INFERTILITY

Check Scope of Benefits Call for Benefits See Health Plan Prov. List

INPATIENT ADMISSIONS

Copy to ED/PR Rep Fax the completed Humana Form Fertility Centers of Illinois

Northwest Community Hospital

Contracted vendor

Contracted vendor

LITHOTRIPSY

United Shockwave

United Shockwave

MENTAL HEALTH

PsycHealth Self Refer

MRI'S

Northwest Community Hospital Green

Northwest Community Hospital Green

MRI'S (OPEN)

Northwest Community Hospital NWCH Schaumburg Tx. Center MRI of Arlington Hgts

Northwest Community Hospital NWCH Schaumburg Tx. Center MRI of Arlington Hgts

NWCH

NWCH

Self Refer (800) 753-5456

Green

NON-COMPLIANCE POLICY

NUTRITIONAL COUNSELING

OBSERVATION - 23 HOUR

Yes

Northwest Community Hospital

(877) 393-8844 07/01/08)

ORTHOTIC/PROSTHETIC (See L Code List) OUTPATIENT LABS

(800) 331-9040

Green

Yes

Northwest Community Hospital Green Referral

Davis Vision

OPTOMETRY

Red

Northwest Community Hospital

IV THERAPY

MRA

Red

(effective

Any contracted vendor

Northwest Community Hospital Green Referral

Northwest Community Hospital Cole Vision Self Refer (800) 334-7591

Any contracted vendor

Quest Diagnostic Quest Diagnostic Northwest Community Hospital Northwest Community Hospital Stats only Stats only

N:/MM/REFERRAL MANAGEMENT/Service Grid by Site

08/21/2009

OUTPATIENT PHP/IOP

OUTPATIENT SURGICAL PROCS

Northwest Community Hospital or Day Surgery Center Check Appendix B

Northwest Community Hospital or Day Surgery Center

PACEMAKER CHECKS

Northwest Community Hospital Red

Northwest Community Hospital Red

PAIN MGMT

In the office of ORS

In the office of ORS

CORTISONE

EPIDURAL INJECTIONS

In the office of AN

Red

Northwest Community Hospital Green

PET SCANS

PULMONARY REHABILITATION

RADIATION THERAPY

Northwest Community Hospital

SLEEP STUDY - ADULT

SLEEP STUDY - PEDS.

Northwest Community Hospital Green

Red

Northwest Community Hospital

Any contracted vendor

Northwest Community Hospital Green

Children's Memorial Hospital (>3 y/o)

Children's Memorial Hospital (>3 y/o)

Check Benefit

Check Benefit

Check Benefit

SUBSTANCE ABUSE

Check Benefit

Not Managed by NAMM - Call Health Plan

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

SYNVISC

TERTIARY HOSPITALS - ADULT

Green

Northwest Community Hospital Green

Any contracted vendor

Vasectomy Tubal Ligation

SYNAGIS

In the office of AN

Provided by Radiation/Onc at Provided by Radiation/Onc at Northwest Community Hospital Northwest Community Hospital

SKILLED NURSING FACILITY

STERILIZATION

Green

Ortho Office

Loyola University Hospital U of C

Ortho Office

Loyola University Hospital U of C

TERTIARY HOSPITALS - PEDS.

U of C

THALLIUM STRESS TEST

Northwest Community Hospital Green

Northwest Community Hospital Green

THERAPY - OCCUPATIONAL

Northwest Community Hospital (Age 10 and up)

Northwest Community Hospital (Age 10 and up)

THERAPY - PEDS. PT/OT/ST

Assential Therapies Assential Therapies Physiotherapy Assoc. (Pediatric Place) Physiotherapy Assoc. (Pediatric Place) Arlington Arlington Pediatric Therapy Pediatric Therapy

THERAPY - PHYSICAL

Northwest Community Hospital (Age 10 and up)

Children's Memorial Hospital

N:/MM/REFERRAL MANAGEMENT/Service Grid by Site

U of C

Children's Memorial Hospital

Northwest Community Hospital (Age 10 and up)

08/21/2009

THERAPY - SPEECH

TRANSPLANTS

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

Northwest Community Hospital

Per Healthplan

(800) 626-2698

TRANSPORTATION

N/A

N/A

X-rays Allowed in Ortho Office (Fracture Care)

Yes

Yes

X-rays Allowed in Ortho. Office

Yes

Yes

McKesson

McKesson

XOLAIR ***THIS IS NOT AN ALL-INCLUSIVE LISTING

N:/MM/REFERRAL MANAGEMENT/Service Grid by Site

08/21/2009

Oak West Primary Physician Assoc. TID # 36-4008699

Please notify Lourdes Reyes for all FHN Inpt/Outpt procedures 312-491-1956 x17, Fx 312-7383116 or e-mail at [email protected]

P.O. Box 7820, Westchester, IL 60154 Customer Service # : 708-432-1287

Health Plan Precert Medical Leadership Review SERVICES ABORTION

HMOI/BADV

Self Refer

335

#

(800) 892-2803

UNICARE Self Refer

(888) 234-8855

FHN Eligibility # 312-491-1956 Limited Coverage Refer to FHN/Valerie (312) 491-1956 X48

ACUPUNCTURE

No Coverage

AMBULANCE

Superior (708) 832-2000 or ANY Contracted Ambulance

BARIATRIC - MUST MEET MILLIMAN SURGICAL CRITERIA AND OAK GUIDELINES PRIOR TO CONSULT (CONSULT-RED REFERRAL)

Dr. Tiesenda @ Westlake Dr. Tiesenda @ Westlake Dr. Diniotis at Our Lady Dr. Diniotis at Our of Res. Lady of Res.

