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.