Service Grid by Site

Elmcare, LLC
TID # 36-3994179
P.O. Box 7759, Westchester, IL 60154 Health Plan Precert

Customer Service # : 708-432-4050 Medical Leadership Review
Aetna (ELMO)
HMOI/BADV
SERVICES HUMANA Self-Funded Employer
# 312
Plan
Check Benefit
Check Benefit
ABORTION See BCBS
Per Healthplan
Planned Parenthood
Contracted Vendor List
ACUPUNCTURE See ED/PR See ED/PR See ED/PR
Superior (708) 832-2000 or Chicago Ambulance Alliance

AMBULANCE ANY Contracted Ambulance (800) 558-6050
Vandenburg
UIC UIC
Dr. Joseph Vitello Dr. Joseph Vitello
BARIATRIC Dr. Dr. Not A Covered Benefit
Carlos Galvani Carlos Galvani
Dr. Subhashini Ayloo Dr. Subhashini Ayloo
Cardiac Svc/Angioplasty/CABG Elmhurst Memorial Hospital Elmhurst Memorial Hospital Elmhurst Memorial Hospital
Elmhurst Memorial Hospital Elmhurst Memorial Hospital Elmhurst Memorial Hospital

CHEMOTHERAPY Green Red Green
Dr. Jevitz Dr. Jevitz Dr. Jevitz

CHIROPRACTIC (630) 834-3391 (630) 834-3391 (630) 834-3391
Consult not required Consult not required Consult not required

COLONOSCOPY SCREENING Colonoscopy @ Hospital Colonoscopy @ Hospital Colonoscopy @ Hospital
Consult required Consult required Consult required

COLONOSCOPY DIAGNOSTIC Colonoscopy @ Hospital Colonoscopy @ Hospital Colonoscopy @ Hospital
CT SCAN
Green Green Green
CT SCAN - 64 SLICE Only if ordered Only if ordered by Only if ordered
by Cardiologist Red Cardiologist Red by Cardiologist Red
BLOOD TRANSFUSION Green Green Green
Per Health Plan Renal Care Group of Villa Park

DIALYSIS See Appendix E
(800) 626-2698 DuPage Peritoneal
The first preferred DME is:

Action 630-758-7000
Walgreens Home Medical Action - if not see Aetna list
DURABLE MED. EQUIPMENT/SUP. Dependicare (800) 224-7404
(800) 323-2828 (Attached)
Walgreens (800) 323-2828 or
ANY Contracted DME Vendor
EEG - 24 HOUR Tertiary Tertiary Tertiary
Group Allows Specialists to

N/A N/A N/A
Request Referrals
N:/MM/REFERRAL MANAGEMENT/Service Grid by Site 08/21/2009

GREEN REFERRAL PROCESS Script with Elmcare stamp/sticker 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
GYNECOLOGICAL ONCOLOGY @ Loyola / Red @ Loyola / Red @ Loyola / Red
Check Benefits
Check Benefits
Per BCBS -
HEARING AIDS Hearing aids may be obtained from
Contracted Vendor Not Covered
any vendor
Lutheran General Providers Lutheran General Providers
Lutheran General Providers
Loyola Maternal Fetal Medicine Loyola Maternal Fetal Medicine
HIGH RISK MATERNITY Loyola Maternal Fetal Medicine
Elmhurst Home Health Elmhurst Home Health

HOME HEALTH CARE (or see attached list)
Advocate
(or see attached list)
Check Benefit Check Benefit

Loyola University Medical Center
IMMUNIZATIONS - TRAVEL Public Health Department
Loyola University Medical Center Loyola University Medical Center
Public Health Department Public Health Department
Check Scope of Benefits

Fax the completed Humana Form/ Enter in system as 99999
INFERTILITY Call for Benefits
Fertility Centers of Illinois Patient to call 800-575-5999
See Health Plan Prov. List
INPATIENT ADMISSIONS Elmhurst Memorial Hospital Elmhurst Memorial Hospital Elmhurst Memorial Hospital
Adult: Alexian Brothers

Children:
1) Lutheran
INPATIENT ADMISSIONS-PSYCH General 2)
Alexian Brothers
3) Linden Oaks
IV THERAPY Elmhurst Memorial Hospital Elmhurst Memorial Hospital Elmhurst Memorial Hospital
LITHOTRIPSY United Shockwave United Shockwave United Shockwave
See All red list

Self Refer
MENTAL HEALTH Inpt. Peds at Lutheran
(800) 331-9040
Not Managed by Namm
General

MRI'S Green Green Green
Midwest Imaging Midwest Imaging Midwest Imaging

MRI'S (OPEN) Red Red Red
MRA 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
OBSERVATION - 23 HOUR Elmhurst Memorial Hospital Elmhurst Memorial Hospital Elmhurst Memorial Hospital
Cole Vision Cole Vision

Davis Vision
Self Refer Self Refer
OPTOMETRY (877)-393-8844
(800) 334-7591 (800) 334-7591
(effective 07/01/08)
Scheck & Siress Scheck & Siress Elmhurst Clinic

ORTHOTIC/PROSTHETIC
Hanger Prosthetic & Orthotics Hanger Prosthetic & Orthotics or
(See L Code List) MD Orthotics MD Orthotics Aetna provider

Elmhurst Hospital Elmhurst Hospital Elmhurst Hospital
OUTPATIENT LABS Elmhurst Clinic Elmhurst Clinic Elmhurst Clinic
OUTPATIENT PHP/IOP Elmhurst Memorial Hospital Not Managed Not Managed
Elmhurst Memorial Hospital

Elmhurst Memorial Hospital Elmhurst Memorial Hospital
OUTPATIENT SURGICAL PROCS Elmhurst OP Surgical Center
Elmhurst OP Surgical Center Elmhurst OP Surgical Center
Check Appendix B
PODS ADE - Midwest Heart/Green PODS ADE - Midwest Heart/Green PODS ADE - Midwest Heart/Green
PODS B-Elmhurst Clinic/Green PODS B-Elmhurst Clinic/Green PODS B-Elmhurst Clinic/Green
PACEMAKER CHECKS If Cross PODS, If Cross PODS, If Cross PODS,
becomes a Red becomes a Red becomes a Red
In the office of ORS/RHU In the office of ORS/RHU In the office of ORS/RHU
PAIN MGMT CORTISONE Green Green Green
Given by Pain Clinic Spec. Given by Pain Clinic Spec. Given by Pain Clinic Spec.
EPIDURAL INJECTIONS at EOSC or EMH at EOSC or EMH at EOSC or EMH
Medical Out Sourcing @Elmhurst Medical Out Sourcing @Elmhurst Medical Out Sourcing @Elmhurst
PET SCANS Memorial Hospital Memorial Hospital Memorial Hospital
PULMONARY REHABILITATION Elmhurst Memorial Hospital Elmhurst Memorial Hospital Elmhurst Memorial Hospital

RADIATION THERAPY Green Red Green
Elmhurst Memorial Hospital Skilled Elmhurst Memorial Hospital Skilled

SKILLED NURSING FACILITY Nursing Facility Or Manor Care Nursing Facility Or Manor Care
Elmhurst Extended Care
Elmhurst Memorial Hospital (Green Elmhurst Memorial Hospital (Green Elmhurst Memorial Hospital (Green
SLEEP STUDY - ADULT Referral) Referral) Referral)
Loyola University Medical Center Loyola University Medical Center Loyola University Medical Center
SLEEP STUDY - PEDS. Lutheran General Hospital Lutheran General Hospital Lutheran General Hospital
Check benefit Check benefit Covered - Hospital

STERILIZATION Vasectomy
Tubal Ligation Check benefit Check benefit Covered - Hospital
Not Managed by Namm Not Managed by Namm Not Managed by Namm

SUBSTANCE ABUSE Call Health Plan Call Health Plan Call Health Plan
Ultra Care Ultra Care Ultra Care

Elmhurst Mem Hosp. Elmhurst Mem Hosp. Infusion Elmhurst Mem Hosp. Infusion
SYNAGIS Infusion Ctr Medical Ctr Medical review if no Ctr Medical review if no
review if no Milliman Milliman Milliman
Ortho (Green) Ortho (Green) Ortho (Green)
SYNVISC Injection Injection
Injection (Red) (Red) (Red)
Lutheran General Hospital, Loyola,

Rush (See list if Ortho), or University Lutheran General Hospital, Loyola, Lutheran General Hospital, Loyola,
TERTIARY HOSPITALS - ADULT of Illinois Rush (See list if Ortho), or University Rush (See list if Ortho), or University
Loyola Physician Foundation- #800003 of Illinois of Illinois
Loyola Medical Center- #200038
Lutheran Generan Hospital, Loyola, Lutheran General Hospital, Loyola, Lutheran General Hospital, Loyola,
TERTIARY HOSPITALS - PEDS. 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 Elmhurst Memorial Hospital Elmhurst Memorial Hospital Elmhurst Memorial Hospital
(Red or Green referral) Green Green Green

THERAPY - OCCUPATIONAL Elmhurst Rehab Elmhurst Rehab Elmhurst Rehab
Elmhurst Memorial Hospital / Elmhurst Memorial Hospital / Elmhurst Memorial Hospital /

Loyola Loyola Loyola
THERAPY - PEDS. PT/OT/ST University Medical Center University Medical Center University Medical Center
Lutheran General Hospital Lutheran General Hospital Lutheran General Hospital

THERAPY - PHYSICAL Elmhurst Rehab Elmhurst Rehab Elmhurst Rehab

THERAPY - SPEECH Elmhurst Rehab Elmhurst Rehab Elmhurst Rehab
See Scope of Benefits

Audrey Johnson-Tarver Per Healthplan Per Aetna Network
TRANSPLANTS (312) 997-6615 Fax (312) 938- (800) 626-2698 (877) 212-8811
4682
TRANSPORTATION N/A N/A N/A
X-rays Allowed in Ortho Office Yes Yes Yes