Superior (708) 832-2000

Door to Door Transportation L and L Transportation

Dr. Tiesenda @ Westlake Dr. Diniotis at Our Lady of Resurrection (Contact Lourdes Reyes 312-491-1956 x 17)

BLOOD TRANSFUSION

Cardiac Svc/Angioplasty/CABG

CHEMOTHERAPY

CHIROPRACTIC

COLONOSCOPY SCREENING

COLONOSCOPY DIAGNOSTIC

Pods A - B/Westlake Pods C/Our Lady of Resurrection Pods A - B/Westlake Pods A -B/Cardiac Pods C/Our Lady of Resurrection rehab to be sent to Our Lady of Resurrection .(cross pod) Pods A-B/ Dr. Banerji,Lyster,Rosi Pods C/ Dr. Nathan,Drazkiewicz Failed conservative tx. Eval. w/Dr. F. Robinson, D.O.

Pods A-B/ Dr. Banerji,Lyster,Rosi Pods C/ Dr. Nathan,Drazkiewicz Failed conservative tx. Eval. w/Dr. F. Robinson, D.O.

Westlake

In the office of Dr. Ebie Red Failed conservative tx. Eval. w/Dr. F. Robinson, D.O.

Consult not required

Consult not required

Consult not required

Colonoscopy @ Hospital

Colonoscopy @ Hospital

Colonoscopy @ Hospital

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

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

Colonoscopy @ Hospital

CT SCAN

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

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

Westlake

CT SCAN - 64 SLICE

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

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

Westlake

DIALYSIS

Per Appendix E

Per Healthplan (312) 234-8800

Contact Health Plan Valerie (312) 491-1956 Ext. 48

Check Benefit Purchase<$1000 No precert needed

Dependicare

DURABLE MED. EQUIPMENT/SUP.

Dependicare Walgreens or Any contracted DME vendor

Dependicare/Walgreens

EEG - 24 HOUR

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

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

N:/MM/REFERRAL MANAGEMENT/Service Grid by Site

Apria

UltraCare

Westlake

08/21/2009

Schwab Rehab Hospital Audiology Dept. (773) 522-5870

Group Allows Specialists to Request Referrals and Imaging

Yes

Yes

GREEN REFERRAL PROCESS

Patient obtains Green Referral and Script from PCP

Patient obtains Green Referral and Script from PCP

GYNECOLOGICAL ONCOLOGY

Dr. Donna Smith @ Loyola

Red

Dr. Donna Smith @ Loyola

Red

Patient obtains Green Referral and Script from PCP Dr. Donna Smith @ Loyola Red

Check Benefits

HEARING AIDS

HIGH RISK MATERNITY

HOME HEALTH CARE

IMMUNIZATIONS - TRAVEL

INFERTILITY

Per BCBS - Hearing aids Check Benefits may be obtained from any vendor. Contracted Vendor Hearing test no longer done @Westlake Hosp. Loyola University Medical Ctr.

Loyola University Medical Ctr.

Resurrection Home Health

Resurrection Home Health

Loyola University Medical Ctr.

Call for Benefits Any contracted BCBS infertility provider

Check Benefit Loyola University Medical Ctr. Diagnostic to be done by IPA/GYNE Infertility Review Form to be completed

Yes

Mt. Sinai Hospital

Mt. Sinai Hospital

No Coverage

Coram Specialty Infusion Services (Effective May 13th). Coram nurse / PCP to determine care setting.

INFUSION SERVICES - IVIG AND REMICADE

INPATIENT ADMISSIONS

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

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

Westlake

IV THERAPY

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

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

Westlake

United Shockwave

United Shockwave

Mt. Sinai Hospital

LITHOTRIPSY

MENTAL HEALTH

Procare

Wellpoint Dr. Piyaka

Self Refer (800) 746-6294

Self Refer PsycHealth (800) 753-5456

MRI'S

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

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

Westlake

MRI'S (OPEN)

Midwest Open MRI MRI Lincoln Imaging Center Red

Midwest Open MRI MRI Lincoln Imaging Center Red

Westlake

MRA

Red

Red

Red

NON-COMPLIANCE POLICY

Yes

Yes

Yes

NUTRITIONAL COUNSELING

Green Referral

Green Referral

Green Referral

OBSERVATION - 23 HOUR

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

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

Westlake

OCCUPATIONAL THERAPY

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

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

Westlake

N:/MM/REFERRAL MANAGEMENT/Service Grid by Site

08/21/2009

Davis Vision (877) 393-8844

OPTOMETRY ORTHOTIC/PROSTHETIC (See L Code List)

(effective 07/01/08) Hanger Prosthetic & Orthotics MD Orthotics or Any Contracted O/P Vendor

Must use Westlake Hospital or Our Lady of Resurrection

INPATIENT LABS

PACEMAKER CHECKS

Per Plan Vision Rider

Scheck & Siress Hanger Prosthetic & Orthotics MD Orthotics Must use Westlake Hospital or Our Lady of Resurrection

Pods A - B/Westlake Pods C/Our Lady of Resurrection Check Appendix B Westlake Community Hospital or Our Lady of the Res.

