Coventry Total Care (HMO): A Partnership with SwedishAmerican is a health maintenance
organization (HMO) plan.
Choosing a primary care physician (PCP)
Total Care members must choose a PCP to manage their health care. The PCP handles referrals to specialists in the Total
Care network. You can find a list of Total Care providers at www.chcillinois.com.
How to submit a specialist referral
Total Care members need referrals to see specialists, except chiropractors, OB/Gyns and physical therapists.
Use directprovider.com to submit the referral request.
Where to file a prior authorization request
Total Care plans use the Coventry Health Care of Illinois, Inc., standard prior authorization list. Prior authorization requests
can be done at directprovider.com. You can also call us at 1-866-557-8748.
How to verify network providers
You can find network providers at www.chcillinois.com. Click on “Find a Doctor” at the top of the page.
Claims address
Provider hotline
Electronic payor ID
PO Box 7141
1-800-562-579225133
London, KY 40742-7141
8 a.m. to 6 p.m. CT, Monday–Friday
80.02.800.1-SA2 (1/15)
Frequently asked questions
Q:When are referrals required?
A: When members need to see specialists, except chiropractors, physical therapists and OB/Gyns.
Q:Do members have out-of-network coverage?
A: No, unless it’s an emergency.
Q:What’s covered when a PCP refers their patient to a specialist?
A:As long as a PCP submits an in-network referral for a specialist, the specialist may order or perform whatever services he or she thinks medically necessary. Prior authorization guidelines apply. The specialist must get prior approval for any services that require prior authorization.
Q:How many specialist visits are covered with each referral?
A: Typically, a referral allows for 12 visits in a 12-month period. A PCP can request fewer visits or the same amount of visits over a shorter period of time.
Q:Can a member receive services from a physician in the same medical group if the
referral is for a different physician?
A:Yes. Claims are based on the tax ID number and specialty type. If the member needs to see a different type of specialist
in the group, their PCP must issue a new referral.
Q:Can a specialist refer a member to another specialist?
A: No. If the specialist needs to refer the member to another specialist, they must tell the member’s PCP. The PCP’s office
will confirm the specialist is in the Total Care network and issue a referral.
Q.How can a member change their PCP?
A. Members should call the number on the back of their ID card. Once the change has been processed, the member will
receive a new ID card that shows the name and phone number of their new PCP.
Q.Where is Coventry Total Care (HMO): A Partnership with SwedishAmerican
available?
A. This plan is available in Boone and Winnebago counties.
Q.What if a member needs to see a specialist that isn’t in the Total Care network?
A. The PCP should call Coventry’s prior authorization department. In certain circumstances, Coventry may allow medically
necessary services from out-of-network providers. These services will be covered at the in-network rate.
Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance
Company, Coventry Health and Life Insurance Company and their affiliates (Aetna).
80.02.800.1-SA2 (1/15)