1 - Doc. Control No. For Central Office use only. This is the unique number assigned to each Form 2449.
2 - Late Change Not for FCRC use.
3 - Cycle Not for FCRC use.

Section A - Transaction Information

4 - Add For FCRC use only. Enter an X in this box if new information (new income or level of care) is added to a segment. This action results in adding a new income or level of care segment and automatically closes the past segment. For example, MMIS LTC system indicates current patient credit data has an effective date of 11/01/96 and the end date is open. An increase in the client's monthly countable income is effective 01/01/97. Complete the most current Form 2449 and enter an X in Item 4 Add of Section A. Under Section C, Item 24 Income Beginning Date, line through the information and print in 01/01/97 above the old entry. Do not enter an income end date in Item 25. This add action creates a new current patient credit segment and automatically enters an end date for the past segment of 12/31/96.
5 - Discharge For FCRC use only. If the FCRC checked the Discharge box on the previous Form 2449, an entry will not appear in this box as a result of Central Office action. An entry is made by the FCRC when a discharge action is processed.
6 - Correction

For FCRC use only. Place an X in this box when correcting a past segment with new information.

When information must be corrected for a past segment, 2 transactions must be processed.

Example: MMIS LTC system shows the current patient credit segment has an effective date of 01/01/97 and the end date is open. The FCRC finds a correction of the patient credit is required for the period 06/01/96 through 12/31/96. The MMIS LTC system shows a past segment covers the period 01/01/96 through 12/31/96. The 2 transactions are:

Complete Form 2449 to correct the end date of the past segment 01/01/96 through 12/31/96. Put an X in Item 6 - Correction. Line through the information in Item 24 - Income Beginning Date and print 01/01/96 above the old entry. Enter 05/31/96 in Item 25 - Income End Date. Enter the appropriate patient credit amount for this past segment under Item 26 - Amount. This corrects the end date of this segment. When the first transaction is completed, the new information (patient credit) can be entered immediately into the system as the 2nd transaction.

Immediately complete a 2nd Form 2449 for an Add Action to enter the new information and create a past segment for the new information. Enter an X in Item 4 - Add. Line through the information in Item 24 - Income Beginning Date. Print 06/01/96 above the old entry. Enter 12/31/96 under Item 25 - Income End Date. Place the new patient credit amount for this past segment in Item 26 - Amount. This enters the new information and creates a past patient credit segment for the period 06/01/96 through 12/31/96. An adjustment of a future payment to the facility is centrally processed.

When information must be corrected and the segment to be corrected remains unchanged, only a Correction Action is processed. For example, using the previous example it is found the level of care must be corrected for the entire period covered by this past segment. Complete Form 2449 and enter an X in Item 6 - Correction. Line through the information in Item 28 - Level of Care Effective Date. Print 01/01/96 above the old entry. Enter 12/31/96 in Item 29 - Level of Care End Date. Line through the information in Item 30 - Category of Service and print the 2-digit code for the specific category of service above the old entry.

7 - Discharge Date Date (MM/DD/YY) client is discharged from the facility. This date cannot be changed.
8 - Discharge Dest. Enter the 2-digit code showing the discharge destination of the client. This code cannot be changed.
D1 - Death
D2 - Returned Home
D3 - Transferred to another Facility
D4 - Admitted to General Hospital
D5 - Transferred to a State Operated Facility
D6 - Left the State
D7 - Left the County
D8 - Unknown
D9 - Other
D0 - Receiving Community Integrated Living Arrangement (CILA) Services
DS - Transferred from a Long Term Care Facility to a Supportive Living Facility
9 - Item 9 -12, 13 or 14 Enter an X in this box if information about the Submittal Number, Caseload, or Caseworker ID Number in Section A requires an Add action.
10 - Income For FCRC use only. An entry will not appear in this item as a result of Central Office action. If the income information currently appearing in Section C is incorrect and an Add or Correction action is required, enter an X in this box.
11 - Care For FCRC use only. An entry will not appear in this item as a result of Central Office action. If the level of care information appearing in Section D is incorrect and an Add or Correction action is required, enter an X in this box.
12 - Submittal No. If an Add action is necessary, line through the printed information. Enter a 3-digit number. Enter the last digit of the current year in the first position. Enter the number of Forms 2449 submitted for the client in the calendar year in the 2nd and 3rd positions. For example, the 3rd Form 2449 processed in 1996 is numbered 603. The 17th Form 2449 would be numbered 617.
13 - Caseload No. If an Add action is necessary to revise the caseload number, line through the printed information. Enter the caseload number from Form 552.
14 - Caseworker I.D. Shows the 9-digit number assigned to the caseworker handling the case (the same number used to report REDEs on Form 552). If an Add action is necessary to revise the caseworker ID number, line through the printed information. Enter the caseworker ID number from Form 552.
15 - Transaction Date For FCRC use only. An entry will not appear in this item as a result of Central Office action. If a transaction is necessary, enter the date Form 2449 is completed by the caseworker.