(Fracture Care)
Yes Yes Yes

X-rays Allowed in Ortho. Office
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

Health Options of Illinois
TID # 36-3680139
HMOI/BADV
SERVICES # 275
Check Benefit
ABORTION See BCBS Contracted Vendor List
Lewis Chiropractic Center

ACUPUNCTURE (847) 336-3400
AMBULANCE Any contracted ambulance
BARIATRIC - MUST MEET MILLIMAN SURGICAL

CRITERIA AND HOI GUIDELINES PRIOR TO Dr. Michael Scheer @ Vista East
CONSULT (CONSULT-RED REFERRAL)
BLOOD TRANSFUSION Red
Cardiac Svc/Angioplasty/CABG Vista East
Dr. Mehta, Dr. Kapadia

Check BCBS self injection drug list, if MD is
CHEMOTHERAPY 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

CHIROPRACTIC (847) 336-3400
Consult not required if over 50

Colonoscopy @
COLONOSCOPY SCREENING Hospital (HP Pre-
cert not required)
Consult required (Red)
COLONOSCOPY DIAGNOSTIC Colonoscopy at Hospital
(HP Pre-cert not required)
Vista East or Vista West

CT SCAN Green
CT SCAN 64 SLICE Vista East
DIALYSIS See Appendix E
DURABLE MED. EQUIPMENT/SUP. Any contracted DME vendor
EEG - 24 HOUR Vista East
OB/GYN Only
Group Allows Specialists to Request Referrals (May only refer to selected specialties--See
Attached)

GREEN REFERRAL PROCESS
GYNECOLOGICAL ONCOLOGY NorthShore University / Red
Check Benefits
HEARING AIDS Per BCBS - Hearing aids may be obtained
from any vendor
HIGH RISK MATERNITY NorthShore University HealthSystem
HOME HEALTH CARE Per BCBS List
Passport Health - Gurnee

IMMUNIZATIONS - TRAVEL (888) 499-7277

Vista East / Vista West

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

MENTAL HEALTH
Inpt-Vista East and Vista West
MRI Institute
MRI'S Only if criteria not met
Vista MRI Institute

MRI'S (OPEN) Only if criteria not met
MRA Red
NON-COMPLIANCE POLICY Yes
NUTRITIONAL COUNSELING Red Referral
OBSERVATION - 23 HOUR Vista East
Davis Vision
OPTOMETRY (877) 393-8844
ORTHOTIC/PROSTHETIC
Any contracted vendor
(See L code List)
Quest
INPATIENT LABS Vista East -
STAT only

OUTPATIENT PHP/IOP N/A
Vista East (Victory) or Vista Surgical & Tx Ctr. Only

OUTPATIENT SURGICAL PROCS if criteria not met check Appendix B
Cardiac E.P. Consultants, SC

PACEMAKER CHECKS Red
In the office of ORS

PAIN MANAGEMENT CORTISONE Red
In the office of Dr. Arber
EPIDURAL INJECTIONS Red
PET SCANS Vista West MRI
PULMONARY REHABILITATION Vista East
Dr. Kurup
RADIATION THERAPY Dr. Mehta
SKILLED NURSING FACILITY Per BCBS List
SLEEP STUDY - ADULT Vista East
SLEEP STUDY - PEDS. Children's Hospital of Wisconsin
Check Benefit
STERILIZATION Vasectomy In the office of Dr. Khan
Tubal Ligation Check Benefit
Vista East
Not Managed by NAMM

SUBSTANCE ABUSE Contact Healthplan
SYNAGIS Ultra Care or Peds Office
SYNVISC Ortho Office
Northshore University Health System

TERTIARY HOSPITALS - ADULT
Northshore University Health System

TERTIARY HOSPITALS - PEDS. Children's Hospital of Wisconsin--See
Attached
THALLIUM STRESS TEST Vista East

(Red or Green referral) Green
THERAPY - OCCUPATIONAL Vista Physical Medicine
THERAPY - PEDS. PT/OT/ST Vista Physical Medicine
THERAPY - PHYSICAL Vista Physical Medicine

THERAPY - SPEECH Vista Physical Medicine
See Scope of benefits

TRANSPLANTS Audrey Johnson-Tarver
312-997-6615 Fax 312-938-4682
TRANSPORTATION N/A
X-rays Allowed in Ortho Office

Yes
(Fracture Care)
X-rays Allowed in Ortho. Office No
XOLAIR Walgreens

Hinsdale Physicians Healthcare
TID # 36-3851702

HMOI/BADV
SERVICES HUMANA UNICARE
# 257
Check Benefit
ABORTION See BCBS Contracted
Per Healthplan Per Healthplan
Vendor List

Dr. Xlaoping Xu
ACUPUNCTURE (630) 655-9988
Dr. Xlaoping Xu Dr. Xlaoping Xu
(630) 655-9988 (630) 655-9988
Superior (708-832-2000) or Chicago Ambulance Alliance

Superior (708) 832-2000
BARIATRIC Loyola University Medical Center Loyola University Medical Center Loyola University Medical Center
Hinsdale Hospital Hinsdale Hospital Hinsdale Hospital

Cardiac Svc/Angioplasty/CABG LaGrange Hospital LaGrange Hospital LaGrange Hospital
HPH Hematology/Onc HPH Hematology/Onc HPH Hematology/Onc

CHEMOTHERAPY Specialist Specialist Specialist
Green Green Green

CHIROPRACTIC See Red List
See Red List See Red List
Consult Required (Green) Consult Required (Green) Consult Required (Green)

COLONOSCOPY SCREENING
Colonoscopy @ Hospital Colonoscopy @ Hospital Colonoscopy @ Hospital
Consult Required (Green) Consult Required (Green) Consult Required (Green)

COLONOSCOPY DIAGNOSTIC
LaGrange Hospital LaGrange Hospital LaGrange Hospital
CT SCAN Glen Oaks Medical Center Glen Oaks Medical Center Glen Oaks Medical Center
Bolingbrook Bolingbrook Bolingbrook
(Green) (Green) (Green)
Cardiologist or contracted Hospital Cardiologist or contracted Hospital Cardiologist or contracted Hospital

CT SCAN - 64 SLICE Green Green Green
BLOOD TRANSFUSION Red Red Red
DIALYSIS See Appendix E Per Health Plan Per Health Plan
Check Benefit
Dependicare (800) 224-7404
Walgreens Home Medical <$1000 No precert needed
DURABLE MED. EQUIPMENT/SUP. Walgreens (800) 323-2828 or
(800) 323-2828 Dependicare/Walgreens
Any Contracted DME Vendor

EEG - 24 HOUR Glen Oaks Medical Center Glen Oaks Medical Center Glen Oaks Medical Center
(Red) (Red) (Red)
Group Allows Specialists to Yes - Capitated Specialists Only (Green List) Ortho - only for diagnostics
Request Referrals May only refer for diagnostics at the Hospital & for procedures they are performing themselves
GREEN REFERRAL PROCESS Patient obtains Green Referral Patient obtains Green Referral Patient obtains Green Referral
N:/MM/REFERRAL MANAGEMENT//Service Grid by Site 08/21/2009

Drs. Sameer Sharma and Sudarshan Drs. Sameer Sharma and Sudarshan Drs. Sameer Sharma and Sudarshan
GYNECOLOGICAL ONCOLOGY Sharma @ Hinsdale / Red Sharma @ Hinsdale / Red Sharma @ Hinsdale / Red
Check Benefits
Check Benefits Check Benefits
HEARING AIDS Per BCBS - Hearing
Contracted Vendor Contracted Vendor
aids may be obtained from any vendor
Dr. Daniel Gauthier - Hinsdale Hospital (630) 856-6741

HIGH RISK MATERNITY (For Dr. Gauthier, when entering Auth for Maternal Fetal Medicine the place of service is 22)
Dr. Meyer--Hinsdale Hospital
Orsini (847) 734-7373

Health Care at Home (630) 856-6901
HOME HEALTH CARE Orsini (847) 734-7373
Advocate HHC (800) 564-2025 Chartwell (infusion) (800) 551-9355
Ultracare (800) 222-9444

IMMUNIZATIONS - TRAVEL Loyola University Medical Center

Fax the completed Humana Form Contact Unicare - HPH does not
Fertility Centers of Illinois manage
Coram Specialty Infusion Services

INFUSION SERVICES - IVIG AND
(Effective May 13th). Coram nurse /
REMICADE PCP to determine care setting.