CORTISONE

EPIDURAL INJECTIONS PET SCANS

PULMONARY REHABILITATION

RADIATION THERAPY

1155

(800) 424-

Hanger Prosthetic & Orthotics Must use Westlake Hospital or Our Lady of Resurrection

Pods A - B/Westlake Pods C/Our Lady of Resurrection Westlake Community Hospital or Our Lady of the Res.

Red

PAIN MGMT

Adult - No Coverage Under 21 - Self Refer

Not managed by NAMM Patients need to call Health Plan

OUTPATIENT PHP/IOP

OUTPATIENT SURGICAL PROCS

Self Refer

In the office of ORS Red

In the office of AN Red

In the office of AN Red

MRI Lincoln Imaging Center Regional PET Imaging

C - Our Lady of Res.

Westlake Community Hospital or Our Lady of the Res.

Red

In the office of ORS Red

POS AB - Westlake

Westlake

MRI Lincoln Imaging Center Regional PET Imaging

PODS

Dr. Beck/Hem-Onc Assoc. POS 11 CT Planning-Gottlieb Hospital

POS AB - Westlake PODS C - Our Lady of Res.

Red In the office of ORS In the office of AN Red High Tech Lakeshore P.E.T. Imaging

Schwab Rehab Hospital

Dr. Beck/Hem-Onc Assoc. POS 11 CT Planning-Gottlieb Hospital

SKILLED NURSING FACILITY

SLEEP STUDY - ADULT

SLEEP STUDY - PEDS

STERILIZATION Vasectomy Tubal Ligation

SUBSTANCE ABUSE

SYNAGIS

SYNVISC

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

Check Benefit

Urology Office

Check Benefit IPA-GYNE at Gottlieb Hospital Not managed by NAMM Patients need to call Health Plan Ultra Care and/or Peds Office Medical Director review if Milliman not met

Ortho Office

Urology Office

Check Benefit IPA-GYNE at Gottlieb Hospital Not managed by NAMM Patients need to call Health Plan

Merit Sleep Management (888) 637-4848

University of Chicago Hospital

Limited Coverage Refer to FHN/Valerie (312) 491-1956 X48

Not Managed by NAMM Patients need to call Healthplan

Ultra Care Ultra Care and/or Peds Office Red Referral from Medical Director review if Milliman PCP Office not met Medical Director review if Milliman not met Ortho Office

TERTIARY HOSPITALS - ADULT

Loyola University Medical Ctr. University of Chicago

Loyola University Medical Ctr. University of Chicago

TERTIARY HOSPITALS - PEDS.

Loyola University Medical Ctr. University of Chicago

Loyola University Medical Ctr. University of Chicago

THALLIUM STRESS TEST

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

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

N:/MM/REFERRAL MANAGEMENT/Service Grid by Site

Mt. Sinai Hospital

Mt. Sinai Hospital Rush Medical Center

Green

08/21/2009

THERAPY - PEDS PT/OT/ST

Pods A-B/Westlake Pods Pods A-B/Westlake C/Our Lady of Resurrection Pods C/Our Lady of Resurrection Loyola University Medical Ctr/ST Loyola University Medical Ctr/ST

THERAPY - PHYSICAL

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

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

Westlake

THERAPY - SPEECH

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

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

Westlake

TRANSPLANTS

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

Per Healthplan (866) 694-0724

Transportation

N/A

N/A

X-rays Allowed in ortho office (Fracture Care)

Yes

Yes

X-rays Allowed in Ortho. Office

No

No

Care Mark

Care Mark

XOLAIR

Westlake

Mt. Sinai Hospital UNLIMITED

UNLIMITED

UNLIMITED

Contact Healthplan Valerie (312) 491-1956 Ext.48 L & L Medical Transport Self Refer (888) 346-4968

Yes

No

Care Mark

***THIS IS NOT AN ALL-INCLUSIVE LISTING

N:/MM/REFERRAL MANAGEMENT/Service Grid by Site

08/21/2009

Senior Care Partners TID # 20-4763091 WILL COUNTY P.O. Box , Westchester, IL 60154 Customer Service #: 708-240-5221 SERVICES ABORTION

ACUPUNCTURE

Health Plan Precert HealthSpring

847-993-1928

Health Plan Precert HealthSpring

847-993-1928

N/A

N/A

Not a covered benefit

Not a covered benefit

AMBULANCE

Superior Ambulance (708) 832-2000

BARIATRIC

Not done in Network Dr. Cahill @ Little Company of Mary (OON) (708) 422-5658

Superior Ambulance (708) 832-2000

?

