Quality Tools

Panel Rosters

The IHC Panel Roster is a listing of all the patients that are currently linked to that PCP for a medical home. The Panel Rosters are posted online on the IHC Provider Portal. PCPs can access the IHC Provider Portal through HFS’ MEDI System. The online Panel Roster is updated daily and available in a CSV (Excel) format so that it can be sorted or even used for a mail merge to send notices to patients. The IHC Panel Rosters contain the most recent demographic data and clinical information about each patient.

The front page to the Panel Roster contains monthly updates about the IHC program such as notices about upcoming webinars or changes in HFS billing policies. The last page of the Panel Rosters gives a summary of the clinical recommendations for the preventive services listed. If you have additional questions about your IHC Panel Roster or registering for the MEDI system, contact the Provider Services Helpdesk at 1-877-912-1999.

Click on links to view roster definition legend and sample panel roster.

Provider Profiles


In order to assist busy clinicians in improving the quality of care, Illinois Health Connect will be sending each Primary Care Provider (PCP) a Provider Profile that summarizes each PCP’s performance on several clinical indicators. Provider Profiles will be sent semi-annually.

The data reflected in the Provider Profiles is gathered from adjudicated claims data from the Illinois Department of Healthcare and Family Services (HFS). The use of claims data has some advantages. For example, if a patient receives a recommended immunization from the health department, that data can be captured and reflected in the Provider Profiles. On the other hand, claims data cannot always accurately reflect what happens in the clinical encounter. Accurate, complete and detailed submission of claims information will enhance the accuracy of the Provider Profiles.

The Subcommittee meets via teleconference quarterly. Anyone interested in participating in the QM Subcommittee can contact the Subcommittee Chairperson and IHC Quality Assurance Manager, Cari Vonderhaar, RN, using our Online Contact Us form.

Provider Profiles will be posted on the Illinois Health Connect secure Provider Portal. In order to access the Provider Portal, providers or provider designees must obtain a digital certification through HFS’ Medical Electronic Data Interchange System (MEDI). The MEDI system links providers or provider designees to the IHC Provider Portal.

PDFs to download and review:

Provider Profile Summary Table:

The "Provider Profile Summary Table" was developed to assist PCPs in understanding the various clinical measures reflected on the Provider Profiles. Most of the measures are adapted from the National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS). Expanded information about HEDIS measures can be obtained at http://www.ncqa.org/.

Explanation of "Provider Profile Summary Table":

  1. The first column of the table gives the definition of the clinical quality indicator.
  2. The second column is 2009 national comparison data for Medicaid patients from the NCQA. It shows, nationally across all Medicaid programs, what percentage of patients must receive the service to hit the national 50th percentile. While all of the measures are nationally recognized clinical standards of care, not every measure has a HEDIS definition and some of the measures on the Provider Profile have been slightly modified from the exact HEDIS format.
  3. The third column shows the CPT or ICD-9 codes that reflect the clinical criteria and allow the measure to be calculated from claims data. Practices are strongly encouraged to revise their charge sheets (superbills) to reflect these codes for consistent data collection.
  4. The fourth column provides some useful clinical references. Additional information about clinical standards and billing/coding can be found in the HFS Handbooks for Providers. The Handbook for Providers of Healthy Kids Services (Handbook Chapter 200-HK) is particularly useful for clinicians working with the pediatric population. Illinois Health Connect Provider Service Representatives can deliver a copy of the Handbook to your office (call 1-877-912-1999) or it can be downloaded from the HFS website (linked above).

Providers can obtain information about individual patients and whether they have received many of the clinical services reflected on the Provider Profiles by checking their Illinois Health Connect Panel Rosters. The Panel Rosters are mailed to each provider monthly and are available electronically via the Illinois Health Connect Provider Portal which can be accessed through HFS’ MEDI system. The electronic Panel Rosters are updated daily. Information on accessing the electronic Panel Roster through MEDI is available on the Illinois Health Connect website or you can contact the Illinois Health Connect Provider Services Help Desk for assistance at 1-877-912-1999.

Bonus Payment for High Performance

The Illinois Department of Healthcare and Family Services has renewed the Illinois Health Connect Bonus Payment For High Performance program, now in its fourth year. In the 2011 program, qualifying Illinois Health Connect Primary Care Providers (PCPs) are eligible to receive bonus payments for each qualifying service for the following six bonus measurements. New for 2011 is a bonus measurement for blood lead screening prior to 24 months.

What are the Bonus Measurements?
  • Immunization Combo 3: Children who receive designated immunizations by age 24 months (benchmark 71.0%).
  • Developmental Screening: Children who receive at least one objective screening by the age of 12 months (benchmark 65%), between the ages of 12 and 24 months (benchmark 55%), and between the ages of 24 and 36 months (benchmark 50%). A bonus will be available for each separate age group.
  • Asthma management: Patients with persistent asthma, ages 5-11 years (benchmark 92.2%), ages 12-50 years (benchmark 86.3%) who fill an asthma controller medication prescription. A bonus will be available for each separate age group.
  • Diabetes Management: Patients with diabetes, ages 18 to 65 years who receive at least one HbA1c test annually (benchmark 81.1%).
  • Breast Cancer Screening: Women ages between ages 40 and 69 who have had a mammogram in the last two years (benchmark 52.0%).
  • Lead Screening: Children who have had at least one capillary or venous blood test by their second birthday. (benchmark 71.6%).
Who is a qualifying PCP?