INPATIENT ADMISSIONS Glen Oaks Medical Center Glen Oaks Medical Center Glen Oaks Medical Center
Adventist Bolingbrook Hospital Adventist Bolingbrook Hospital Adventist Bolingbrook Hospital
IV THERAPY
LITHOTRIPSY United Shockwave United Shockwave United Shockwave

Mental Health Specialty Services
Self Refer Wellpoint
PsycHealth
(800) 331-9040 Self Refer
MENTAL HEALTH Self Refer
(800) 746-6294
(800) 753-5456
Hinsdale Hospital (Hinsdale Ortho in Hinsdale Hospital (Hinsdale Ortho in Hinsdale Hospital (Hinsdale Ortho in off.
off. without authorization) off. without authorization) without authorization)
MRI'S Glen Oaks Medical Center Glen Oaks Medical Center Glen Oaks Medical Center
(Green) (Green) (Green)
Oakbrook MRI dba Open Advanced Oakbrook MRI dba Open Advanced Oakbrook MRI dba Open Advanced MRI
MRI of Oakbrook/Westbrook Open MRI of Oakbrook/Westbrook Open of Oakbrook/Westbrook Open
MRI'S (OPEN) MRI/Midwest Imaging, Molecular MRI/Midwest Imaging, Molecular MRI/Midwest Imaging, Molecular
Imaging Imaging Imaging
NON-COMPLIANCE POLICY Yes Yes Yes
Oakbrook Health and Nutrition Oakbrook Health and Nutrition Oakbrook Health and Nutrition
NUTRITIONAL COUNSELING Dr. Ghani or Dr. Auriemma Dr. Ghani or Dr. Auriemma Dr. Ghani or Dr. Auriemma

OBSERVATION - 23 HOUR Glen Oaks Medical Center Glen Oaks Medical Center Glen Oaks Medical Center
Adventist Bolingbrook Hospital Adventist Bolingbrook Hospital Adventist Bolingbrook Hospital
Davis Vision Cole Vision Cole Vision
(877) 393-8844 Self Refer Self Refer
OPTOMETRY (effective (800) 334-7591 (800) 334-7591
07/01/08)
Scheck & Siress
ORTHOTIC/PROSTHETIC Scheck & Siress
Hanger Prosthetics & Orthotics Scheck & Siress
(See L Code List) MD Orthotics
Hanger Prosthetics & Orthotics

Quest Diagnostics Quest Diagnostics Quest Diagnostics
OUTPATIENT LABS 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 PHP/IOP

Glen Oaks Medical Center Glen Oaks Medical Center Glen Oaks Medical Center
Bolingbrook Med. Ctr Bolingbrook Med. Ctr Bolingbrook Med. Ctr
OUTPATIENT SURGICAL PROCS 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
Highland Pacemaker Clinic Highland Pacemaker Clinic Highland Pacemaker Clinic

PACEMAKER CHECKS Red Red Red
In the office of ORS In the office of ORS In the office of ORS

PAIN MGMT CORTISONE Red Referral Red Referral Red Referral
Any Adventist facility
In the office of Pain Spec. In the office of Pain Spec.
EPIDURAL INJECTIONS Red Referral, review after
Red Referral Red Referral
3rd inj.
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
PEDIATRIC PT/OT/ST 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
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,
PET SCANS 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
LaGrange Hosp - Dr. Awan LaGrange Hosp - Dr. Awan LaGrange Hosp - Dr. Awan
RADIATION THERAPY Hinsdale Hosp. - Dr. Feinstein Hinsdale Hosp. - Dr. Feinstein Hinsdale Hosp. - Dr. Feinstein
Green Referral Green Referral Green Referral
Manor Care Hinsdale(630) 325-9630
Multiple Vendors including the
Manor Care Westmont(630)323-4400 Manor Care Hinsdale(630) 325-9630
SKILLED NURSING FACILITY Burgess Sq. Westmont(630) 971- Manor Care Westmont(630)323-4400
Manor Care Facilities
Call Case Management
2645
SLEEP STUDY - ADULT Glen Oaks Medical Center Glen Oaks Medical Center Glen Oaks Medical Center
Bolingbrook Hospital Bolingbrook Hospital Bolingbrook Hospital
Green Green Green

SLEEP STUDY - PEDS. Rush University Medical Center Rush University Medical Center
University of Chicago Hospital

Check Benefit
STERILIZATION: Vasectomy Per Healthplan Per Healthplan
Not managed by Namm Not managed by Namm Not managed by Namm

SUBSTANCE ABUSE Call (800) 346- Call Healthplan Call Healthplan
3986
McKesson McKesson McKesson

SYNAGIS Ultra Care Ultra Care Ultra Care
Green Green Green
Ortho Office or PCP Office Ortho Office or PCP Office Ortho Office or PCP Office
SYNVISC Injection ordered through Injection ordered through Injection ordered through
Ultracare Ultracare Ultracare
TERTIARY HOSPITALS - ADULT Rush University Medical Center Rush University Medical Centerof University of Chicago Hospital
University
University of Chicago Hospital Chicago Hospital
University of Chicago Hospital
University
TERTIARY HOSPITALS - PEDS. Rush University Medical Center
of Chicago Hospital
University of Chicago Hospital Rush University Medical Center

Cardiologist or Hospital Cardiologist or Hospital Cardiologist or Hospital
THALLIUM STRESS TEST
Illinois Heart & Vascular Illinois Heart & Vascular Illinois Heart & Vascular
(Red or Green referral) Green Green Green
Hinsdale Orthopaedics can provide Occupational & Physical Therapy services in their office. (They can also call
THERAPY - OCCUPATIONAL 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.
THERAPY - PHYSICAL Paulsen Rehab
Glen Oaks Sports & Spine LaGrange -

THERAPY - SPEECH Westbrook - Bolingbrook

Audrey Johnson-Tarver Per Healthplan Per Healthplan
TRANSPLANTS (312) 997-6615 Fax (312) 938- (800) 626-2698 (866) 694-0724
4682
Yes Yes Yes

X-Rays Allowed in Ortho Office
(3 visits, 1 x- (3 visits, 1 x- (3 visits, 1 x-ray
(Fracture Care) ray and casting) ray and casting) and casting)
X-rays Allowed in Ortho. Office Hinsadale Ortho Only Hinsadale Ortho Only Hinsadale Ortho Only
McKesson McKesson McKesson

Walgreens Walgreens Walgreens
XOLAIR Ultracare Ultracare Ultracare
*Please note that HPH PODS Leaders may review their partners' referrals. Referrals for their own members must be
reviewed by the Medical Director.

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
HMOI/BADV
SERVICES UNICARE
# 334
Self Refer
ABORTION (312) 653-6600
Must call Unicare for Auth (888) 234-8855
ACUPUNCTURE See PR for Letter of Agreement See PR for Letter of Agreement
Superior (708-832-2000)
AMBULANCE or Any Contracted Ambulance
Superior (708) 832-2000
BARIATRIC Dr. Ayloo @ U IC Dr. Ayloo @ U IC
BLOOD TRANSFUSION Red Red
Advocate Ill. Masonic Med. Ctr. Advocate Ill. Masonic Med. Ctr.
Cardiac Svc/Angioplasty/CABG U of C and UIC U of C and UIC
HCHP Physician's Office (Green) HCHP Physician's Office (Green)

CHEMOTHERAPY Holy Cross Hospital (Red) Holy Cross Hospital (Red)
CHIROPRACTIC See PR for Letter of Agreement See PR for Letter of Agreement
Consult required (Green) Consult required (Green)

Colonoscopy @ Hospital Colonoscopy @ Hospital

COLONSCOPY DIAGNOSTIC
Holy Cross Hospital Holy Cross Hospital

CT SCAN Green Green
CT SCAN - 64 SLICE Advocate Illinois Masonic Advocate Illinois Masonic
DIALYSIS See Appendix E Per Health Plan
Integrated
Check Benefit, <$1000
Dependicare(800) 224-7404
DURABLE MED EQUIPMENT/SUP Walgreens (800) 323-2828
No precert needed
Dependicare/Walgreens
or Any Contracted DME
EEG - 24 HOUR U of C U of C
Office Setting (Red Referral)

ENDOSCOPIES (INCLUDING
Office or Hospital Setting (Red Referral)
CAPSULE ENDOSCOPIES) Hospital Setting (Red Referral)
Group Allows Specialists to Yes, In-network providers and Yes, In-network providers and
Request Referrals home hospital only home hospital only
N:MM/REFERRAL MANAGEMENT/Service Grid by Site 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
Check Benefits
HEARING AIDS Per BCBS - Hearing aids may be
Contracted Vendor
obtained from any vendor
University of Chicago University of Chicago

HIGH RISK MATERNITY University of Illinois University of Illinois
Refer to HMOI Must call Unicare for Auth

HOME HEALTH CARE Contracted Providers (888) 234-8855
Check Benefit
IMMUNIZATIONS - TRAVEL UIC Travel Clinic
UIC Travel Clinic
Check Scope of Benefits Call

Check Benefit
INFERTILITY for Benefits
Per Healthplan
Coram Specialty Infusion Services (Effective

May 13th). Coram nurse / PCP to determine
REMICADE care setting.
Holy Cross Hospital

INPATIENT ADMISSIONS (Dr. Alston can deliver babies @ St. Holy Cross Hospital
Bernard and/or Trinity Hospital - Red Referral)
Per Healthplan
IV THERAPY Ultracare
(888) 234-8855
LITHOTRIPSY United Shockwave United Shockwave
PsycHealth Wellpoint
MENTAL HEALTH Self Refer Self Refer
(800) 753-5456 (800) 746-6294

MRI'S Green Green
Regional MRI Regional MRI

MRI'S (OPEN) Preferred Open MRI Preferred Open MRI
MRA Green Green
NON-COMPLIANCE POLICY Yes Yes
NUTRITIONAL COUNSELING Red Referral Red Referral
OBSERVATION - 23 HOUR Holy Cross Hospital Holy Cross Hospital
Davis Vision
Self Refer
OPTOMETRY (877) 393-8844
Per Plan Vision Rider
Scheck & Siress

ORTHOTIC/PROSTHETIC Must call Unicare for Auth
Hanger Prosthetic & Orthotics, MD
(See L code list) Orthotics, Contracted physicians
(888) 234-8855

OUTPATIENT LABS (Green) (Green)

OUTPATIENT PHP/IOP
Holy Cross Hospital

OUTPATIENT SURGICAL PROCS Check Appendix B
Holy Cross Hospital

PACEMAKER CHECKS (Green) (Green)
PAIN MGMT CORTISONE In the Office of ORS/POD/AN In the Office of ORS/POD/AN
EPIDURAL INJECTIONS In the Office of Dr. Singa/AN In the Office of Dr. Singa/AN
PET SCANS Lake Shore PET Imaging or Life Scan Chicago Lake Shore PET Imaging or Life Scan Chicago
PULMONARY REHABILITATION U of C U of C
Radiation Therapy Radiation Therapy

RADIATION THERAPY Consultants, Ltd. Consultants, Ltd.
Refer to HMOI Must call Unicare for Auth

SKILLED NURSING FACILITY Contracted Providers: (888)
Renaissance of Midway 234-8855
SLEEP STUDY - ADULT Southwest Sleep Center Southwest Sleep Center
SLEEP STUDY - PEDS U of C U of C

Tubal Ligation Check Benefit Check Benefit
Not Managed by NAMM No Managed by NAMM

SUBSTANCE ABUSE Call Health Plan Call Health Plan
Red Referral made out to Walgreen's Home Red Referral made out to Walgreen's Home
SYNAGIS Medical Supply or Ultra Care Medical Supply or Ultra Care
Provider is Ultracare or Provider is Ultracare or

SYNVISC Walgreens Home Care Walgreens Home Care
U of C U of C
UIC UIC
TERTIARY HOSPITALS - ADULT Advocate Illinois Masonic Advocate Illinois Masonic
Medical Center (Christ Hospital-Wound Clinic Medical Center (Christ Hospital-Wound Clinic
ONLY) ONLY)
TERTIARY HOSPITALS - PEDS. University of Illinois at Chicago University of Illinois at Chicago
THALLIUM STRESS TEST Holy Cross Hospital Holy Cross Hospital

Green Referral Green Referral
Holy Cross Hospital (PT & ST) Holy Cross Hospital (PT & ST)
THERAPY - PEDS. PT/OT/ST University of Chgo (OT) University of Chgo (OT)
THERAPY - OCCUPATIONAL Maximum Rehab Services, Ltd. Maximum Rehab Services, Ltd.

