Clinical Care & Guidelines

CountyCare Clinical Practice Guidelines

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.

Clinical Practice Guidelines

Preventative Health Guidelines & Minimum Standard of Care

Clinical Practice Guidelines

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SAMHSA: Family-Centered Treatment for Women with Substance Abuse Disorders

Pediatric Behavioral Health

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

Special Needs Children

Health Services for Children with Special Needs
Developmental Surveillance and Screening

Psychotropic Medication Management

World Health Organization: Pharmacological Treatment of Mental Disorders

American Academy of Child & Adolescent Psychiatry: Psychotropic Medication

Pain Management

CDC: Prescribing Opioids for Chronic Pain

Clinical Pharmacy Medication Review

Patient-Centered Primary Care Collaborative

Long-term Supports & Services (LTSS)

Centers for Medicare & Medicaid

Home & Community Based Services
Long-term Care
- IL DHS: Community Reintegration Program

Dental Services

American Dental Association

Community Reintegration

American Heart Association

IL DHS: Community Reintegration Program

Substance Abuse and Mental Health Services Administration

Reproductive Health Care

American Academy of Pediatrics and the American College of Obstetrics & Gynecology

Preventative Health Guidelines and Minimum Standards of Care

CountyCare providers must adhere to minimum standards of care as outlined in the following guidelines:

Medically Necessary Services

CountyCare providers are expected to provide any further medically necessary diagnostic study or treatment for any known condition or conditions discovered during the complete health history and physical examination if the study or treatment is within the scope of covered services
Any condition discovered during the screening examination or screening test requiring further diagnostic study or treatment must be provided if within the scope of Covered
If a condition is discovered that requires treatment outside the scope of service, the provider should refer to an appropriate source of care and may look to CountyCare to assist with such referral.

Specialty Care Services

CountyCare provides for a full range of specialty care services within the scope of covered services.
Primary care clinicians are expected to refer members to CountyCare network specialists, as medically appropriate, when managing the healthcare needs of members beyond the primary clinician’s training and knowledge.
Specialists may also refer to other specialists, as appropriate, in consultation with the member’s primary care clinician.
CountyCare will assist in identifying available specialists through our case management program. Case managers may be identified by calling Member Services at 312-864-8200.

HFS Preventative Health Guidelines

All CountyCare network providers should follow the preventative health guidelines outlined below by Illinois Healthcare and Family Services.

Preventative Health Guidelines

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.

¹For 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

Initial and interval history, including past medical and surgical history of each Enrollee, history of allergies, an updated list of medications used (prescribed and over the counter), and a family medical history.
Height and weight measurement for body mass index (BMI).
Blood pressure, temperature, and pulse rate measurements.
Nutrition and physical activity assessment and counseling.
Assessment of social and economic determinants of health; housing, transportation availability, and employment
Screening for alcohol, tobacco, substance abuse, intimate partner violence, and depression screening and counseling.
Counseling for advanced directives (living will and healthcare power of attorney) and collection of those documents, if available.
Verification of contact information for medical follow up when necessary such as postal address, e-mail, and phone number (landline, mobile, and alternate number for a family member if unable to reach patient directly); and
Health promotion and anticipatory guidance, as clinically appropriate.

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:

Under Age One: Birth, During first 2 weeks, 1 month, 2 months, 4 months, 6 months, 9 months
Age 1-3: 12 months, 15 months, 18 months, 24 months/30 months
Age 3-6: Annually
Age 6-21: Every other year, at a minimum, or more often if medically necessary

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

Cervical Cancer Screening

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.

Breast Cancer Screening

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.

Colorectal Cancer Screening

US Preventive Services Task Force

Routine screening recommended for Persons 45-75 years of age. Screening intervals and strategies include the following:

Flexible sigmoidoscopy every 10 years + FIT every year OR Colonoscopy screening every 10 years
CT tomography colonography every 5 years OR Flexible sigmoidoscopy every 5 years

High-sensitivity guaiac fecal occult blood test (HSgFOBT) or fecal immunochemical test (FIT) every year OR Stool DNA-FIT every 1 to 3 years

Prostate Cancer Screening

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.

Skin Cancer Screening

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.

Diabetes Mellitus Type 2 Screening

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.

Lipid Disorder Screening

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.

Hepatitis C Screening

US Preventive Services Task Force

The USPSTF recommends screening for hepatitis C virus (HCV) infection in adults aged 18 to 79 years.

Osteoporosis Screening

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.

Tuberculosis Screening

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.

Immunizations: Age & Interval Recommendations

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:

Influenza: One (1) dose annually
Tetanus/ Diphtheria (Tdap/Td): One Tdap and one Td booster every ten (10) years
Varicella: One (1) two dose series for all adults without previous evidence of immunity
Human Papilloma Virus (HPV): One (1) three dose series up through age 26.
Shingles (zoster): One (1) dose at 60 years of age and older
Hepatitis A & B: combined Hepatitis A and Hepatitis B one (1) three dose series or Hepatitis A one (1) two dose series or Hepatitis B one (1) three dose series provided at any age for any Enrollee requesting protection.