A qualifying PCP is an Illinois Health Connect PCP who meets or exceeds the 2010 HEDIS 50th percentile benchmark collectively for all the Illinois Health Connect enrollees on their panel roster for a particular measure, or, in the case of developmental screening, the benchmark target set forth above. A PCP may be a qualifying PCP for one or more measurement.

What is HEDIS?

HEDIS is the Healthcare Effectiveness Data and Information Set, which is a national reporting system administered by the National Committee for Quality Assurance (NCQA) to measure performance on a number of important measures of care and service. Most commercial health plans and state Medicaid programs utilize these measures. National benchmarks are reported annually which provide a summary of the various metrics. HFS is using the 50th percentile (meaning half of all Medicaid plans performs above and half perform below the benchmark) as a minimal threshold of performance.

How we will measure whether you met the benchmark.

HFS will count the number of qualifying patients for each measure enrolled on each PCP’s Illinois Health Connect panel roster on December 1, 2011. We will then look to see which of those patients received the measured service during the measurement period. HFS claims data will be used to determine whether a service was rendered (for immunizations, Cornerstone data will also be used). Although providers have 12 months from the date of service to bill in order to be paid for the service, the bonus payment will be based on measurement year 2010 claims, after a three month run out (January through March of 2012). This means all claims for measurement year 2011 services must be submitted to HFS prior to April 1, 2012 to be counted. We will then determine and pay the bonus payments by June 2012.

PCPs do not have to report any special information to earn a bonus payment; but they need to submit a detailed claim for the services that are rendered. A measured service is counted whether or not it was the current PCP or another provider who rendered the service during the measurement period. We will use the date of service for the measured service to determine if it was rendered in the measurement period. Ordering a service for a patient does not qualify for a bonus payment, the service must actually be received by the patient. A sheet is attached for each bonus measurement giving details on the billing codes measured, the time period measured and other details to maximize the opportunity for bonus payments.

For which services will bonus payments be made?

If a PCP meets or exceeds the benchmark for a particular measured service, a bonus payment will be made for each patient that received the measured service. If the PCP does not meet the benchmark, there will be no bonus payment made for any patients, whether they received the service or not.

How much are the bonus payments?

The 2011 bonus payments will be at least $20.00 per patient. The bonus payment may be higher depending on the number of qualifying PCPs and the number of patients receiving a measured service from those PCPs as determined by the Department.

For example, for the diabetes measurement, the HEDIS 2009 50th percentile is 80.7%(meaning that half of the nation’s Medicaid programs had achieved a rate of 80.7%or higher for diabetic patients receiving at least one HcA1c test). A PCP would need 80.7% or more of their Illinois Health Connect diabetic patients to have received at least one HbA1c test in the past 12 months to qualify for the bonus payment. The PCP would receive the bonus payment for each patient that met the criteria. If less than 80.7% of the Illinois Health Connect diabetic patients on the PCP’s panel roster did not have the test, then no bonus would be available for any of their diabetic patients.
For specific information about each of the clinical measures, click on the links below:

Electronic Tools For Providers

Claims History Report

In order to assist clinicians with providing care, Illinois Health Connect will provide electronic access to a summary of the claims for any current HFS client. The Claims History contains all claims submitted to HFS for the past 2 years, including pharmacy claims, and contains at least four years for immunization claims. The immunization claims will be retained in the Claims History for seven years. The information provided on the Claims History report adheres to all Illinois confidentiality statutes. The Claims History only reflects claims received by HFS so services paid by other payers are not included.

In order to protect patient confidentiality, this Claims History will only be available to any HFS provider or provider designee who has obtained a digital certification through HFS Medical Electronic Data Interchange (MEDI) System.

To access the Claims History, providers or provider designees will access the Illinois Health Connect Provider Portal through the MEDI system. Once on the Provider Portal, access to the Claims History can be obtained by clicking on the "Claims History" link and providing at least three pieces of identifying information about a specific client including name, RIN, DOB or SSN. For more information or assistance in accessing this information, contact the Illinois Health Connect Provider Services Help Desk at 1-888-912-1999.

Drug Search Engine

HFS is pleased to announce that a drug search engine has been incorporated into its website that will allow providers to search for drugs by both generic and brand names to immediately determine if the drug requires prior authorization (PA). This web page also contains links to information regarding the PA process, PA forms and PA requirements so that prescribing for HFS clients can be streamlined. The web address is: http://www.hfs.illinois.gov/pharmacy/. Click on "Search for Prior Approval Status by Drug" on the left side of the page.

This search engine was developed and is maintained by the University of Illinois at Chicago (UIC) College of Pharmacy. The Department would like to sincerely thank UIC for the hard work that they invested in the search engine.