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

?

Joliet Oncology / Hematology Associates

CHEMOTHERAPY

CHIROPRACTIC

COLONOSCOPY SCREENING

COLONOSCOPY DIAGNOSTIC

CT SCAN

CT SCAN - 64 SLICE

DIABETIC EDUCATION

DIALYSIS

Kurt Keppner, D.C. (708) 460-8688

John Hertko, D.C. (815) 725-7700

Consult required (Red)

Consult required (Red)

Colonoscopy @ Hospital

Colonoscopy @ Hospital

Consult required (Red)

Consult required (Red)

Colonoscopy @ Hospital

Colonoscopy @ Hospital

Metro South Medical Center Green Metro South Medical Center

Will County Medical Associates Green

Provena St. Joseph Hospital

Westlake Our Lady of Resurrection Little Company of Mary Green

Will County Medical Associates (Sheri Magnuson, R.N. C.D.E.) Green

Fresenius Medical

Fresenius Medical Naperville Dialysis Center

NeoMedica (Cannot go to South Holland location)

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

EEG - 24 HOUR

Metro South Medical Center Red

Provena St. Joseph Hospital Red

Consult required (Red)

Consult required (Red)

EGD @ Hospital

EGD @ Hospital

EGD

N:/MM/REFERRAL MANAGEMENT/Service Grid by Site

08/21/2009

Group Allows Specialists to Request Referrals

GYNECOLOGICAL ONCOLOGY

No

No

Little Company of Mary / Red

Joliet Oncology / Hematology Associates

Self Refer to Bell Tone

HEARING AIDS

St. Joliet

4240

HIGH RISK MATERNITY

HOME HEALTH CARE

IMMUNIZATIONS - TRAVEL

600 Theodore 815-722-

Self Refer to Bell Tone St. Joliet

N/A

4240

600 Theodore 815-722-

N/A

SSM Home Health @ Metro South Medical Center

Provena Home Health CNS Home Health

Not a covered benefit

Not a covered benefit

Call HealthSpring for benefit determination

Call HealthSpring for benefit determination

Red

Red

INPATIENT ADMISSIONS

Metro South Medical Center

Provena St. Joseph Hospital

IV THERAPY

Metro South Medical Center

Provena St. Joseph Hospital

INFERTILITY INJECTIBLE MEDICATIONS - EPOGEN, REMICAID, SYNVISC

LITHOTRIPSY

LUPRON INJECTIONS

United Shockwave Contact Nancy/Healthspring (847) 993-1928 Pre-cert required for any diagnosis except prostate cancer

MENTAL HEALTH

Self Refer MHN (866) 780-8546

MRI'S

High Tech Advantage MRI (South Holland Only)

Green

High Tech Advantage MRI (South Holland Only)

MRI'S (OPEN)

MRA

Olympia Fields Open MRI Open MRI

OBSERVATION - 23 HOUR

Pre-cert required for any diagnosis except prostate cancer Self Refer MHN (866) 780-8546

Will County Medical Associates Green

Open MRI of Joliet Open MRI Joliet Prairie

Green

Green Will County Medical Associates (Head Only), otherwise Provena St. Joseph Hospital Green

Green

NON-COMPLIANCE POLICY

NUTRITIONAL COUNSELING

United Shockwave Contact Nancy/Healthspring (847) 993-1928

Yes

Westlake Hospital

Yes

Green

Metro South Medical Center

N:/MM/REFERRAL MANAGEMENT/Service Grid by Site

Will County Medical Associates (Sheri Magnuson, R.N. C.D.E.) Green Provena St. Joseph Hospital

08/21/2009

OPTOMETRY

ORTHOTIC/PROSTHETIC

OUTPATIENT LABS

No Coverage

No Coverage

Scheck & Siress

Scheck & Siress

Metro South Medical Center

Self Refer MHN (800) 511-6946

OUTPATIENT PHP/IOP

OUTPATIENT SURGICAL PROCS

Metro South Medical Center

PACEMAKER CHECKS

Heart Care Centers of Illinois Red

PAIN MGMT.

In the office of ORS or RHU Red

CORTISONE

In the office of AN Red

EPIDURAL STEROID

High Tech

PET SCANS

RADIATION THERAPY

STERILIZATION:

Provena St. Joseph Hospital (Cancer Treatment Group) Drs. Griffin, Ommar, Crossan Red

?

?

?

SUBSTANCE ABUSE

SYNAGIS

Metro South Green

N/A Office-no precert Hospital-Precert

Tubal Ligation

Red

Provena St. Joseph Hospital

Medical Center

Vasectomy

Mauricio Orbegozo (815) 725-6331

Metro South Medical Center

DRW & Associates

SLEEP STUDY - PEDS.

