All services coordinated by CountyCare must be in accordance with established evidence-based best practice standards of care. Clinical practice guidelines are intended to optimize our members care, and are adopted in consultation with CountyCare Network Providers.
Guidelines are reviewed no less than biennially or in timely response to changes in best practice. For questions or comments, providers may email [email protected].
Below please find CountyCare’s Clinical Practice Guidelines.
American Heart Association & American College of Cardiology (link works best in Internet Explorer browser)
American Psychiatric Association: Psychiatric Evaluation of Adults**
American Psychiatric Association: Acute Stress Disorder and PTSD**
American Psychiatric Association: Major Depressive Disorder**
American Psychiatric Association: Obsessive-Compulsive Disorder**
American Psychiatric Association: Substance Use**
**please press cancel at login page
SAMHSA: Family-Centered Treatment for Women with Substance Abuse Disorders
American Academy of Child & Adolescent Psychiatry: Psychotropic Medication
American Academy of Child & Adolescent Psychiatry: Autism Spectrum
American Academy of Pediatrics: Attention Deficit Hyperactivity Disorder
American Academy of Child & Adolescent Psychiatry: Obsessive-Compulsive Disorder
American Academy of Child & Adolescent Psychiatry: Cultural Competence
Centers for Medicare & Medicaid
CountyCare providers must adhere to minimum standards of care as outlined in the following guidelines:
Medically Necessary Services
Specialty Care Services
All CountyCare network providers should follow the preventative health guidelines outlined below by Illinois Healthcare and Family Services.
Adult: General
US Preventive Services Task Force
CountyCare expects that a complete health history and physical examination 1 is provided to each member initially within the first year of enrollment and every 1-3 years thereafter, or as indicated by need and clinical care guidelines. For those aged 65 and older, a complete health history and physical examination should be conducted annually. With each health history and physical examination, screening, counseling, and immunization should be provided in accordance with national medical organizations’ guidelines.
1 For purposes of this section, a “complete health history and physical examination” shall include, at a minimum, the following health services regardless of age and gender of each Enrollee
Pediatric: General
US Preventive Services Task Force
Illinois Healthcare and Family Services
CountyCare expects that a complete health history and physical examination is provided to each member per the following schedule from Illinois Healthcare and Family Services guidelines:
Pediatric: EPSDT
Illinois Department of Healthcare and Family Services
Centers for Medicare & Medicaid Services: EPSDT Services
CountyCare providers are expected to employ strategies to ensure that children receive comprehensive child EPSDT health services as needed in in conformance with the Handbook for Providers of Healthy Kids Services, which can be found at https://www.illinois.gov/hfs/SiteCollectionDocuments/72517HK200Handbook.pdf
US Preventive Services Task Force
American Society for Colposcopy & Cervical Pathology
Women aged 21-29 should have cervical cancer screening with a pap smear every three years. For women 30-65, extended screening to every five years (5) is appropriate after three satisfactory normal cytology results and a negative human papillomavirus (HPV) test. Women over 65 with adequate screening or women of any age who have had a hysterectomy with removal of the cervix for benign reasons and without a history of high-grade lesion or at low risk for cervical cancer do not need screening. The HPV vaccine series should also be offered for those up to age 26 years old, if not already immunized.
US Preventive Services Task Force**
**Recommendation is currently being updated by US Preventive Services Task Force
Women aged 40 to 49 are recommended to have biennial mammogram screenings and annual screenings begin at age 50. Clinical breast exams are recommended everyone (1) to three (3) years from 20 to 40 years old and annually thereafter. Breast self-awareness to recognize changes can be discussed from age 20 years old. Using one of several tools, women with a family history of breast, ovarian, tubal, or peritoneal cancer should be offered the gene mutation screening for BRCA1 and BRCA2. Subsequent positive testing should be offered genetic counseling. Women who are at increased risk for breast cancer should be counseled and offered risk reducing medication such as selective estrogen response modulators.
US Preventive Services Task Force
Routine screening recommended for Persons 45-75 years of age. Screening intervals and strategies include the following:
High-sensitivity guaiac fecal occult blood test (HSgFOBT) or fecal immunochemical test (FIT) every year OR Stool DNA-FIT every 1 to 3 years
US Preventive Services Task Force
There is no recommendation to screen for prostate cancer with prostate specific antigen (PSA) testing for the asymptomatic, low risk man. Along the same line, digital rectal exam (DRE) is at the discretion of the provider and after informed discussion with the patient. Screening with both PSA and DRE may be considered at age 40 for African American ancestry or family history risk of a first degree relative diagnosed at younger than 65 years of age.
US Preventive Services Task Force
The US Preventive Services Task Force has concluded that the current evidence is insufficient and that the balance of benefit and harms of visual skin by a clinician to screen for skin cancer in asymptomatic adults cannot be determined.
US Preventive Services Task Force
The USPSTF recommends screening for abnormal blood glucose as part of cardiovascular risk assessment in adults aged 35 to 70 years who are overweight or obese. Clinicians should offer or refer patients with abnormal blood glucose to intensive behavioral counseling interventions to promote a healthful diet and physical activity.
