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 Provider Profiles are created with input from the Quality Management Subcommittee. 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.

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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 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.

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