Will County Medical Associates (815) 725-2121

Will County Medical Associates (815) 725-2121 Drs. Bailey and Klemm

SKILLED NURSING FACILITY

SLEEP STUDY - ADULT

Provena St. Joseph Hospital

Provena St. Joseph Hospital Green

Green

Dr. Tolentino

SCLEROTHERAPY

Self Refer MHN (800) 511-6946

Green

PODIATRY

PULMONARY REHABILITATION

Will County Medical Associates (815) 725-2121

Call HealthSpring for benefit determination Self Refer MHN (800) 511-6946

Cardinal Sleep Center (815) 773-9090

Green

N/A Office-no precert Hospital-Precert Call HealthSpring for benefit determination Self Refer MHN (800) 511-6946

N/A

N/A

TERTIARY HOSPITALS - ADULT

Loyola

Loyola

TERTIARY HOSPITALS - PEDS.

N/A

N/A

N:/MM/REFERRAL MANAGEMENT/Service Grid by Site

08/21/2009

THALLIUM STRESS TEST

Metro South Medical Center Green

THERAPY - OCCUPATIONAL

Metro South Medical Center

THERAPY - PEDS PT/OT/ST

Provena St. Joseph Hospital Green

Will County Medical Associates

N/A

THERAPY - PHYSICAL

Metro South Medical Center

THERAPY - SPEECH

Metro South Medical Center

TMJ/DENTAL PROCEDURES

?

N/A

Will County Medical Associates

Provena St. Joseph Hospital

Dr. Stephen Morimoto

TRANSPLANTS

Contact Nancy/Healthspring (847) 993-1928

Contact Nancy/Healthspring (847) 993-1928

TRANSPORTATION

Fresh Air

Fresh Air

(30 One way rides per year)

(30 One way rides per year)

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

N:/MM/REFERRAL MANAGEMENT/Service Grid by Site

08/21/2009

Silver Cross MCO TID # 36-3876019 P.O. Box 7849, Westchester, IL 60154 Customer Service # : 815-727-1998 SERVICES

Health Plan Precert Medical Leadership Review

HMOI/BADV

# 266

HUMANA

UNICARE

ABORTION

Check Benefit Check Benefit See BCBS Contracted Vender List Per Healthplan

ACUPUNCTURE

Peter Harvey, Eastern Healing, Inc. Peter Harvey, Eastern Healing, Inc. Peter Harvey, Eastern Healing, Inc. 630-653630-653630-6534358 4359 4360

AMBULANCE

Superior (708) 832-2000 or ANY Contracted Ambulance

BARIATRIC

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

BLOOD TRANSFUSION

CARDIAC STRESS TEST

Green

Silver Cross Hospital

Green

Chicago Ambulance Alliance (800) 558-6050

Green

Silver Cross Hospital Red

Check Benefit Per Healthplan

Superior (708) 832-2000

Green

Silver Cross Hospital

Green

Silver Cross Hospital Provena St. Joseph

Silver Cross Hospital Provena St. Joseph

Silver Cross Hospital Provena St. Joseph

CHEMOTHERAPY

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

CHIROPRACTIC

Davidson Chiropractic

Davidson Chiropractic

Davidson Chiropractic

Cardiac Svc/Angioplasty/CABG

COLONOSCOPY SCREENING

COLONOSCOPY DIAGNOSTIC

CT SCAN

CT SCAN - 64 SLICE

CT SCAN-CORONARY CALCIUM SCORING

DIALYSIS

Consult not required

Consult not required

Consult not required

Colonoscopy @ Hospital

Colonoscopy @ Hospital

Colonoscopy @ Hospital

Consult required (Green)

Consult required (Green)

Consult required (Green)

Colonoscopy @ Hospital

Colonoscopy @ Hospital

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 Homer Glen Facility CPT 0144T Facility ID 10031 (PA Review Mandatory-Red Ref.)

Silver Cross Hospital Red Referral Must be reviewed by Dr. Hindo Silver Cross Hospital Homer Glen Facility CPT 0144T Facility ID 10031 (PA Review Mandatory-Red Ref.)

Silver Cross Hospital Red Referral Must be reviewed by Dr. Hindo Silver Cross Hospital Homer Glen Facility CPT 0144T Facility ID 10031 (PA Review Mandatory-Red Ref.)

Silver Cross Hospital

Silver Cross Hospital

Silver Cross Hospital

Dependicare

DURABLE MED. EQUIPMENT/SUP. Walgreens Home Medical

or Any Contracted DME Vendor

EEG - 24 HOUR

Colonoscopy @ Hospital

Silver Cross Hospital Homer Glen Facility-Non contrast Imaging Green

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

N:/MM/REFERRAL MANAGEMENT/Service Grid by Site

Walgreens Home Medical

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

Check Benefit Purchase<$1000 No precert needed Dependicare/Walgreens Home Medical Provena St. Joseph Med. Ctr Peds - Hope/Christ Hospital