**Please use the links above to visit the CDC website for more periodicity schedules and vaccines specific to adults and children.

Family Planning & Reproductive Health Care

Centers for Disease Control & Prevention

Quality Family Planning

Recommendations for Contraceptive Use

American Society for Colposcopy & Cervical Pathology

The full spectrum of family planning options and reproductive health services shall be appropriately provided within the Provider’s scope of practice and competence. The family planning and reproductive health services are defined as those services offered, arranged, or furnished for the purpose of preventing an unintended pregnancy, or to improve maternal health and birth outcomes. Standards of care and guidelines comply with the requirements of the Affordable Care Act. Federal and State laws regarding minor consents and confidentiality will be followed.
Education and counseling on all contraceptive methods with emphasis on presenting the most effective methods first, specifically long-acting reversible contraceptives (LARC) such as intrauterine devices (IUD) and the implantable rod.
Reproductive Life Plan which may include a preconception care risk assessment and preconception and interconception care discussions
Education and Counseling on all contraceptive methods with emphasis on presenting the most effective methods first, specifically long-acting reversible contraceptives (LARC) such as intrauterine devices (IUD) and the implantable rod
Emergency Contraception methods must include over-the-counter and prescription emergency contraception as well as the provision of the copper IUD for emergency contraception
Permanent Methods of Birth Control: tubal ligation, transcervical sterilization and vasectomy
Basic Infertility Counseling consisting of medical/sexual history review and fertility awareness education. Infertility medications and procedures are NOT covered
Reproductive Health Exam with pelvic exam decoupled from the provision of contraception
Sexually Transmitted Infections
- < 26 y/o Sexually Active Females & Males should be screened annually for chlamydia and gonorrhea.
- All Enrollees > 26 y/o should be screened based on risk factors (symptoms, new partner, multiple partners, or recent history of another STI)
Universal HIV Testing, Counseling & Screening
Testing & Treatment for genital and related infections, and other pathological conditions
Lab Testing necessary for family planning and reproductive health services
Cervical Cancer Screening, Management, and Early Treatment
Vaccines for Preventable Reproductive Health Related Conditions, such as HPV and Hepatitis B
Mammography Referral and BRCA Genetic Counseling & Testing

Barriers or Restrictions to Access to Care

Health Services Research

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.

Maternity Care

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.

Prenatal Care

American Academy of Family Physicians (AAFP)

Risk Counseling for STI/HIV, intimate partner violence, teratogen exposure, substance use and abuse and potential for pre-term delivery screenings, and education on use of 17 P, if appropriate.
Screening For, Diagnosing, And Treating Depression before, during and after pregnancy with any number of tested screening tools (refer to the Healthy Kids Handbook for a list of approved screening tools).
Health Maintenance promotion includes nutrition, exercise, dental care, immunizations, management of current chronic disease, over the counter and prescription medication, breastfeeding counseling and recommendation, appropriate weight gain in pregnancy, obesity counseling, managing signs and symptoms of common pregnancy ailments, and referral to breastfeeding, childbirth classes, and text4baby. The influenza vaccine should be offered to all pregnant women during influenza season regardless of gestational age. Tdap should be provided regardless of prior interval of Td or Tdap.
Routine Laboratory Screening and Physical Exam, which includes dating by ultrasound for accurate gestational age. Every prenatal exam at minimum should include blood pressure check, fetal growth assessment, and fetal heart rate check. In the absence of patient symptoms and/or suspicion for preeclampsia, renal disease, or urinary tract infection, a urine analysis and culture is only required at the initial visit. Routine laboratory screening should include the following: blood type, Rh type, antibody, CBC (routine screening for anemia), rubella, hepatitis B, syphilis/gonorrhea/chlamydia/HIV, varicella, diabetes, and tuberculosis to applicable populations.
Genetic Screening should be counseled and offered depending on patient’s age, medical/ family history, and ethnic background.
Visit Protocols. Visits approximate to the third trimester should include labor preparation, education regarding preeclampsia, warning signs of miscarriage, fetal movements/kick count, preterm labor and labor, options for intrapartum care, breastfeeding encouragement, postpartum family planning including LARC or permanent sterilization with informed consent done prior to labor and delivery, circumcision, newborn provider care, car seat, SIDS, the importance of waiting at least 39 weeks to deliver, referral to parenting classes and WIC, and transition of maternal healthcare after the postpartum visit, as well as protocols to facilitate the continuum of care after the obstetric period.

Identify High-Risk Pregnancies

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.

Postpartum Care

Clinical Guidelines for Postpartum Women and Infants in Primary Care

Immediate And Subsequent Postpartum Visits, in accordance with the Department’s approved schedule, to assess and provide education on areas such as perineum care, breastfeeding/feeding practices, nutrition, exercise, immunization, sexual activity, effective family planning, pregnancy intervals, physical activity, SIDS, and the importance of ongoing well woman care, and referral to parenting classes, text4baby and WIC.
Postpartum Depression Screening during the one-year period after delivery to identify high risk mothers who have an acute or long-term history of depression, using an HFS-approved screening tool.