Adult: US Preventive Services Task Force
Pediatric: US Preventive Services Task Force
Adult: Cholesterol screening for men should begin at 35 years old and at five (5) year intervals. For women and men at risk of coronary artery disease (CAD), screening should start at 20 years old. The risk of coronary artery disease may include a family history of CAD, obesity, hypertension, diabetes, and current tobacco use.
Pediatric: US Preventive Services Task Force has concluded that the current evidence is insufficient to assess the balance of benefits and harms of screening for lipid disorders in children and adolescents 20 years or younger.
US Preventive Services Task Force
The USPSTF recommends screening for hepatitis C virus (HCV) infection in adults aged 18 to 79 years.
US Preventive Services Task Force**
**Recommendation is currently being updated by US Preventive Services Task Force
Screen all women 65 years and older for bone mineral density with dual energy x-ray absorptiometry. For those with one risk factor or having a fracture risk equivalent to a 65 year old white woman, screening may begin earlier. An interval of two (2) years is usually sufficient for clinical changes. Risk factor may include certain ethnicities, very low BMI, history of fractures, tobacco use, limited exercise, and other chronic diseases.
US Preventive Services Task Force **
**Recommendation is currently being updated by US Preventive Services Task Force
Annual tuberculin (Mantoux) skin testing for all at risk Enrollees. At risk may include signs and symptoms of tuberculosis, recent contact with someone diagnosed with tuberculosis, occupational or living hazard of close quarters, and recent immigrants from county with high prevalence of tuberculosis, illicit drug use, compromised immune system, or healthcare workers.
Adult: Centers for Disease Control & Prevention**
Pediatric: Centers for Disease Control & Prevention**
The following are recommended immunizations by age and interval for both males and females, unless contraindicated:
**Please use the links above to visit the CDC website for more periodicity schedules and vaccines specific to adults and children.
Centers for Disease Control & Prevention
Recommendations for Contraceptive Use
American Society for Colposcopy & Cervical Pathology
CountyCare is committed to key principles of access to healthcare: affordability, accommodation, availability, accessibility, and acceptability. In its use of utilization management methods, such as prior authorizations or step-failure therapy requirements, CountyCare does not present barriers or restrictions to access to care for medically necessary services. CountyCare covers and offers all FDA-approved birth control methods with education and counseling on the most effective methods first, specifically long-acting reversible contraception (LARC). Enrollees have the freedom to choose the preferred birth control method that is most appropriate for them.
American Academy of Family Physician and American College of Obstetrics & Gynecology
Prenatal Evaluation
A comprehensive prenatal evaluation and care in accordance with the latest standards as recommended by the American College of Obstetricians and Gynecology or the American Academy of Family Physicians, including ongoing risk assessment and development of individualized care plans that take into consideration the medical, psychosocial, cultural/linguistic, and educational needs of the patient and her family.
Systems & Protocols
Providers shall have systems and protocols in place to handle regular appointments, early entry to care appointments, after hours care with emergency appointment slots, seamless process for transmitting prenatal records to the delivering facility, and a referral network for mental health, social services, and specialty care. All pregnant women must be referred to the Women, Infants and Children’s (WIC) Supplemental Nutrition Program and have or be linked to case management services for identified high risk Enrollees. Providers shall be able to provide equal, high quality obstetrical care to special populations such as adolescent, homeless, developmentally, and intellectually disabled pregnant patients.
American Academy of Family Physicians (AAFP)
American College of Obstetrics & Gynecology
All Providers are required to timely identify high-risk pregnancies and arrange for maternal fetal medicine specialist or transfer to Level III perinatal facilities in accordance with ACOG guidelines and the Illinois Perinatal Act requirements for referral and/or transfer of high-risk women. Risk appropriate care will be ongoing during the perinatal period.
Clinical Guidelines for Postpartum Women and Infants in Primary Care
American College of Obstetrics and Gynecology
* Recommendation is in the process of being updated by US Preventive Services Task Force
(1)A “complete health history and physical examination” includes, at a minimum, the following health services regardless of age and gender of each member:
To do this, we have established rights and responsibilities for both members and providers. Providers and members can apply their rights without any action taken against them.
If you believe your rights, or the rights of a CountyCare member were violated, please call Provider Services at 312-864-8200 /855-444-1661 (toll-free)/ 711 (TTD/TTY).
To read more about your rights and responsibilities as a CountyCare provider, click here to read the Provider Manual.
Providers must verify a member’s eligibility on each date of service. To verify member eligibility, please use one of the following methods:
*Note that while PCPs are able to access their monthly member panel list through the provider portal, panel lists should not be used to determine eligibility for benefits. Member eligibility can vary in a given month. Please use one of the methods described above to verify member eligibility on the date of service.
CountyCare members may also qualify for home and community-based waiver services (HCBS), supportive living facility (SLF), or long-term care (LTC). The state of Illinois determines eligibility for these programs. To confirm if a member is eligible for these services, contact CountyCare’s Provider Services at 312-864-8200 / 855-444-1661 (toll-free) / 711 (TDD/TTY).