08/21/2009

EKG Group Allows Specialists to Request Referrals GREEN REFERRAL PROCESS

Silver Cross Hospital

Green PCP

Homer Glen Facility

Silver Cross Hospital

Homer Glen Facility

Green Providers to Green Providers

Green Specialist

Stamp Script

Silver Cross Hospital

Green Providers to Green Providers

Stamp Script

Stamp Script

GYNECOLOGICAL ONCOLOGY

Dr. Rotmensch @ RUMC

GLOBAL OB

Gloval OB referral not required for global OB Gloval OB referral not required for global OB Gloval OB referral not required for global OB care care care

HEARING AIDS

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

Red

Dr. Rotmensch @ RUMC

Homer Glen Facility

Red

Red

Check Benefits Contracted Vendor

Women's Health Consultants/RUMC

HIGH RISK MATERNITY

HOME HEALTH CARE

IMMUNIZATIONS - TRAVEL

INFERTILITY

Women's Health Consultants/RUMC (Level (Level II Ultrasound's at Women's Health II Ultrasound's at Women's Health Consultants: Use Prov. ID 200041) Consultants: Use Prov. ID 200041) Loyola University Medical Center Loyola University Medical Center

Loyola

Silver Cross Home Health

Interim & Advocate

Call Unicare

University of Chicago

University of Chicago

University of Chicago

Call for Benefits Fax the completed Humana Form Any contracted BCBS infertility provider Fertility Centers of Illinois

Fertility Center of Illinois Coram Specialty Infusion Services (Effective May 13th). Coram nurse / PCP to determine care setting.

INFUSION SERVICES - IVIG AND REMICADE INPATIENT ADMISSIONS

Loyola University Medical Center

Silver Cross Hospital

Silver Cross Hospital

Silver Cross Hospital

IV THERAPY

LABS

89230 - Chloride Sweat Test / Sweat 89230 - Chloride Sweat Test / Sweat 89230 - Chloride Sweat Test / Sweat 82435 - Chloride Sweat Test / Blood These 82435 - Chloride Sweat Test / Blood These 82435 - Chloride Sweat Test / Blood These Labs Only, Direct to Provena St. Joseph Labs Only, Direct to Provena St. Joseph Labs Only, Direct to Provena St. Joseph Hospital. Request will be generated by Hospital. Request will be generated by Hospital. Request will be generated by allergy providers via queue. (Red Referral) allergy providers via queue. (Red Referral) allergy providers via queue. (Red Referral)

LITHOTRIPSY

United Shockwave "O" note-Ingalls Surg Ct.

United Shockwave "O" note-Ingalls Surg Ct.

United Shockwave "O" note-Ingalls Surg Ct.

MENTAL HEALTH

Central Professional Group Green

Self Refer

Wellpoint Self Refer

MRI'S

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

Open Advanced MRI

Open Advanced MRI

MRI'S (OPEN)

MRA

NON-COMPLIANCE POLICY

Red

(800) 331-9040

Red

(800) 746-6294

Red

Green

Green

Green

N/A

N/A

N/A

N:/MM/REFERRAL MANAGEMENT/Service Grid by Site

08/21/2009

NUTRITIONAL COUNSELING

OBSERVATION - 23 HOUR

Silver Cross Hospital

Silver Cross Hospital Davis Vision (877) 393-8844

OPTOMETRY

Green Referral

Silver Cross Hospital

Green Referral

Silver Cross Hospital Eye Med Self Refer

(effective 07/01/08)

ORTHOTIC/PROSTHETIC (See L Code List)

Scheck & Siress Hanger Prosthetic & Orthotics MD Orthotics

OUTPATIENT LABS

Silver Cross Hospital Homer Glen Facility

Silver Cross Hospital

Scheck & Siress

Silver Cross Hospital

Self Refer

(866) 273-0817 MD Orthotics

Silver Cross Hospital Homer Glen Facility

Green Referral

Per Plan Vision Rider

Scheck & Siress Hanger Prosthetic & Orthotics MD Orthotics Silver Cross Hospital Homer Glen Facility

OUTPATIENT PHP/IOP

OUTPATIENT SURGICAL PROCS

Silver Cross Hospital Check Appendix B

Silver Cross Hospital

Silver Cross Hospital

PACEMAKER CHECKS

Silver Cross Hospital - Red

Silver Cross Hospital - Red

Silver Cross Hospital - Red

PAIN MGMT

In the office of ORS/Green

In the office of ORS/Green

In the office of ORS/Green

In the office of AN/Green

In the office of AN/Green

In the office of AN/Green

CORTISONE

EPIDURAL INJECTIONS PET SCANS

PULMONARY FUNCTION TEST

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

Silver Cross Hospital

Silver Cross Hospital

Green

Red

Green

PULMONARY REHABILITATION

Silver Cross Hospital Green

Silver Cross Hospital Green

Silver Cross Hospital Green

RADIATION THERAPY

Dr. Asaad@Hoffman Center Green

Dr. Asaad@Hoffman Center Red

Dr. Asaad@Hoffman Center Green

SLEEP STUDY ADULT

Cardinal Sleep Center Green

Cardinal Sleep Center Green

Cardinal Sleep Center Green

SLEEP STUDY PEDS.