Maximum Rehab Services, Ltd. Maximum Rehab Services, Ltd.
THERAPY - PHYSICAL Therapy Providers (Dr. Labanauskas- Therapy Providers (Dr. Labanauskas-
Surgical Only) (Green for Holy Cross Only) Surgical Only) (Green for Holy Cross Only)

THERAPY - SPEECH Maximum Rehab Services, Ltd. Maximum Rehab Services, Ltd.
(Green for Holy Cross only) (Green for Holy Cross only)
Audrey Johnson-Tarver Per Healthplan
TRANSPLANTS 312-997-6615 Fax (866) 694-0724
312-938-4682
TRANSPORTATION N/A N/A

Yes Yes
(Fracture Care)
No
No
X-rays Allowed in Ortho. Office (Unless Urgent)
(Unless
Urgent)
XOLAIR Walgreens Walgreens

Ingalls Provider Group
TID # 36-3485578

HMOI/BADV
SERVICES UNICARE
# 213
Check Benefit
Check Benefit
ABORTION See BCBS Contracted Vender
Per Healthplan
List
Check benefits
ACUPUNCTURE Vaught Chiropractic
Vaught Chiropractic
Superior (708-832-2000) or
AMBULANCE ANY Contracted Ambulance
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
BARIATRIC Gastric Bypass consult
Lap Band Dr. Jonathan Myers/Rush or
Dr. Vivek Prachand/U of C Dr. Vivek Prachand only
Must Must complete solutions program at Ingalls
complete solutions program at Ingalls Wellness Center prior to consult
Wellness Center prior to consult
Ingalls Ingalls
BLOOD TRANSFUSION Green Green
Cardiac Svc/Angioplasty/CABG Ingalls Ingalls
IPG Hematology/Onc IPG Hematology/Onc

CHEMOTHERAPY Specialist Specialist
Green Green
Check benefits
CHIROPRACTIC Vaught Chiropractic
Vaught Chiropractic


Ingalls Ingalls
CT SCAN Green Green
CT SCAN - 64 SLICE Not a covered benefit Not a covered benefit
Check Benefit
Dependicare (800) 224-7404
<$1000 No precert needed
DURABLE MED. EQUIPMENT/SUP. Walgreens (800) 323-2828
Any Contracted DME Vendor
EEG- 24 HOUR Ingalls Ingalls
Group Allows Specialists to Only general surgeons, ortho for surgery, Only general surgeons, ortho for surgery,
Request Referrals oncology oncology

Script Script
GREEN REFERRAL PROCESS Usually there is a 90 day Usually there is a 90 day
exp. date exp. date
Dr. Rotmensch @ Rush and Dr. Yamada

GYNECOLOGICAL ONCOLOGY @ U of C / Red
Dr. Yamada @ U of C / Red
Check Benefits
Check Benefits
HEARING AIDS Per BCBS - Hearing aids
Contracted Vendor
may be obtained from any vendor
HIGH RISK MATERNITY University of Chicago Hospital University of Chicago Hospital
Call Unicare for Authorization

HOME HEALTH CARE Refer to HMOI Contracted Vendor
888-234-8855
Check Benefit
IMMUNIZATIONS - TRAVEL University of Chicago Travel Clinic
University of Chicago Travel Clinic
INFERTILITY
Semen Analysis Referrals to Fertility Check Scope of Benefits Check benefits - IPG Risk
Call for Benefits
Centers of Illinois--Orland Park (Red See Health Plan Prov. List
No Precert needed from Unicare
Referral)

(Effective May 13th). Coram nurse / PCP
REMICADE to determine care setting.
INPATIENT ADMISSIONS Ingalls Ingalls
Per Healthplan
IV THERAPY Ultracare
888-234-8855
United Shockwave United Shockwave

LITHOTRIPSY Ingalls T.P. Ingalls T.P.
Wellpoint
PsycHealth
Self Refer
800-746-6294
800-753-5456
Ingalls Ingalls
MRI'S Green Green
Ingalls Memorial Hospital Ingalls Memorial Hospital

MRI'S (OPEN) Green Referral Green Referral
Ingalls Ingalls
MRA Green Green
NON-COMPLIANCE POLICY
Yes Yes
(Sanction)
Ingalls Memorial Hospital Dietician Ingalls Memorial Hospital Dietician

NUTRITIONAL COUNSELING Red Referral Red Referral
OBSERVATION- 23 HOUR Ingalls Ingalls
Davis Vision Cole Vision

OPTOMETRY (877) 393-8844 Self Refer
(effective 07/01/08) 800-334-7591
Scheck & Siress Scheck & Siress

ORTHOTIC/PROSTHETIC
Hanger Prosthetic & Orthotics Hanger Prosthetic & Orthotics
(See L Code List) MD Orthotics MD Orthotics

OUTPATIENT LABS Ingalls Memorial Hopsital Ingalls Memorial Hopsital
OUTPATIENT PHP/IOP
Ingalls Harvey or Tinley Park

Midwest Eye Surgical Ingalls Harvey or Tinley Park
OUTPATIENT SURGICAL PROCS Center
Check Appendix B
Ingalls Ingalls
PACEMAKER CHECKS Red Red
In the office of ORS In the office of ORS

PAIN MGMT CORTISONE Red Red
Drs. Holly Carobene, Howard Robinson & Drs. Holly Carobene, Howard Robinson &
EPIDURAL INJECTIONS John Hong / Red John Hong / Red
Ingalls Ingalls
PET SCANS Green Green
PULMONARY REHABILITATION Ingalls Ingalls
Ingalls Cancer Care Ctr. Ingalls Cancer Care Ctr.

RADIATION THERAPY Tx Only-Red Tx Only-Red
Must call Unicare for Authorization

SKILLED NURSING FACILITY HMOI Contracted Providers
888-234-8855
Ingalls Ingalls
SLEEP STUDY - ADULT Green Green
Ingalls Ingalls
SLEEP STUDY - PEDS. Green Green
STERILIZATION: Vasectomy
Semen Analysis Referrals to Check Benefit
Check Benefit
Per Healthplan
Fertility Centers of Illinois--Orland
Park (Red Referral)
Check Benefit
Per Healthplan
Not Managed by NAMM Not Managed by NAMM

SUBSTANCE ABUSE Call Healthplan Call Healthplan
SYNAGIS Dependicare from PCP Office Dependicare from PCP Office
SYNVISC Ultracare Ultracare
Rush Presbyterian
TERTIARY HOSPITALS - ADULT University of Chicago
University of Chicago
University of Chicago
Children's Memorial Hospital University of Chicago
TERTIARY HOSPITALS - PEDS Hope Children's Memorial Hospital
Children's Hospital
THALLIUM STRESS TEST Ingalls Ingalls

(Red or Green referral) Green Green
THERAPY - OCCUPATIONAL Ingalls Ingalls
THERAPY - PEDS. PT/OT/ST Ingalls Ingalls

Ingalls or Ingalls or
THERAPY - PHYSICAL ICOR (Ingalls Center for Outpatient ICOR (Ingalls Center for Outpatient
Rehab.) Rehab.)
THERAPY - SPEECH Ingalls Ingalls

Per Healthplan
(866) 694-0724
(312) 997-6615 Fax (312) 938-4682
X-rays Allowed in Ortho office

Yes Yes
(Fracture Care)
X-rays Allowed in Ortho. Office No No
XOLAIR Walgreens Walgreens

Northwest Community Health Partners
TID # 36-2340313

HMOI/BADV
SERVICES HUMANA
# 336
Check Benefit
Check Benefit
ABORTION See BCBS Contracted Vender
Per Healthplan
List
Des Plaines Chiropractic Center Des Plaines Chiropractic Center

ACUPUNCTURE (847) 299-3440 (847) 299-3440
Chicago Ambulance Alliance

AMBULANCE Any contracted ambulance
(800) 558-6050
BARIATRIC Gastric Bypass Dr. Joyce @ Silver Cross Dr. Joyce @ Silver Cross
Lap Band Dr. S. Sarker @ Loyola Dr. S. Sarker @ Loyola
Red Red
BLOOD TRANSFUSION (Including Type & Cross) (Including Type & Cross)
Cardiac Svc/Angioplasty/CABG Northwest Community Hospital

Northwest Community Hospital
(EP Study--Dr. Lin)
Office of NWC Hematology/Onc Office of NWC Hematology/Onc

CHEMOTHERAPY Specialist Specialist
Tx only Red Tx only Red
Des Plaines Chiropractic Ctr. Des Plaines Chiropractic Ctr.

