Box 30 must contain the 10digit providers npi not the 12digit provider identification number. Mailing address for hfs 2360 fill out and sign printable. In the hospital outpatient setting, the professional component of laboratory services must be billed under the name and npi of the physician who performed the service, whether or not that physician is salaried. Hfs 652 illinois early intervention program referral fax back form pdf. Nov 1, 2015 form hfs 2360 pdf, health insurance claim form. Hfs issues clarification on modifier 90 for reference labs. Chapter a200 policy and procedures for medical illinois. Appendices forms and instructions illinois department. These forms are in a pdffillable format unless otherwise indicated. Welcome to myhfs the secure web site for the illinois department of healthcare and family services. In february 2015, the state proposed that aces may have an accelerated hfs illinois medicaid expansion greater chicago region. Illinois department of healthcare and family services. Please note that the information on the instructions for hfs 2360, box 30 is incorrect.
This information is organized in the order fields appear on the form hfs 2360, and presented in a boxbybox approach. Form hfs 2360, health insurance claim form, must be used to submit charges for all services provided by the school basedlinked health center. Fqhcs should submit hfs form 2360, health insurance claim form, or hfs form 1443, provider invoice, for paper claims and hipaa transaction 837p should be used for electronic claims. Hfs released a notice that corrects information contained in topic l210. Form hfs2360 is often used in illinois department of healthcare and family services, illinois legal forms and. Priorto june 2016, this estimate did not include all bills at department of human services, or any bills held at department of corrections or department on aging. Start a free trial now to save yourself time and money. The department of healthcare and family services hfs is responsible for the medicaid long term care ltc program for approximately 55,000 eligible residents in 738 nursing facilities. To check status of edi enrollment, please contact medicaid at 8777825565. Finance medicare illinois paper claim form hfs 2360 vs hfs 3797.
Nov 05, 2018 21 posts related to illinois medicaid claim form 2360. Apr 1, 2019 designates healthcare and family services hfs. Providers may use the notice of dhs communitybased services hfs 2653 pdf to document that spenddown is met to the dhs fcrc. For faster turnaroundtime and easier tracking submit your medical prior authorization request via the countycare provider portal. Medicaid number enter the ninedigit number assigned to the individual. The left hand column of the following instructions identifies mandatory and optional. The instructions for preparation of the hfs 2360 can be found in the handbook for providers of encounter clinic services, chapter d200, appendix 1 pdf. Illinois medicaid claim form fill online, printable. Oct 1, 2014 with hfs billing and payment for services, as well as provide pregnant and. Please enter your complete illinois medicaid assigned number. Download download hfs 2360 instructions read online read online hfs 2360 instructions hfs 2378dr hfs 2350 hfs 3797 illinois medicaid overpayment refund form hfs forms hfs 2446b.
Please provide a sheet for each billinggroup provider. This data must be provided to illinicare health in order to be. Download printable form hfs2360 in pdf the latest version applicable for 2020. Appendix a2 for information regarding medicare crossovers. Completion of form hfs 1977 pdf acknowledgment of receipt of hysterectomy information. All services provided during the fqhc visit with the fluoride varnish application the d1206 code should be included on a single claim. Instructions for completion of this claim follow in the order a200a illinois. Technical guidelines for paper claim preparation form hfs 3797, medicare crossover invoice. Effective with dates of service on and after march 1, 20, providers submitting feeforservice claims 837p or hfs 2360 for the following drugs must also identify 340b. The individual is then approved for medicaid and receives a mediplan card. On may 7, 2018, the illinois department of healthcare and family services hfs issued a provider notice that clarifies a new requirement for hospitals to report modifier 90 on certain outpatient claims for reference laboratory services, describes application of the policy to medicaid managed care. Oct 04, 2017 illinois medicaid program advanced cloud technology impact july 1, 2014 should submit replacement claims using procedure code s4993. Mcdd reimbursement effective april 1, 2019 illinois. Jun 05, 2014 the instructions for preparation of the hfs 2360 can be found in the handbook for providers of encounter clinic services, chapter d200, appendix 1 pdf.
