PM 15-08-11.

  1. (FCRC) Issue Form 2432/2432C for any bill incurred on the date spenddown is met and for which HFS may make payment.

    Issue a Form 2432/2432C even if you don't know if the service is covered, or if the amount at HFS rates is less than the amount needed to meet spenddown.

    Issue Form 2432/2432C no later than 14 calendar days from the date of receipt of the bills which caused spenddown to be met. 

  2. (FCRC) For all medical expenses for which a split bill form is necessary, issue the original Form 2432 to the provider.

    Form 2432/2432C must be attached to the provider billing form for HFS to make payment on a bill for services or items incurred on spenddown met day.

    When completing Form 2432 always complete the entry "IDPA Control Number ____ of ____". Enter the total number of Forms 2432 completed for spenddown met day in the 2nd blank, and the number of each form in the first blank. Such as 1 of 1 if only one form was completed, or 1 of 3, 2 of 4, etc. 

    1. Send a copy to the client.
    2. File a copy in the case record.
  3. (FCRC) Do not issue a split bill form if the client meets spenddown as the result of a bill incurred by a spouse/dependent who does not receive assistance, but who is included in the standard.

    Example: The monthly spenddown is $230 for each month of a January through December enrollment period. The client wants a determination of spenddown met/unmet for January, based on the following bills submitted to the Family Community Resource Center. The bills are listed on HFS 2430ASP as follows: 

    01/01 (Receipt for bill paid on 01/09) $ 30
    01/01 (Remaining unused carryover from bill applied to spenddown in previous month) +15
    Accumulated Charge 45
    Bill for 01/10 Service 90
    Accumulated Charge 135
    Bill for 01/22 Service 102
    Accumulated Charge 237 

    On 01/22 the $230 spenddown has been met. $237 in receipts and bills have been presented to the Family Community Resource Center to apply to January. 01/22 is spenddown met day.

  4. (FCRC) Complete a HFS 2432/2432C for each bill incurred on spenddown met day for which the HFS may make full or partial payment.

    If a bill for a service for which HFS may make payment is incurred on the same day spenddown is met but was not used to meet spenddown, complete HFS 2432/2432C showing no client liability. 

  5. (FCRC) When you learn of a provider who provided a service on spenddown met day that you didn't know about when you completed the first HFS 2432s, complete an additional split bill form. Enter the word "REVISED" immediately above the entry "IDPA Control Number ____ of ____". Enter the new total number of HFS 2432s completed for spenddown met day, in the blanks.

Example: If HFS 2432s were originally submitted and the Family Community Resource Center learns another must be completed, enter "REVISED" and the blanks "1 of 1".

Each item on HFS 2432 must be completed. Once an entry is made it cannot be changed. If an entry is incorrect complete a new form.

If multiple bills are incurred on the same day, the total of which is larger than the enrolled client's spenddown, consider the bills towards spenddown in the required order (see PM 15-08-08).

Example: Spenddown met is determined as follows:

SPENDDOWN =$230
Less: Charges incurred on 03/03 -150
Unmet spenddown =80
Less: Bills incurred on 03/17
Coinsurance -15
Unmet spenddown =65
Acupuncturist Charge -55 (non-covered service)
Unmet spenddown =10
Drug Bill -17
Spenddown is now exceeded by $7

The $17 drug bill is designated as a split bill. In this example, for the drug bill to be paid the FCRC must complete HFS 2432/2432C, showing a spenddown of $10.

HFS would make payment on the drug bill at HFS rates, for all but $10 of the bill, if the provider was approved to participate in the MANG program.

The coinsurance charge and the acupuncturist bill are not split bills because HFS does not pay these bills.

This form must also be completed for any other bill(s) incurred on 03/17 for which payment by HFS is to be made. Do not show a spenddown on any other HFS 2432/2432C for other bills designated to be paid. For these bills enter "NONE" in the box titled, "Less Recipient Liability Amount."