(847) 299-3440 (847) 299-3440
CHIROPRACTIC Clark Chiro & Rehab, PC Clark Chiro & Rehab, PC
(847) 259-9864 (847) 259-9864
COLONOSCOPY SCREENING Colonoscopy @ Hospital Colonoscopy @ Hospital
COLONOSCOPY DIAGNOSTIC Colonoscopy @ Hospital Colonoscopy @ Hospital
Northwest Community Hospital Northwest Community Hospital

CT SCAN Green Green
Medical Director conversation with the Medical Director conversation with the
CT SCAN - 64 SLICE Cardiologist is required Cardiologist is required
Dependicare(800) 224-7404 Walgreens Home Medical

DURABLE MED. EQUIPMENT/SUP. Walgreens (800) 323-2828 (800) 323-2828

EEG - 24 HOUR Green Green
Yes--All Specialists performing surgery Yes--All Specialists performing surgery

Group Allows Specialists to (Submitted on a (Submitted on a
Request Referrals Surgical Request Form rather than a Red Surgical Request Form rather than a Red
Referral) Referral)
A short referral form needs to be A short referral form needs to be
GREEN REFERRAL PROCESS completed in order to refer to a green list completed in order to refer to a green list
physician physician

Drs. J. Tunca, R. Weiss and S. Kwon @ Drs. J. Tunca, R. Weiss and S. Kwon @
GYNECOLOGICAL ONCOLOGY NWC / Red NWC / Red
Check Benefit Check Benefits

HEARING AIDS Northwest Community Hospital Contracted Vendor
St. Alexius Group St. Alexius Group

Suburban Maternal Fetal Medicine Suburban Maternal Fetal Medicine
HIGH RISK MATERNITY (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 Northwest Community Hospital Home

HOME HEALTH CARE Health Care Health Care
NWCH Occupational Health Dept. Check Benefit

IMMUNIZATIONS - TRAVEL Provider ID # 800003 NWCH Occupational Health Dept.
Red Red
NWCH Occupational Health Dept. Check Benefit

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

Fax the completed Humana Form
Fertility Centers of Illinois
INPATIENT ADMISSIONS Northwest Community Hospital Northwest Community Hospital
IV THERAPY Contracted vendor Contracted vendor
LITHOTRIPSY United Shockwave United Shockwave
PsycHealth
Self Refer
(800) 331-9040
(800) 753-5456

MRI'S Green Green

MRI'S (OPEN) NWCH Schaumburg Tx. Center NWCH Schaumburg Tx. Center
MRI of Arlington Hgts MRI of Arlington Hgts
NWCH NWCH
MRA Green Green

NUTRITIONAL COUNSELING Green Referral Green Referral
OBSERVATION - 23 HOUR Northwest Community Hospital Northwest Community Hospital
Davis Vision Cole Vision

(877) 393-8844 Self Refer
OPTOMETRY (effective (800) 334-7591
07/01/08)
ORTHOTIC/PROSTHETIC
Any contracted vendor Any contracted vendor
(See L Code List)
Quest Diagnostic Quest Diagnostic

OUTPATIENT LABS Northwest Community Hospital - Northwest Community Hospital -
Stats only Stats only

OUTPATIENT PHP/IOP
Northwest Community Hospital or

Northwest Community Hospital or
Day Surgery
OUTPATIENT SURGICAL PROCS Center
Day Surgery
Center
Check Appendix B

PACEMAKER CHECKS Red Red

PAIN MGMT CORTISONE Green Green
In the office of AN In the office of AN
EPIDURAL INJECTIONS Red Red

PET SCANS Green Green
PULMONARY REHABILITATION Northwest Community Hospital Northwest Community Hospital
Provided by Radiation/Onc at Provided by Radiation/Onc at

RADIATION THERAPY Northwest Community Hospital Northwest Community Hospital
SKILLED NURSING FACILITY Any contracted vendor Any contracted vendor

SLEEP STUDY - ADULT Green Green
SLEEP STUDY - PEDS. Children's Memorial Hospital (>3 y/o) Children's Memorial Hospital (>3 y/o)

Check Benefit
SUBSTANCE ABUSE Not Managed by NAMM - Call Health Plan
Red Referral and McKesson order form (See attached form)

SYNAGIS Apply Millimen
SYNVISC Ortho Office Ortho Office
Loyola University Hospital

Loyola University Hospital
TERTIARY HOSPITALS - ADULT U of C
U of C
U of C U of C
TERTIARY HOSPITALS - PEDS. Children's Memorial Hospital Children's Memorial Hospital
THALLIUM STRESS TEST Northwest Community Hospital Northwest Community Hospital

Green Green

THERAPY - OCCUPATIONAL (Age 10 and up) (Age 10 and up)
Assential Therapies Assential Therapies

Physiotherapy Assoc. (Pediatric Place) Physiotherapy Assoc. (Pediatric Place)
THERAPY - PEDS. PT/OT/ST Arlington Arlington
Pediatric Therapy Pediatric Therapy

THERAPY - PHYSICAL (Age 10 and up) (Age 10 and up)

THERAPY - SPEECH Northwest Community Hospital Northwest Community Hospital

Audrey Johnson-Tarver Per Healthplan
TRANSPLANTS (312) 997-6615 Fax (312) 938-4682 (800) 626-2698
X-rays Allowed in Ortho Office

Yes Yes
(Fracture Care)
X-rays Allowed in Ortho. Office Yes Yes
XOLAIR McKesson McKesson

Oak West Primary Physician Assoc.
TID # 36-4008699
Please notify Lourdes Reyes for
all FHN Inpt/Outpt procedures
312-491-1956 x17, Fx 312-738-
3116 or e-mail at
lrey@fhnchicago.com
P.O. Box 7820, Westchester, IL 60154
Customer Service # : 708-432-1287
Health Plan Precert
Medical Leadership Review
HMOI/BADV # FHN
SERVICES UNICARE
335 Eligibility # 312-491-1956
Limited Coverage
ABORTION (800) 892-2803 (888) 234-8855
Refer to FHN/Valerie
(312) 491-1956 X48
ACUPUNCTURE No Coverage
Superior (708) 832-2000 or Door to Door Transportation

AMBULANCE ANY Contracted Ambulance
Superior (708) 832-2000
L and L Transportation
BARIATRIC - MUST MEET

MILLIMAN SURGICAL CRITERIA Dr. Tiesenda @ Westlake
Dr. Tiesenda @ Westlake Dr. Tiesenda @ Westlake
Dr. Diniotis at Our
AND OAK GUIDELINES PRIOR TO Dr. Diniotis at Our Lady Dr. Diniotis at Our
Lady of Resurrection (Contact -
CONSULT (CONSULT-RED of Res. Lady of Res.
Lourdes Reyes 312-491-1956 x 17)
REFERRAL)
BLOOD TRANSFUSION
Pods A - B/Westlake
Pods C/Our Lady of Resurrection
Pods A - B/Westlake
Cardiac Svc/Angioplasty/CABG Pods A -B/Cardiac
Pods C/Our Lady of Resurrection
Westlake
rehab to be sent to Our Lady of
Resurrection .(cross pod)
Pods A-B/ Dr. Banerji,Lyster,Rosi

Pods A-B/ Dr. Banerji,Lyster,Rosi
In the office of Dr. Ebie
CHEMOTHERAPY Pods C/ Dr. Red
Pods C/ Dr. Nathan,Drazkiewicz
Nathan,Drazkiewicz
Failed conservative tx. Failed conservative tx. Failed conservative tx.

CHIROPRACTIC Eval. w/Dr. F. Robinson, D.O. Eval. w/Dr. F. Robinson, D.O. Eval. w/Dr. F. Robinson, D.O.


(Red ref. for PODS C only) (Red ref. for PODS C only) (Red ref. for PODS C only)
Pods A - B/Westlake Pods A - B/Westlake

CT SCAN Pods C/Our Lady of Resurrection Pods C/Our Lady of Resurrection Westlake
Red Red

CT SCAN - 64 SLICE Pods C/Our Lady of Resurrection Pods C/Our Lady of Resurrection Westlake
Red Red
Per Healthplan Contact Health Plan

DIALYSIS Per Appendix E
(312) 234-8800 Valerie (312) 491-1956 Ext. 48
Check Benefit
Dependicare Purchase<$1000 No precert needed Dependicare
DURABLE MED. EQUIPMENT/SUP. Walgreens Apria
or Any contracted DME vendor Dependicare/Walgreens UltraCare

EEG - 24 HOUR Pods C/Our Lady of Resurrection Pods C/Our Lady of Resurrection
Westlake

Schwab Rehab Hospital
Yes Yes Audiology Dept.
Request Referrals and Imaging (773) 522-5870
Patient obtains Green Referral and Script Patient obtains Green Referral and Patient obtains Green Referral and
GREEN REFERRAL PROCESS from PCP Script from PCP Script from PCP
Dr. Donna Smith @ Loyola Dr. Donna Smith @ Loyola Dr. Donna Smith @ Loyola
GYNECOLOGICAL ONCOLOGY Red Red Red
Check Benefits
Per BCBS - Hearing aids
Check Benefits
HEARING AIDS may be obtained from any vendor.
Contracted Vendor
Yes
Hearing test no longer done @Westlake
Hosp.
HIGH RISK MATERNITY Loyola University Medical Ctr. Loyola University Medical Ctr. Mt. Sinai Hospital
HOME HEALTH CARE Resurrection Home Health Resurrection Home Health
Check Benefit
IMMUNIZATIONS - TRAVEL Loyola University Medical Ctr.
Loyola University Medical Ctr.
Mt. Sinai Hospital
Diagnostic to be done by IPA/GYNE

Call for Benefits
INFERTILITY Any contracted BCBS infertility provider
Infertility Review Form to be No Coverage
completed

INFUSION SERVICES - IVIG AND (Effective May 13th). Coram nurse /
REMICADE PCP to determine care setting.