Cardinal Sleep Center Green

Cardinal Sleep Center Green

Cardinal Sleep Center Green

SKILLED NURSING FACILITY

STERILIZATION

Vasectomy Tubal Ligation

SUBSTANCE ABUSE

Check Benefit/Red Check Benefit Not managed by NAMM Patients need to call Healthplan

Check Benefit/Red Check Benefit

Not managed by NAMM Patients need to call Healthplan

Check Benefit/Red Check Benefit

Not managed by NAMM Patients need to call Healthplan

SYNAGIS

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

SYNVISC

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.

N:/MM/REFERRAL MANAGEMENT/Service Grid by Site

08/21/2009

U of C

TERTIARY HOSPITALS - ADULT

TERTIARY HOSPITALS - PEDS.

Rush University Medical Center

Loyola University Medical Center UIC

Rush University Medical Center

Loyola University Medical Center

U of C Center

Loyola University Medical

UIC UIC Rehabilitation Rehabilitation Institute of Rehabilitation Institute of Institute of Chicago U of C or UIC Chicago U of C or UIC Chicago Advocate Hpoe Children's (Refer to SCMCO Advocate Hpoe Children's (Refer to SCMCO U of C or UIC Approved Provider List) Approved Provider List) Loyola Rush University Medical Center Rush University Medical Center University Medical Center Advocate Hpoe Children's (Refer to Loyola University Medical Center Loyola University Medical Center SCMCO Approved Provider List) Children's Memorial Hospital Children's Memorial Hospital Children's Memorial Hospital Rehabilitation institute Rehabilitation institute Rehabilitation institute of Chicago of Chicago of Chicago

THALLIUM STRESS TEST

Silver Cross Hospital

THERAPY - OCCUPATIONAL

Silver Cross Hospital

THERAPY - PEDS. PT/OT/ST

Silver Cross Hospital

THERAPY - PHYSICAL

Silver Cross Hospital

THERAPY - SPEECH

Silver Cross Hospital

TRANSPLANTS

U of C

Green

Green

Green

Green

Green

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

Silver Cross Hospital

Silver Cross Hospital

Silver Cross Hospital

Silver Cross Hospital

Silver Cross Hospital

Per Healthplan

Green

Green

Green

Green

Green

(800) 626-2698

Silver Cross Hospital

Silver Cross Hospital

Silver Cross Hospital

Silver Cross Hospital

Silver Cross Hospital

Per Healthplan

N/A

N/A

N/A

X-Rays Allowed in Ortho Office (Fracture Care)

Yes

Yes

Yes

X-rays Allowed in Ortho. Office

Yes

Yes

Yes

XOLAIR

Silver Cross Hospital Homer Glen Facility

Red

Silver Cross Hospital Homer Glen Facility

Red

Green

Green

Green

Green

(866) 694-0724

TRANSPORTATION

X-RAYS

Green

Silver Cross Hospital Homer Glen Facility

Red

***THIS IS NOT AN ALL-INCLUSIVE LISTING

N:/MM/REFERRAL MANAGEMENT/Service Grid by Site

08/21/2009

Swedish Covenant Managed Care TID # 36-4118659 P.O. Box 7850, Westchester, IL 60154 Customer Service # : 708-432-4055

Health Plan Precert Medical Leadership Review

HUMANA SERVICES ABORTION

ACUPUNCTURE

Commercial Check Benefit Per Healthplan Swedish - After all conservative treatments have been exhausted

Medicare

HealthSpring

Check Benefit Per Healthplan Swedish - After all conservative treatments have been exhausted

N/A

Swedish - After all conservative treatments have been exhausted

AMBULANCE

Chicago Ambulance Alliance Chicago Ambulance Alliance Chicago Ambulance Alliance (800) 558-6050 (800) 558-6050 (800) 558-6050

BARIATRIC

Dr. Denham @ Evanston Northwestern Dr. Denham @ Evanston Northwestern Dr. Denham @ Evanston Northwestern

BLOOD TRANSFUSION

Red

Red

Swedish

Swedish

Swedish

In the office of Dr. Philip

In the office of Dr. Philip

In the office of Dr. Philip

Swedish - After all conservative treatments have been exhausted

Swedish - After all conservative treatments have been exhausted

Swedish - After all conservative treatments have been exhausted

Cardiac Svc/Angioplasty/CABG

CHEMOTHERAPY

CHIROPRACTIC

COLONOSCOPY SCREENING

COLONOSCOPY DIAGNOSTIC

CT SCAN

CT SCAN - 64 SLICE

Consult not required

Consult not required

Consult not required

Colonoscopy @ Hospital

Colonoscopy @ Hospital

Colonoscopy @ Hospital

Consult required (Green)

Consult required (Green)

Consult required (Green)

Colonoscopy @ Hospital

Colonoscopy @ Hospital

Colonoscopy @ Hospital

Swedish

EEG - 24 HOUR Group Allows Specialists to Request Referrals GREEN REFERRAL PROCESS

Red

Swedish

Red

Swedish

Red

Swedish Evanston Hospital Red

Swedish Evanston Hospital Red

Swedish Evanston Hospital Red

Swedish

Swedish

Swedish

DIALYSIS

DURABLE MED. EQUIPMENT/SUP.

