State of Illinois - HealthLink

Note: Preventive care benefits can be provided only for charges your contracted
physician identifies as routine. Services for which a diagnosis is provided or symptom
indicated will be paid in accordance with regular plan benefits.
I. Behavioral Health Services – This is a covered benefit both in- and out-of-network. You
may go to any provider you choose and receive psychiatric services, and alcohol and
substance abuse care.
Note: Pre-certification authorization is required for all inpatient, partial hospital
admissions and intensive outpatient (IOP) programs. (Two partial hospitalization
sessions equal one day of inpatient care) whether rendered by a contracted or out-ofnetwork
provider.
Authorization for Services – Calling the Behavioral Health Department toll free at 1-877-284-
0102, Option 3, begins the authorization process for services outlined above to avoid penalties
for non-authorization of benefits. In an emergency or a life threatening situation, call 911 or go
to the nearest hospital emergency room. You must call the Behavioral Health Department
within 48 hours to avoid a potential penalty. A licensed Behavioral Health professional will
conduct a review to determine whether treatment meets medical necessity criteria and
appropriateness of care. If treatment is authorized, services are eligible for benefit coverage.
Services determined not medically necessary will not be eligible for coverage.
1. Inpatient services must be authorized prior to admission or within 48 hours of an
emergency admission. Authorization is required with each new admission.
2. Partial hospitalization and intensive outpatient treatment must be authorized prior
to admission.
Note: All of the above services require authorization, or a $500 penalty or denial of
services may be incurred for out-of-network providers.
Outpatient Care for Behavioral Health Services – Treatment received as an outpatient or in a
doctor's office will be treated the same as any other illness and considered a specialist co-pay.
Inpatient Care for Behavioral Health (Psychiatric Services) – The plan will pay benefits as
it does for any other inpatient care.
Inpatient Care for Behavioral Health (Alcohol/Substance Abuse) – The plan will pay
benefits as it does for any other inpatient care.
J. Maternity Care – Maternity services provided by Tier I (HMO) contracted providers have
a co-pay of $50 once per pregnancy plus an inpatient admission co-pay of: Tier I $325;
Tier II $375; or Tier III $475. All services provided by Tier II (PPO) contracted providers
and out-of-network providers are subject to deductible and coinsurance, as well as Tier II
and Tier III inpatient admission co-pays. A single co-pay is applicable for both mother and
newborn (well baby care); if the newborn remains after the mother is discharged, a separate
co-pay will apply. If a female is pregnant when she becomes a participant in this plan,
coverage is effective upon enrollment. Newly enrolled members who are in the third
trimester of pregnancy will be allowed continuity of care provided by their current
obstetrician. Pre-certification of maternity care is not required.
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