INPATIENT ADMISSIONS Pods C/Our Lady of Resurrection Pods C/Our Lady of Resurrection
Westlake

IV THERAPY Pods C/Our Lady of Resurrection Pods C/Our Lady of Resurrection
Westlake
LITHOTRIPSY United Shockwave United Shockwave Mt. Sinai Hospital
Wellpoint
Procare Self Refer
MENTAL HEALTH Dr. Piyaka
Self Refer
PsycHealth (800) 753-5456
(800) 746-6294

MRI'S Pods C/Our Lady of Resurrection Pods C/Our Lady of Resurrection Westlake
Red Red
Midwest Open MRI Midwest Open MRI

MRI'S (OPEN) MRI Lincoln Imaging Center MRI Lincoln Imaging Center Westlake
Red Red
MRA Red Red Red
NON-COMPLIANCE POLICY Yes Yes Yes

OBSERVATION - 23 HOUR Pods C/Our Lady of Resurrection Pods C/Our Lady of Resurrection
Westlake

OCCUPATIONAL THERAPY Pods C/Our Lady of Resurrection Pods C/Our Lady of Resurrection Westlake

Davis Vision Adult - No Coverage
(877) 393-8844 Self Refer Under 21 - Self Refer
OPTOMETRY (effective Per Plan Vision Rider (800) 424-
07/01/08) 1155
Hanger Prosthetic & Orthotics Scheck & Siress
ORTHOTIC/PROSTHETIC MD Orthotics Hanger Prosthetic &
Hanger Prosthetic & Orthotics
(See L Code List) or Any Contracted Orthotics MD
O/P Vendor Orthotics
Must use Westlake Hospital or Must use Westlake Hospital or
Must use Westlake Hospital or
INPATIENT LABS Our Lady of Resurrection
Our Lady of Our Lady of
Resurrection Resurrection
Not managed by NAMM

OUTPATIENT PHP/IOP Patients need to call
Health Plan
Pods A - B/Westlake
Pods C/Our Lady of Resurrection Pods A - B/Westlake
OUTPATIENT SURGICAL PROCS Check Pods C/Our Lady of Resurrection
Westlake
Appendix B
Westlake Community Hospital or Westlake Community Hospital or Westlake Community Hospital or
Our Lady of the Res. Our Lady of the Res. Our Lady of the Res.
PACEMAKER CHECKS
Red Red Red
PAIN MGMT CORTISONE Red Red
In the office of ORS
In the office of AN In the office of AN In the office of AN

EPIDURAL INJECTIONS Red Red Red
MRI Lincoln Imaging Center MRI Lincoln Imaging Center High Tech
PET SCANS Regional PET Imaging Regional PET Imaging Lakeshore P.E.T. Imaging
POS AB - Westlake POS AB - Westlake

PULMONARY REHABILITATION PODS Schwab Rehab Hospital
C - Our Lady of Res. PODS C - Our Lady of Res.
Dr. Beck/Hem-Onc Assoc. Dr. Beck/Hem-Onc Assoc.

RADIATION THERAPY POS 11 POS 11
CT Planning-Gottlieb Hospital CT Planning-Gottlieb Hospital
SKILLED NURSING FACILITY
Merit Sleep Management Merit Sleep Management Merit Sleep Management

SLEEP STUDY - ADULT (888) 637-4848 (888) 637-4848 (888) 637-4848
Pods A - B/Merit Sleep Management Pods A - B/Merit Sleep Management

SLEEP STUDY - PEDS Pods C/Our Lady of Pods C/Our Lady University of Chicago Hospital
Resurrection of Resurrection

STERILIZATION Vasectomy Urology Office Urology Office Limited Coverage Refer to
FHN/Valerie (312)
Tubal Ligation Check Benefit Check Benefit 491-1956 X48
IPA-GYNE at Gottlieb Hospital IPA-GYNE at Gottlieb Hospital
Not managed by NAMM
Not managed by NAMM
Not Managed by NAMM
SUBSTANCE ABUSE Patients need to call Health Patients need to call Healthplan
Patients need to call Health Plan
Plan
Ultra Care
Ultra Care and/or Peds Office Ultra Care and/or Peds Office Red Referral from
SYNAGIS Medical Director review if Medical Director review if Milliman PCP Office
Milliman not met not met Medical Director review if Milliman
not met
SYNVISC Ortho Office Ortho Office
Loyola University Medical Ctr. Loyola University Medical Ctr. Mt. Sinai Hospital
TERTIARY HOSPITALS - ADULT University of Chicago University of Chicago
Mt. Sinai Hospital

Loyola University Medical Ctr. Loyola University Medical Ctr.
TERTIARY HOSPITALS - PEDS. University of Chicago University of Chicago
Rush Medical Center

THALLIUM STRESS TEST Westlake
Pods C/Our Lady of Resurrection Pods C/Our Lady of Resurrection
Green
Green Green

Pods A-B/Westlake Pods Pods A-B/Westlake
Westlake
C/Our Lady of Resurrection Pods C/Our Lady of Resurrection
THERAPY - PEDS PT/OT/ST Loyola University Medical Ctr/ST Loyola University
Mt. Sinai Hospital
UNLIMITED
Medical Ctr/ST
Pods A - B/Westlake Pods A - B/Westlake Westlake

THERAPY - PHYSICAL Pods C/Our Lady of Resurrection Pods C/Our Lady of Resurrection UNLIMITED
Pods A - B/Westlake Pods A - B/Westlake Westlake

THERAPY - SPEECH Pods C/Our Lady of Resurrection Pods C/Our Lady of Resurrection UNLIMITED

Audrey Johnson-Tarver Per Healthplan Contact Healthplan
TRANSPLANTS (312) 997-6615 (866) 694-0724 Valerie (312) 491-1956 Ext.48
Fax (312) 938-4682
L & L Medical Transport

Transportation N/A N/A
Self Refer (888) 346-4968
X-rays Allowed in ortho office

Yes Yes Yes
(Fracture Care)
X-rays Allowed in Ortho. Office No No No
XOLAIR Care Mark Care Mark Care Mark

Senior Care Partners
TID # 20-4763091
WILL COUNTY
P.O. Box , Westchester, IL 60154
Customer Service #: 708-240-5221 Health Plan Precert Health Plan Precert
HealthSpring HealthSpring
SERVICES
847-993-1928 847-993-1928
ABORTION N/A N/A
ACUPUNCTURE Not a covered benefit Not a covered benefit
Superior Ambulance Superior Ambulance

AMBULANCE (708) 832-2000 (708) 832-2000
Not done in Network

BARIATRIC Dr. Cahill @ Little Company of Mary ?
(OON) (708) 422-5658
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

CHEMOTHERAPY ?
Associates
John Hertko, D.C.

Kurt Keppner, D.C.
CHIROPRACTIC (708) 460-8688
(815) 725-7700
Consult required (Red) Consult required (Red)


Metro South Medical Center Will County Medical Associates

CT SCAN Green Green
Metro South Medical Center

CT SCAN - 64 SLICE Provena St. Joseph Hospital
Westlake
Will County Medical Associates (Sheri
Our Lady of Resurrection
DIABETIC EDUCATION Little Company of Mary
Magnuson, R.N. C.D.E.)
Green
Green
Fresenius Medical
Fresenius Medical
Naperville Dialysis Center
NeoMedica
DIALYSIS (Cannot go to South
NeoMedica
(Cannot go to
Holland location)
South Holland location)
DURABLE MED. EQUIPMENT/SUP. Dependicare Dependicare
DME products under $150.00 are not covered, Total Home Health Total Home Health
are member responsibility. Walgreens Home Medical Walgreens Home Medical
Metro South Medical Center Provena St. Joseph Hospital

EEG - 24 HOUR Red Red

EGD
EGD @ Hospital EGD @ Hospital

Group Allows Specialists to Request Referrals No No
Joliet Oncology / Hematology

GYNECOLOGICAL ONCOLOGY Little Company of Mary / Red
Associates
Self Refer to Bell Tone Self Refer to Bell Tone

600 Theodore 600 Theodore
HEARING AIDS St. Joliet 815-722- St. Joliet 815-722-
4240 4240
HIGH RISK MATERNITY N/A N/A
SSM Home Health @ Metro South Provena Home Health

HOME HEALTH CARE Medical Center CNS Home Health
IMMUNIZATIONS - TRAVEL Not a covered benefit Not a covered benefit
Call HealthSpring for benefit Call HealthSpring for benefit

INFERTILITY determination determination
INJECTIBLE MEDICATIONS - EPOGEN,

Red Red
REMICAID, SYNVISC
INPATIENT ADMISSIONS Metro South Medical Center Provena St. Joseph Hospital
IV THERAPY Metro South Medical Center Provena St. Joseph Hospital
United Shockwave United Shockwave

LITHOTRIPSY Contact Nancy/Healthspring Contact Nancy/Healthspring
(847) 993-1928 (847) 993-1928
Pre-cert required for any diagnosis Pre-cert required for any diagnosis
LUPRON INJECTIONS except prostate cancer except prostate cancer

MENTAL HEALTH MHN (866) 780-8546 MHN (866) 780-8546
High Tech
Advantage MRI Will County Medical Associates
MRI'S (South Holland Only) Green
Green
High Tech
Advantage MRI
(South Holland Only)
Open MRI of Joliet Open MRI
MRI'S (OPEN) Olympia Fields Joliet Green
Open MRI Prairie
Open MRI
Green
Will County Medical Associates

(Head Only), otherwise Provena
MRA Green
St. Joseph Hospital
Green

Westlake Hospital
NUTRITIONAL COUNSELING Green
(Sheri Magnuson, R.N. C.D.E.)
Green
OBSERVATION - 23 HOUR Metro South Medical Center Provena St. Joseph Hospital

OPTOMETRY No Coverage No Coverage
ORTHOTIC/PROSTHETIC Scheck & Siress Scheck & Siress

