Below please find CountyCare’s Clinical Practice Guidelines.
Clinical Practice Guidelines
Acute Respiratory Distress Syndrome (ARDS)
Congestive Heart Failure
Coronary Artery Disease
Chronic Obstructive Pulmonary Disease
Human Immunodeficiency Virus (HIV)
Adult Preventative Care
Adult Behavioral Health
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**
**Please press cancel on the login page
American Psychiatric Association: Substance Use
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
Clinical Pharmacy Medication Review
Long-term Supports & Services (LTSS)
Reproductive Health Care
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 perform medically necessary diagnostic study or treatment for any known condition or conditions discovered during the complete health history and physical examination if the research 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 Services.
- Providers should refer members to an appropriate source of care request CountyCare to assist with such referrals if there are any conditions requiring treatment and outside the provider’s expertise.
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 members’ healthcare needs 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
CountyCare expects that a complete health history and physical examination is given 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
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.
CountyCare providers are expected to employ strategies to ensure that children receive comprehensive child EPSDT health services as needed in conformance with the Handbook for Providers of Healthy Kids Services.
Cervical Cancer Screening
Women aged 21-29 should have cervical cancer screening with a Pap smear every three years. For women 30-65, comprehensive screening every five years (5) is appropriate after three satisfactory average 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. If not already immunized, the HPV vaccine series should also be offered for those up to the age of 26 years old.
*Breast Cancer Screening
Women aged 40 to 49 are recommended to have biennial mammogram screenings, and annual screenings begin at age 50. Clinical breast exams are recommended for everyone one (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. Women with a family history of breast, ovarian, tubal, or peritoneal cancer should be offered the gene mutation screening for BRCA1 and BRCA2. Those with subsequent positive test results 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
**Recommendation is currently being updated by US Preventive Services Task Force
Colonoscopy at age 50, every ten (10) years OR fecal occult blood test (FOBT) every three years with flexible sigmoidoscopy every five (5) years OR annual FOBT until age 75 years.
Prostate Cancer Screening
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, a digital rectal exam (DRE) is at the provider’s discretion and after an 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
The US Preventive Services Task Force has concluded that the current evidence is insufficient. The balance of the benefits and harms to visual skin by a clinician screening for skin cancer in asymptomatic adults is yet to be determined.
*Diabetes Mellitus Type 2 Screening
**Recommendation is currently being updated by US Preventive Services Task Force.
The USPSTF recommends screening for abnormal blood glucose as part of cardiovascular risk assessment in adults aged 40 to 70 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: 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
**Recommendation is currently being updated by US Preventive Services Task Force
The USPSTF recommends screening for hepatitis C virus (HCV) infection in adults aged 18 to 79.
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 factors may include certain ethnicities, very low BMI, history of fractures, tobacco use, limited exercise, and other chronic diseases.
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, the occupational or living hazard of close quarters, and recent immigrants from a county with a high prevalence of tuberculosis, illicit drug use, compromised immune system, or healthcare workers.
Immunizations: Age & Interval Recommendations
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
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
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.
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
- 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
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.
- 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
- 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.
- Age 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
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.
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).