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components where applicable) or the base amount payable for ages 21 years and older when

(State Maximum)

followed by “(A)”.

Add-On

Surg

The amount added to the state maximum when the procedure is performed in the practitioner’s

office. This amount covers such items as casting and surgical supplies.

Child

•

The amount added to the state maximum for services rendered by any practitioner to

participants age 0-20 years, with the exception of preventive E/M codes.

•

Add-ons for preventive Evaluation and Management codes are payable only to Primary

Care Providers.

Adult

•

The amount added to the state maximum for services rendered by any practitioner to

participants age 21 years and older, with the exception of preventive E/M codes.

•

Add-ons for preventive Evaluation and Management codes are payable only to Primary

Care Providers.

Rate reduced by

Maximum amount payable after 2.7% rate reduction per the SMART Act (PA097- 0689).

Exempt: Physicians, Dentists, Advanced Practice Nurses, Community Mental Health

2.7%

Providers, FQHCs, RHCs, ERCs, LEAs, DORS Schools, School-based Clinics, Local Health

Departments, and Early Intervention.

*Vaccine Information for Notes E, F, I, M, Y:

 All available vaccines for children age 0 through 18 with Title XIX (19) eligibility should be obtained through the

Vaccines for Children (VFC) program. Specialty/sub-specialty OB-GYN practitioners are not required to

participate in the VFC program for the purposes of administering and billing the HPV vaccine.

 For VFC-obtained vaccines administered to Title XIX (19) eligible children, the Department will reimburse the

administrative cost shown in the Unit Price column. Administrative cost refers to the practice expense of

obtaining the vaccine through the VFC program.

 Effective October 1, 2016 through June 30, 2017 private stock vaccines administered to Title XXI (21) and State-

Funded eligible children will be reimbursed at the lesser of the provider charge amount or the $6.40 Unit Price

rate plus the State Max rate as noted on the Practitioner Fee Schedule. This policy does not apply to Federally

Qualified Health Centers (FQHCs), Rural Health Centers (RHCs), and Encounter Rate Clinics (ERCs). Refer to

the January 17, 2017 provider notice for more information.

 The E/M service payment includes reimbursement for the injection service except when noted. Billing guidelines

are available in the Chapter A-200 Practitioner Handbook, Section A-226.

 For vaccines not available through the VFC program and administered to any child, the Department will reimburse

the medically necessary vaccine product as shown in the State Max column. The additional $6.40 administrative

cost reimbursement does not apply.

 FQHCs, RHCs and ERCs may bill private stock vaccines either fee-for-service or as part of a medical encounter

when administered to children age 0 through 18 with Title XXI (21) or state-funded eligibility. Private stock

vaccines for this population must be billed with the GB modifier appended to each vaccine-specific procedure

code and include the provider’s usual and customary charge. The Department will reimburse the medically

necessary vaccine product as shown in the State Max column.

 Vaccine billing instructions and examples may be found in the

Chapter A-200 Practitioner Handbook

and

Appendices or the

Chapter D-200 Encounter Clinic Services Handbook and Appendices

(as applicable by

provider type) as well as on the

Non-Institutional Providers Resources

webpage.

Practitioner Fee Schedule Key - Illinois Department Of Healthcare And Family Services Page 5

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