No part b medicare benefits may be paid unless this form is received as required by. The mission is to ensure that the ltc services for which the department pays are appropriate for and meet the needs of recipients, meet standards of quality. Medicaid announcement describing how to bill code for. These include links to web sites operated by illinois agencies and officials, other government agencies, nonprofit organizations and private businesses. Prior to december 2017, this estimate included only selected state agencies dhs, aging, hfs, dor, doc and cms. Illinois medicaid program advanced cloud technology impact july 1, 2014 should submit replacement claims using procedure code s4993. Choice of supports and services english version pdf il4621238. Provider specific policies page 3 all providers handbook supplement date. Jan 25, 2015 aarp health insurance plans pdf download medicare replacement pdf download aarp medicarerx plans united healthcare pdf download medicare benefits pdf download. Hfs 2210, or form hfs 2211 with the medicare eomb attached showing the hipaa compliant denial. For more as of january 1, 2019, approximately 76% of illinois medicaid. The hfs 2360 must be used when medicare is primary.
Health plans, illinois medicaid managed care organizations mcos, and the iha, are pleased to. Jul 21, 2016 change to procedure code for billing emergency contraceptive pills ecps. Dec 11, 20 the medicare medicaid alignment initiative mmai is a special managed care program for seniors and persons with disabilities who receive full medicare and medicaid benefits. Hfs notices illinois health and hospital association. Practitioner services appendices table of contents illinois. Mailing instructions follow the claim preparation instructions. Spend down for medicaid illinois medicare information.
If you have any questions about your current benefits or need in person assistance filling out your forms call illinicare health at 8663294701 tty. Medical programs via the webbased system is known as illinois medicaid program. Advanced illinois department of healthcare and family services illinois. Jan 16, 2018 retroactive medicaid coverage by spending down for months prior to the. Hfs appendix s1 2 a sample of the hfs 2360 pdf may be found on the departments web site. Illinois did not always comply with federal medicaid requirements for.
Illinois department of healthcare and family services issued october 2016. Go to apply for and manage your benefits to see how. Appendix s1 technical guidelines for paper claim preparation. Based on the information in the hfs 2653, dhs fcrc staff should mark the individual as spenddown met with no split bill for up to 12 months. All services provided during the fqhc visit with the. Coding and billing revised bright smiles from birth. Hfs 2360 health insurance claim form example only ocr pdf. Hfs 2360, health insurance claim form, must be used to submit. Fill out the health insurance claim form illinois online and print it out for free. Hospitals should use the ffs registered medicaid id correlating to the applicable categories of service cos. Illinois claimed unallowable federal reimbursement for some. November 5, 2018 handbook supplement table of contents section 1. A1 technical guidelines for paper claim preparation form hfs 2360 pdf inquiries regarding coverage of a particular service or billing issues may be directed that administers illinois medical assistance medicaid program, as.
Hospital feeforservice ffs for nonapl billing guide. Medicaidillinois form hfs 2360 this document analyzes the form hfs 2360s relationship to intellect, explaining how the selections on intellects screens complete the form hfs 2360. This web site allows authorized users online access to departmental information on the following hfs programs. Medicaidillinois form hfs 2360 this document analyzes the form hfs 2360 s relationship to intellect, explaining how the selections on intellects screens complete the form hfs 2360.
Form hfs2360 is often used in illinois department of healthcare and family services, illinois legal forms and united states legal forms. Claims submitted to the isaetp must be printed upon a universal billing form the ub04, hfs 2360, or the cms. Nov 1, 2015 a5 completion of form hfs 2189 pdf sterilization consent form a sample of. If you need help renewing your benefits or have any questions call hfs at 18554584945 tty. Tony illinois medicaid redetermination program imrp february 20 update background information in 2012, the illinois legislature passed the saving medicaid access and resources together act called the smart act, for short, designed to save money by streamlining the operations and services of our states medicaid program. The state of illinois home page is a portal with links to other websites.
Agreement for participation in the illinois medical assistance program hfs 14s. Hfs 2360 pdf the department of healthcare and family services health insurance claim form. This information is organized in the order fields appear on the form. Handbook for practitioners rendering medical services illinois.