Red

Walgreens

Dependicare

Integrated Walgreens

Dependicare

Integrated Walgreens

Dependicare

Swedish

Swedish

Swedish

No

No

No

Green referral form / script

Green referral form / script

Green referral form / script

N:/MM/REFERRAL MANAGEMENT/Service Grid by Site

08/21/2009

GYNECOLOGICAL ONCOLOGY

Drs. Gustavo Rodriquez and Herbert Drs. Gustavo Rodriquez and Herbert Drs. Gustavo Rodriquez and Herbert Beck @ ENH Beck @ ENH Beck @ ENH Red Red Red

HEARING AIDS

Check Benefits Contracted Vendor

Check Benefits Contracted Vendor

Check Benefits Contracted Vendor

HIGH RISK MATERNITY

Swedish

Swedish

HOME HEALTH CARE

Swedish

Swedish

Metro Infectious Disease

Metro Infectious Disease

Not a Covered Benefit

N/A

N/A

IMMUNIZATIONS - TRAVEL

INFERTILITY

Call for Benefits Fertility Centers of Illinois

N/A

Swedish

HRS Home Health

INPATIENT ADMISSIONS

Swedish

Swedish

Swedish

IV THERAPY

Swedish

Swedish

Swedish

LITHOTRIPSY

Swedish

Swedish

Swedish

MENTAL HEALTH

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

MRI'S

Swedish

Swedish

Swedish

MRI'S (OPEN)

Red

Swedish MRI Lincoln Imaging Red

Red

Swedish MRI Lincoln Imaging Red

Red

Swedish MRI Lincoln Imaging Red

MRA

Red

Red

Red

NON-COMPLIANCE POLICY

No

No

No

NUTRITIONAL COUNSELING

Red Referral

Red Referral

Red Referral

Swedish

Swedish

Swedish

OBSERVATION - 23 HOUR

OPTOMETRY ORTHOTIC/PROSTHETIC (See L Code list) OUTPATIENT LABS

OUTPATIENT PHP/IOP

OUTPATIENT SURGICAL PROCS

Incident to Cataract Surgery

Scheck & Siress MD Orthotics

Swedish Covenant Hospital

Not managed by NAMM Patients need to call Healthplan

Swedish

N:/MM/REFERRAL MANAGEMENT/Service Grid by Site

Incident to Cataract Surgery

Scheck & Siress MD Orthotics

Swedish Covenant Hospital

Not managed by NAMM Patients need to call Healthplan

Swedish

Incident to Cataract Surgery

Scheck & Siress MD Orthotics

Swedish Covenant Hospital

Not managed by NAMM Patients need to call Healthplan

Swedish

08/21/2009

PACEMAKER CHECKS PAIN MGMT

CORTISONE

Swedish Covenant Hospital - Red Swedish Covenant Hospital - Red Swedish Covenant Hospital - Red "O" note Pacemaker Clinic "O" note Pacemaker Clinic "O" note Pacemaker Clinic Swedish Pain Clinic/Dr. Xie

Swedish Pain Clinic/Dr. Xie

Swedish Pain Clinic/Dr. Xie

Swedish Pain Clinic/Dr. Xie

Swedish Pain Clinic/Dr. Xie

Swedish Pain Clinic/Dr. Xie

Swedish

Swedish

Swedish

Evanston Hospital

Evanston Hospital

Evanston Hospital

RADIATION THERAPY

Swedish

Swedish

Swedish

SKILLED NURSING FACILITY

Swedish

Swedish

Swedish

EPIDURAL INJECTIONS PET SCANS

PULMONARY REHABILITATION

SLEEP STUDY - ADULT

DRW & Associates (773) 805-1871

DRW & Associates (773) 805-1871

SLEEP STUDY - PEDS.

DRW & Associates (773) 805-1871

DRW & Associates (773) 805-1871

STERILIZATION

Vasectomy Tubal Ligation

SUBSTANCE ABUSE

DRW & Associates (773) 805-1871

N/A

Check Benefit

Check Benefit

N/A

Check Benefit

Check Benefit

N/A

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

SYNAGIS

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

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

TERTIARY HOSPITALS - PEDS.

Evanston Hospital

Evanston Hospital

N/A

THALLIUM STRESS TEST

Swedish

Green

Swedish

Green

Swedish

Green

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

N:/MM/REFERRAL MANAGEMENT/Service Grid by Site

08/21/2009

TRANSPORTATION

N/A

N/A

N/A

X-rays Allowed in Ortho office (Fracture Care)

Yes

Yes

Yes

X-rays Allowed in Ortho. Office

No

No

No

Walgreens Home Care

Walgreens Home Care

Walgreens Home Care

XOLAIR ***THIS IS NOT AN ALL-INCLUSIVE LISTING

N:/MM/REFERRAL MANAGEMENT/Service Grid by Site

08/21/2009