After delivery and discharge, the Enrollee will have a mechanism to readily communicate with her health team and not be limited to a single “six week” postpartum visit. Enrollees will be engaged in health promotion and chronic disease maintenance through the postpartum mother with Seamless Referrals to avoid interruption of care.
Enrollees will be transitioned to the medical home for ongoing Well Woman Care. Enrollees who delivered and who are at risk of or diagnosed with diabetes, hypertension, heart disease, depression, substance use, obesity or renal disease will be identified and followed closely after the postpartum period.
Interconception care management: Provide or arrange for interconception care management services for these high-risk women for 24 months following delivery.

Well Woman Exam

American College of Obstetrics and Gynecology

Preventive Well Woman Care: Provide evidence based annual preventive well woman care to female Enrollees. At a minimum, the Plan will provide and document the following:
Preconception and interconception care and reproductive life planning.
The annual exam should include screening, counseling, evaluation, education, and immunizations based on age.
The examination may vary but at minimum should include the following: routine vital signs, body mass index, palpation of abdominal and inguinal lymph nodes, and visual inspection of breast and genital.
The components of the exam are based on Enrollee’s age, medical history, symptoms, and provider findings.
Ag- Appropriate Discussions: Exams will include age-appropriate discussions and anticipatory guidance related to reproductive health issues. Education will include, but not be limited to chronic disease management, breastfeeding reinforcement, reproductive life planning, and emphasis on the most effective method of family planning, specifically intrauterine devices, or the implant.
Appropriate Referrals should be made to support services including WIC, interconception care management and parenting classes.
Pelvic Exam: A pelvic examination is an appropriate component of a comprehensive evaluation of any patient who reports or exhibits symptoms suggestive of female genital tract, pelvic, urologic, or rectal problems. A routine pelvic exam is not required for members less than 21 years of age unless there is a clinical indication.
Cervical Cytology Screening every three years from 21 years of age regardless of sexual debut and every 3-5 years after 29 years of age.
Clinical Breast Examination: Annual clinical breast examination for women aged 40 years and older; and in women aged 20-39 years, every 1-3 years.

* 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:

Initial and interval history;
Height and weight measurement for Body Mass Index (BMI);
Blood pressure;
Nutrition and physical activity assessment and counseling;
Alcohol, tobacco, substance abuse, intimate partner violence, and depression screening and counseling;
Health promotion and anticipatory guidance;

Rights & Responsibilities

CountyCare is committed to improving not just our members’ health but also provider satisfaction.

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.

Eligibility Verification

Providers must verify a member’s eligibility on each date of service. To verify member eligibility, please use one of the following methods:

Online: To log on to the secure provider portal where you can check member eligibility Click Here.
Automated Phone Line: Call our touch-tone automated member eligibility interactive voice response (IVR) system. Call 312-864-8200 / 855-444-1661 (toll-free)/ 711 (TDD/TTY) from any touch-tone phone and follow the appropriate menu options to reach our automated member eligibility-verification system 24 hours a day.
Calling CountyCare Provider Services: If you cannot confirm a member’s eligibility using the methods above, call us at 312-864-8200 / 855-444-1661 (toll-free)/ 711 (TDD/TTY).
Medi: Providers can also verify eligibility through the state of Illinois’ MEDI system online at myhfs.illinois.gov.

*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).

Clinical Care & Guidelines

CountyCare Clinical Practice Guidelines

Clinical Practice Guidelines

Acute Respiratory Distress Syndrome (ARDS)

Asthma

Cancer

Chronic Kidney Disease

Cardiovascular Disease and Congestive Heart Failure

Coronary Artery Disease

Coronavirus

Chronic Obstructive Pulmonary Disease

Diabetes

Human Immunodeficiency Virus (HIV)

Myocardial Infarction

Respiratory Syncytial Virus (RSV)

Seizure Disorder

Stroke

Adult Preventive Care

Pediatric Preventive Care

Smoking Cessation

Adult Behavioral Health

Pediatric Behavioral Health

Special Needs Children

Psychotropic Medication Management

Pain Management

Clinical Pharmacy Medication Review

Long-term Supports & Services (LTSS)

Dental Services

Community Reintegration

Reproductive Health Care

Preventative Health Guidelines and Minimum Standards of Care

HFS Preventative Health Guidelines

Preventative Health Guidelines

Cervical Cancer Screening

Breast Cancer Screening

Colorectal Cancer Screening

Prostate Cancer Screening

Skin Cancer Screening

Diabetes Mellitus Type 2 Screening

Lipid Disorder Screening

Hepatitis C Screening

Osteoporosis Screening

Tuberculosis Screening

Immunizations: Age & Interval Recommendations

Family Planning & Reproductive Health Care

Barriers or Restrictions to Access to Care

Maternity Care

Prenatal Care

Identify High-Risk Pregnancies

Postpartum Care

Well Woman Exam

Rights & Responsibilities

CountyCare is committed to improving not just our members’ health but also provider satisfaction.

Eligibility Verification