OUTPATIENT LABS Metro South Medical Center
(815) 725-2121

OUTPATIENT PHP/IOP MHN (800) 511-6946 MHN (800) 511-6946
OUTPATIENT SURGICAL PROCS Metro South Medical Center Provena St. Joseph Hospital
Heart Care Centers of Illinois Will County Medical Associates

PACEMAKER CHECKS Red (815) 725-2121
In the office of ORS or RHU

PAIN MGMT. CORTISONE Red Mauricio Orbegozo
(815) 725-6331
In the office of AN Red
EPIDURAL STEROID Red
High Tech
Provena St. Joseph Hospital
PET SCANS Green
Green

(815) 725-2121
PODIATRY Green
Drs. Bailey and
Klemm
PULMONARY REHABILITATION Metro South Medical Center Provena St. Joseph Hospital
Provena St. Joseph Hospital

RADIATION THERAPY Dr. Tolentino (Cancer Treatment Group)
Drs. Griffin, Ommar, Crossan
SCLEROTHERAPY Red ?
SKILLED NURSING FACILITY ? ?
DRW & Associates Cardinal Sleep Center

SLEEP STUDY - ADULT Metro South (815) 773-9090
Medical Center Green Green
SLEEP STUDY - PEDS. N/A N/A
Office-no precert Office-no precert

STERILIZATION: Vasectomy Hospital-Precert Hospital-Precert
Tubal Ligation Call HealthSpring for benefit Call HealthSpring for benefit
determination determination

SUBSTANCE ABUSE MHN (800) 511-6946 MHN (800) 511-6946
SYNAGIS N/A N/A
TERTIARY HOSPITALS - ADULT Loyola Loyola
TERTIARY HOSPITALS - PEDS. N/A N/A

Metro South Medical Center Provena St. Joseph Hospital
THALLIUM STRESS TEST Green Green

THERAPY - OCCUPATIONAL Will County Medical Associates
THERAPY - PEDS PT/OT/ST N/A N/A

THERAPY - PHYSICAL Will County Medical Associates

THERAPY - SPEECH Provena St. Joseph Hospital
TMJ/DENTAL PROCEDURES ? Dr. Stephen Morimoto
Contact Nancy/Healthspring Contact Nancy/Healthspring

TRANSPLANTS (847) 993-1928 (847) 993-1928
Fresh Air Fresh Air

TRANSPORTATION (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

Silver Cross MCO
TID # 36-3876019

HMOI/BADV
SERVICES HUMANA UNICARE
# 266
Check Benefit Check Benefit Check Benefit

ABORTION See BCBS Contracted Vender List Per Healthplan Per Healthplan
Peter Harvey, Eastern Healing, Inc. Peter Harvey, Eastern Healing, Inc. Peter Harvey, Eastern Healing, Inc.
ACUPUNCTURE 630-653- 630-653- 630-653-
4358 4359 4360
Superior (708) 832-2000 or Chicago Ambulance Alliance

Superior (708) 832-2000
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
BARIATRIC band adjustments in office, band adjustments in office, band adjustments in office,
Per Dr. Hindo Per Dr. Hindo Per Dr. Hindo
BLOOD TRANSFUSION Green Green Green
Silver Cross Hospital Silver Cross Hospital Silver Cross Hospital

CARDIAC STRESS TEST Green Red Green

Cardiac Svc/Angioplasty/CABG Provena St. Joseph Provena St. Joseph Provena St. Joseph
Joliet Oncology/Hem Joliet Oncology/Hem Joliet Oncology/Hem

CHEMOTHERAPY Midwest Center for Hen/Onc. Midwest Center for Hen/Onc. Midwest Center for Hen/Onc.
Green Red Green
CHIROPRACTIC Davidson Chiropractic Davidson Chiropractic Davidson Chiropractic

Consult required (Green) Consult required (Green) Consult required (Green)


CT SCAN Homer Glen Facility-Non contrast Imaging Homer Glen Facility-Non contrast Imaging Homer Glen Facility-Non contrast Imaging
Green Green Green

CT SCAN - 64 SLICE Red Referral Red Referral Red Referral
Must be reviewed by Dr. Hindo Must be reviewed by Dr. Hindo Must be reviewed by Dr. Hindo
Homer Glen Facility Homer Glen Facility Homer Glen Facility
CT SCAN-CORONARY CALCIUM CPT CPT CPT
SCORING 0144T Facility ID 10031 0144T Facility ID 10031 0144T Facility ID 10031
(PA Review (PA Review (PA Review
Mandatory-Red Ref.) Mandatory-Red Ref.) Mandatory-Red Ref.)
DIALYSIS Silver Cross Hospital Silver Cross Hospital Silver Cross Hospital
Check Benefit
Dependicare
Purchase<$1000 No precert needed
DURABLE MED. EQUIPMENT/SUP. Walgreens Home Medical Walgreens Home Medical
or Any Contracted DME Vendor
Home Medical
Provena St. Joseph Med. Ctr Provena St. Joseph Med. Ctr Provena St. Joseph Med. Ctr
EEG - 24 HOUR Peds - Hope/Christ Hospital Peds - Hope/Christ Hospital Peds - Hope/Christ Hospital

EKG Homer Glen Facility Homer Glen Facility Homer Glen Facility
Group Allows Specialists to Green PCP Green Providers to Green Providers to

Request Referrals Green Specialist Green Providers Green Providers
GREEN REFERRAL PROCESS Stamp Script Stamp Script Stamp Script
Dr. Rotmensch @ RUMC Dr. Rotmensch @ RUMC Loyola

GYNECOLOGICAL ONCOLOGY Red Red Red
Gloval OB referral not required for global OB Gloval OB referral not required for global OB Gloval OB referral not required for global OB
GLOBAL OB care care care
Check Benefits
Check Benefits Check Benefits
HEARING AIDS Per BCBS - Hearing aids may
Contracted Vendor Contracted Vendor
be obtained from any vendor
Women's Health Consultants/RUMC Women's Health Consultants/RUMC
(Level (Level
HIGH RISK MATERNITY II Ultrasound's at Women's Health II Ultrasound's at Women's Health Loyola University Medical Center
Consultants: Use Prov. ID 200041) Consultants: Use Prov. ID 200041)
HOME HEALTH CARE Silver Cross Home Health Interim & Advocate Call Unicare
IMMUNIZATIONS - TRAVEL University of Chicago University of Chicago University of Chicago
Call for Benefits

Fax the completed Humana Form
INFERTILITY 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
REMICADE care setting.
INPATIENT ADMISSIONS Silver Cross Hospital Silver Cross Hospital Silver Cross Hospital
IV THERAPY
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 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)
United Shockwave United Shockwave United Shockwave

LITHOTRIPSY "O" note-Ingalls Surg Ct. "O" note-Ingalls Surg Ct. "O" note-Ingalls Surg Ct.
Wellpoint
Central Professional Group Self Refer
MENTAL HEALTH Green (800) 331-9040
Self Refer
(800) 746-6294

MRI'S Homer Glen Facility (non Homer Glen Facility (non Homer Glen Facility (non
contrast imaging only) Green contrast imaging only) Green contrast imaging only) Green
Open Advanced MRI Open Advanced MRI Open Advanced MRI

MRI'S (OPEN) Red Red Red
NON-COMPLIANCE POLICY N/A N/A N/A

OBSERVATION - 23 HOUR Silver Cross Hospital Silver Cross Hospital Silver Cross Hospital
Eye Med
Davis Vision
OPTOMETRY (877) 393-8844
Per Plan Vision Rider
(866) 273-0817
Scheck & Siress Scheck & Siress
ORTHOTIC/PROSTHETIC Scheck & Siress
Hanger Prosthetic & Orthotics Hanger Prosthetic & Orthotics
(See L Code List) MD Orthotics
MD Orthotics
MD Orthotics

OUTPATIENT LABS Homer Glen Facility Homer Glen Facility Homer Glen Facility
OUTPATIENT PHP/IOP
Silver Cross Hospital

OUTPATIENT SURGICAL PROCS 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 CORTISONE In the office of ORS/Green In the office of ORS/Green In the office of ORS/Green
EPIDURAL INJECTIONS In the office of AN/Green In the office of AN/Green In the office of AN/Green
Alliance Healthcare Services, Inc Alliance Healthcare Services, Inc Alliance Healthcare Services, Inc
(866) 667-7226 (866) 667-7226 (866) 667-7226
PET SCANS Provider ID # Provider ID # Provider ID #
1235282344 1235282344 1235282344

PULMONARY FUNCTION TEST Green Red Green

PULMONARY REHABILITATION Green Green Green
Dr. Asaad@Hoffman Center Dr. Asaad@Hoffman Center Dr. Asaad@Hoffman Center

RADIATION THERAPY Green Red Green
SKILLED NURSING FACILITY
Cardinal Sleep Center Cardinal Sleep Center Cardinal Sleep Center

SLEEP STUDY ADULT Green Green Green
Cardinal Sleep Center Cardinal Sleep Center Cardinal Sleep Center

SLEEP STUDY PEDS. Green Green Green
Check Benefit/Red Check Benefit/Red Check Benefit/Red

Not managed by NAMM Not managed by NAMM Not managed by NAMM

SUBSTANCE ABUSE Patients need to call Healthplan Patients need to call Healthplan Patients need to call Healthplan
Red Referral and SCMCO order form (See Red Referral and SCMCO order form (See Red Referral and SCMCO order form (See
SYNAGIS attached guidelines/order form attached guidelines/order form attached guidelines/order form
Office orders from any vendor then we Office orders from any vendor then we Office orders from any vendor then we
reimburse them at their invoice cost. They reimburse them at their invoice cost. They reimburse them at their invoice cost. They
SYNVISC submit invoice with the claim to provider submit invoice with the claim to provider submit invoice with the claim to provider
relations. relations. relations.