Section B - General Information

NOTE: Items 16, 17, 20, 21, and 22 can only be updated centrally using Form 552. Items 18, 19, and 23 cannot be changed by the FCRC.

16 - Client Name Name of client.
17 - Client Number The client's 9-digit number from Item 60 of HFS 552.
18 - Admission Date Date client first became eligible for payment of care in the facility during the client's current stay.
19 - Last Action Central Office process date of the last transaction made by the FCRC to the LTC Recipient Data Base.
20 - Case I.D. No. Case number from Item 1 of HFS 552.
21 - Client Birthdate Client birthdate from Item 61 of HFS 552.
22 - SSN Client SSN from Item 75 of HFS 552.
23 - Last Bill Date For Central Office use only. This is the end date shown on the last prepayment report generated. This date is either the last day of the billing period or the day of discharge if the client was discharged before the last day of the billing period.

Section C - Income (Credit) Information

24 - Income Begin Date If an Add or Correction action is required, line through the printed information. Enter the first day of the billing period affected by the transaction. Income received during the calendar month is considered available for the entire billing period.
25 - Income End Date If an Add or Correction action is required, enter the last day of the billing period affected by the correction or entry of information. End dates are only entered when correcting or entering information into a segment.
26 - Amount If an Add or Correction action is required, line through the printed information. Enter the patient credit amount available to apply towards the cost of care during the current month's billing period or affected transaction.
27 - Central Office Use Only Control numbers for Central Office use only.

Section D - Need for Care Information

28 - Level of Care Eff. Date If an Add or Correction action is required, line through the printed information. Enter the first day of the revised level of care above the old entry.
29 - Level of Care End Date If an Add or Correction action is required, enter the last day affected by the correction or entry of information. End dates are only entered when correcting or entering information into a segment.
30 - Category of Service If an Add or Correction action is required, line through the printed information. Enter the 2-digit code that describes the specific category of service (COS).
*38 Exceptional Care (Central Office use only)
*65 Full Medicare Coverage
***70 Skilled (SNF)
***71 Intermediate (ICF)
*72 Medicare Coinsurance
***73 Intermediate/MR (ICF/MR)
***74 Intermediate/MR (SNF/PED)
*76 Intermediate/MR-SLC (ICF/MR/SLC)
**77 Psychiatric, Age 65 and Over
**78 Psychiatric, Under Age 21
**79 Psychiatric, One Month Only (Age 22 - 64)
*87 Supportive Living Facility (SLF)
31 - Central Office Use Only Control number for Central Office use only.

*Private facility only

**State institution entered only by DHS

***Private facility or state institution.

Section E - Provider Information

32 - Provide Ref. An entry in this box is not required. The reference code (up to 10 characters) is shown if one was entered on HFS 2299 or HFS 2449.
33 - Provider I.D. 12-digit number assigned by HFS.
34 - County 3-digit code identifying the county where the facility is located. It is also used to identify a state if the facility is outside Illinois. HFS 2449 is mailed to the FCRC serving the county shown even if the client's case number shows a different county. However, if the client is in a facility outside Illinois, HFS 2449 is mailed to the county identified in the client's case number.
35 - Provider Provider name and address as it appears on the Provider Information Sheet.
36 - Signature of Caseworker/Date For FCRC use only. Central Office will not make an entry in this item. The form is signed and dated by the caseworker before it is submitted to the Financial Unit for terminal entry.
37 - Approval Signature/Date For FCRC use only. Central Office will not make an entry in this item. If FCRC supervisory approval is required for submittal of this form, it is signed and dated before it is submitted to the Financial Unit for terminal entry.
38 - County No. For FCRC use only. 3-digit code used for identifying the county of origin for the update submission. Central Office will not make an entry in this item. HFS 2449 will be mailed to the code county shown in Item 34.
39 - Caseworker Comments For FCRC use only. Central Office will not make an entry in this item. This section may be used by the caseworker to write notes to the facility and/or to write reminders for future changes, etc.