89 Ill. Adm. Code 150.100
Provider Eligibility
Section
150.100 Provider Eligibility
a) General Requirements. A
provider must:
1) Be
within one of the classes of eligible professionals enumerated in subsection (b).
2) Be
enrolled, and in good standing, with the Department to participate in the
Illinois Medical Assistance Program.
3) Be a
registered user of the Department's Medical Electronic Data Interchange System.
b) Eligible Professionals
(EP).
1) The
health practitioners that may be eligible for incentive payments are limited to
the following:
A) A
certified nurse-midwife.
B) A
dentist.
C) A nurse
practitioner.
D) A
physician.
E) An
optometrist.
F) A
physician assistant (PA) practicing in a federally qualified health center
(FQHC) or a rural health clinic (RHC) that is led by a PA.
2) Eligible
Hospitals (EH). The hospitals that may be eligible for incentive payments are
limited to the following hospitals:
A) Acute
care hospitals.
B) Children's
hospitals.
c) Eligibility
Requirements for EP. For each year for which the practitioner seeks an
incentive payment, the practitioner must:
1) Have
a minimum 30 percent patient volume attributable to individuals receiving
Medicaid, except in the instance of a practitioner:
A) that
is a pediatrician, with a minimum 20 percent patient volume attributable to
individuals receiving Medicaid.
B) that
practices predominately in an FQHC or RHC with a minimum 30 percent patient
volume attributable to needy individuals, as defined at 42 CFR 495.302.
2) Not
be a "hospital-based EP" as defined at 42 CFR 495.4, except this
provision does not apply to a practitioner practicing predominately at an FQHC
or RHC.
d) Eligibility
Requirements for EH. For each year for which the hospital seeks an incentive
payment, an acute care hospital must have at least a 10 percent volume
attributable to individuals receiving Medicaid. A children's hospital is
exempt from meeting a patient volume threshold.