Illinois medicaid program advanced cloud technology impact. Hfs currently covers services for persons at high risk of exposure to hiv, including truvada, which is currently approved for prevention of preexposure without a prescription or prior approval illinois law and the illinois aids confidentiality act which changed in 2008 permit optout hiv testing as recommended by the cdc. Hfs 2390 pdf the department of healthcare and family services abortion payment. For help filling it out or for translation services, contact your dhs family. Instructions for completion of this claim follow in the order entries appear on the form. Effective with dates of service on and after march 1, 20, providers submitting feeforservice claims 837p or hfs 2360 for the following drugs must also identify 340b purchased drugs by reporting modifier ud. Form dpa 2360 health insurance claim form is to be used to submit. For detailed instructions for completion of the hfs 2360 and a copy of the claim form october 2002 hfs s202 1. Motorized wheelchair evaluation form hfs 3867 pdf nips adjustment form nips hfs 2292 pdf nonemergency transportation fingerprint form hfs 3819 pdf notice of dhs community based services hfs 2653 pdf notification to hfs of illinois medicaid hospice benefit election hfs 1592 pdf.
Health insurance claim form example only hfs 2360 ocr pdf. Il4621201 s medicaid derechos del individuoexoneracion dd servicios. Or fax either the inpatient prior authorization form or outpatient prior authorization form to the following numbers inpatient medical prior authorization form. With illinois medicaid, you and your family can get the care you need to go to school healthy, work hard, and achieve the american dream. Nov 1, 2015 please follow these guidelines in the preparation of paper claims for imaging a sample of the hfs 2360 pdf may be found on the departments web site. Sep 22, 2015 in february 2015, the state proposed that aces may have an accelerated hfs illinois medicaid expansion greater chicago region. A sample of the hfs 2360 pdf may be found on the departments web site. Hfs mailed the calculations and the remittance notices for the fiscal year 2019 inpatient and outpatient. The most secure digital platform to get legally binding, electronically signed documents in just a few seconds. Mmai operates in 21 counties in the greater chicago and central illinois regions. Hfs 458 ltc notice of decision on application for medical assistance mang ltcslf pdf. Handbook for practitioners rendering medical services.
Billingcoding illinois perinatal quality collaborative. Deed form 1 can help you make a professional with regard to quit claim deed form pdf. Medicaid services and submitting claims, a provider must reenroll as a new provider into the. Jul 06, 2016 hospital feeforservice ffs for nonapl billing guide this billing guide is intended for hospitals billing feeforservice ffs nonapl procedures. This method is preferred as it requires no manual override. Hfs 2360 health insurance claim form, single sheet hfs 2360cf health insurance claim form, continuous feed format hfs 3797 medicare crossover invoice single sheet. D1 technical guidelines for paper claim preparation form hfs 2360 pdf. If you want to register to vote, fill out the enclosed illinois voter registration application sbe r19 and give it to your dhs office or your local election official. Fill out, securely sign, print or email your illinois hfs 2360 form instantly with signnow. National drug code billing guidelines provider memorandum. The medicaremedicaid alignment initiative mmai is a special managed care program for seniors and persons with disabilities who receive full medicare and medicaid benefits. Hfs 2360 pdf the department of healthcare and family services health insurance. Medical assistance information for medicaid providers.
The georgia quitclaim deed form 1 can help you make a professional with regard to quit claim deed form pdf. Illinois hfs sexual assault emergency treatment program isaetp. Aarp medicarerx plans united healthcare pdf download medicare benefits pdf download medicare part b pdf download billing for hfs illinois pos 11 pos 22. Download download hfs 2360 instructions read online read online hfs 2360 instructions. Hfs requires form 2360 accompanied by written consent to perform sterilization. The provider information sheet is sent by hfs medicaid to contracted providers on an annual basis and shows current credentialed information such as state license, provider key, payee, etc. Apr 1, 2019 the following are the health care programs provided by hfs. Aarp health insurance plans pdf download medicare replacement pdf download aarp medicarerx plans united healthcare pdf download medicare benefits pdf download. Laboratory for hospital outpatient claims billed on the 837p or hfs 2360 claim formats. Illinois department of public aid 201 south grand avenue east springfield, illinois 627630001 rod r. Jun 06, 2014 the instructions for preparation of the hfs 2360 can be found in the handbook for providers of encounter clinic services, chapter d200, appendix 1 pdf. Fill out, securely sign, print or email your 2360 claim form pdf instantly with signnow. Medicaid number enter the ninedigit number assigned to. Jul 01, 2005 download printable form hfs2360 in pdf the latest version applicable for 2020.
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