U of C U of C
U of C
Rush University Medical Center Rush University Medical Center
Loyola University Medical
TERTIARY HOSPITALS - ADULT UIC
Center
UIC
UIC
Rehabilitation
Rehabilitation Institute of Rehabilitation Institute of
U of C or UIC Chicago U of C or UIC Chicago Institute of 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
TERTIARY HOSPITALS - PEDS. 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 Silver Cross Hospital Silver Cross Hospital
Green Green Green

THERAPY - OCCUPATIONAL Green Green Green

THERAPY - PEDS. PT/OT/ST Green Green Green

THERAPY - PHYSICAL Green Green Green

THERAPY - SPEECH Green Green Green

(800) 626-2698 (866) 694-0724
(312) 997-6615 Fax (312) 938-4682

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

X-RAYS Homer Glen Facility Homer Glen Facility Homer Glen Facility
XOLAIR Red Red Red

Swedish Covenant Managed Care
TID # 36-4118659

HUMANA
SERVICES Commercial Medicare HealthSpring

ABORTION Per Healthplan Per Healthplan
N/A
Swedish - After all conservative Swedish - After all conservative Swedish - After all conservative
ACUPUNCTURE treatments have been exhausted treatments have been exhausted treatments have been exhausted
Chicago Ambulance Alliance Chicago Ambulance Alliance Chicago Ambulance Alliance

AMBULANCE (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 Red
Cardiac Svc/Angioplasty/CABG Swedish Swedish Swedish
CHEMOTHERAPY In the office of Dr. Philip In the office of Dr. Philip In the office of Dr. Philip
Swedish - After all conservative Swedish - After all conservative Swedish - After all conservative
CHIROPRACTIC treatments have been exhausted treatments have been exhausted treatments have been exhausted

Consult required (Green) Consult required (Green) Consult required (Green)

Swedish Swedish Swedish

CT SCAN Red Red Red

CT SCAN - 64 SLICE Evanston Hospital Evanston Hospital Evanston Hospital
Red Red Red
DIALYSIS Swedish Swedish Swedish
Walgreens Integrated Integrated

DURABLE MED. EQUIPMENT/SUP. Dependicare Walgreens Walgreens
Dependicare Dependicare
EEG - 24 HOUR Swedish Swedish Swedish

No No No
Request Referrals
GREEN REFERRAL PROCESS Green referral form / script Green referral form / script Green referral form / script

Drs. Gustavo Rodriquez and Herbert Drs. Gustavo Rodriquez and Herbert Drs. Gustavo Rodriquez and Herbert
GYNECOLOGICAL ONCOLOGY Beck @ ENH Beck @ ENH Beck @ ENH
Red Red Red
Check Benefits Check Benefits Check Benefits

HEARING AIDS Contracted Vendor Contracted Vendor Contracted Vendor
HIGH RISK MATERNITY Swedish Swedish N/A
Swedish
HOME HEALTH CARE Swedish Swedish
HRS Home Health
IMMUNIZATIONS - TRAVEL Metro Infectious Disease Metro Infectious Disease Not a Covered Benefit
Call for Benefits

INFERTILITY Fertility Centers of Illinois
N/A N/A
INPATIENT ADMISSIONS Swedish Swedish Swedish
IV THERAPY Swedish Swedish Swedish
LITHOTRIPSY Swedish Swedish Swedish
Not managed by NAMM

Not managed by NAMM Not managed by NAMM
MENTAL HEALTH Patients need to call Healthplan Patients need to call Healthplan
Self refer to Mental
Health Network (800) 511-6946

MRI'S Red Red Red

MRI'S (OPEN) MRI Lincoln Imaging MRI Lincoln Imaging MRI Lincoln Imaging
Red Red Red
MRA Red Red Red
NON-COMPLIANCE POLICY No No No
NUTRITIONAL COUNSELING Red Referral Red Referral Red Referral
OBSERVATION - 23 HOUR Swedish Swedish Swedish
OPTOMETRY Incident to Cataract Surgery Incident to Cataract Surgery Incident to Cataract Surgery
ORTHOTIC/PROSTHETIC Scheck & Siress Scheck & Siress Scheck & Siress
(See L Code list) MD Orthotics MD Orthotics MD Orthotics
OUTPATIENT LABS Swedish Covenant Hospital Swedish Covenant Hospital Swedish Covenant Hospital

OUTPATIENT PHP/IOP Patients need to call Healthplan Patients need to call Healthplan Patients need to call Healthplan
OUTPATIENT SURGICAL PROCS Swedish Swedish Swedish

Swedish Covenant Hospital - Red Swedish Covenant Hospital - Red Swedish Covenant Hospital - Red
PACEMAKER CHECKS "O" note Pacemaker Clinic "O" note Pacemaker Clinic "O" note Pacemaker Clinic
PAIN MGMT CORTISONE Swedish Pain Clinic/Dr. Xie Swedish Pain Clinic/Dr. Xie Swedish Pain Clinic/Dr. Xie
EPIDURAL INJECTIONS Swedish Pain Clinic/Dr. Xie Swedish Pain Clinic/Dr. Xie Swedish Pain Clinic/Dr. Xie
PET SCANS Swedish Swedish Swedish
PULMONARY REHABILITATION Evanston Hospital Evanston Hospital Evanston Hospital
RADIATION THERAPY Swedish Swedish Swedish
SKILLED NURSING FACILITY Swedish Swedish Swedish
DRW & Associates DRW & Associates DRW & Associates

SLEEP STUDY - ADULT (773) 805-1871 (773) 805-1871 (773) 805-1871
DRW & Associates DRW & Associates

SLEEP STUDY - PEDS. (773) 805-1871 (773) 805-1871
N/A
Check Benefit Check Benefit N/A

Tubal Ligation Check Benefit Check Benefit N/A

SUBSTANCE ABUSE Patients need to call Healthplan Patients need to call Healthplan Patients need to call Healthplan
Red Referral made out to Walgreen's Red Referral made out to Walgreen's Red Referral made out to Walgreen's
SYNAGIS Home Medical Supply Home Medical Supply 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 Swedish Swedish

Green Green 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

X-rays Allowed in Ortho office

Yes Yes Yes
(Fracture Care)
X-rays Allowed in Ortho. Office No No No
XOLAIR Walgreens Home Care Walgreens Home Care Walgreens Home Care

Service Grid by Site

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Elmcare, LLC

P.O. Box 7759, Westchester, IL 60154 Health Plan Precert

ACUPUNCTURE See ED/PR See ED/PR See ED/PR

Superior (708) 832-2000 or Chicago Ambulance Alliance

Elmhurst Memorial Hospital Elmhurst Memorial Hospital Elmhurst Memorial Hospital

Dr. Jevitz Dr. Jevitz Dr. Jevitz

Consult not required Consult not required Consult not required

Consult required Consult required Consult required

BLOOD TRANSFUSION Green Green Green

Per Health Plan Renal Care Group of Villa Park

The first preferred DME is:

EEG - 24 HOUR Tertiary Tertiary Tertiary

Group Allows Specialists to

N:/MM/REFERRAL MANAGEMENT/Service Grid by Site 08/21/2009

Elmhurst Home Health Elmhurst Home Health

Check Benefit Check Benefit

Check Scope of Benefits

Adult: Alexian Brothers

LITHOTRIPSY United Shockwave United Shockwave United Shockwave

See All red list

Elmhurst Memorial Hospital Elmhurst Memorial Hospital Elmhurst Memorial Hospital

Midwest Imaging Midwest Imaging Midwest Imaging

MRA Green Green Green

NUTRITIONAL COUNSELING Green Referral Green Referral Green Referral

Cole Vision Cole Vision

Scheck & Siress Scheck & Siress Elmhurst Clinic

N:/MM/REFERRAL MANAGEMENT/Service Grid by Site 08/21/2009

OUTPATIENT PHP/IOP Elmhurst Memorial Hospital Not Managed Not Managed

Elmhurst Memorial Hospital

Elmhurst Memorial Hospital Elmhurst Memorial Hospital Elmhurst Memorial Hospital

Elmhurst Memorial Hospital Skilled Elmhurst Memorial Hospital Skilled

Check benefit Check benefit Covered - Hospital

Not Managed by Namm Not Managed by Namm Not Managed by Namm

Ultra Care Ultra Care Ultra Care

Lutheran General Hospital, Loyola,

Elmhurst Memorial Hospital Elmhurst Memorial Hospital Elmhurst Memorial Hospital

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

N:/MM/REFERRAL MANAGEMENT/Service Grid by Site 08/21/2009

Elmhurst Memorial Hospital Elmhurst Memorial Hospital Elmhurst Memorial Hospital

See Scope of Benefits

TRANSPORTATION N/A N/A N/A

X-rays Allowed in Ortho Office Yes Yes Yes

Yes Yes Yes

Loyola University Physician Foundation - #800003

Durable Medical Equipment - Aetna Website: www.aetna.com/docfind/home.do

N:/MM/REFERRAL MANAGEMENT/Service Grid by Site 08/21/2009

P.O. Box 7760, Westchester, IL 60154 Health Plan Precert

Customer Service # : 847-656-0013 Medical Leadership Review

Lewis Chiropractic Center

AMBULANCE Any contracted ambulance

BARIATRIC - MUST MEET MILLIMAN SURGICAL

BLOOD TRANSFUSION Red

Cardiac Svc/Angioplasty/CABG Vista East

Dr. Mehta, Dr. Kapadia

Lewis Chiropractic Center

Consult not required if over 50

Vista East or Vista West

CT SCAN 64 SLICE Vista East

DIALYSIS See Appendix E

DURABLE MED. EQUIPMENT/SUP. Any contracted DME vendor

EEG - 24 HOUR Vista East

N:/MM/REFERRAL MANAGEMENT/Service Grid by Site 08/21/2009

GYNECOLOGICAL ONCOLOGY NorthShore University / Red

HIGH RISK MATERNITY NorthShore University HealthSystem