Attachment D - Transportation Billing Form Example (pdf)

DHS Early Intervention
Transportation Billing Form

Illinois Department of Human Services
Central Billing Office
3430 Constitution Dr
Suite 118
P.O. Box 19485
Springfield, IL 62794-9485

Must Complete Entire Form Before Submitting

Child's Name: Child Doe

Child's Addresss: 1234 East Street

City, State, ZIP: Anytown, IL 60066

EI#: 155155

Birth Date: 2 / 24 / 2004

Payee Name: ABC Transport Service

Payee Address: 5678 West Street

City State Zip: Anytown, IL 60066

Payee Tax ID#: 36-4567890

Vehicle License Plate #: ABC123

Textual Version of Table:

  • Must Bill One Date of Service per line in Chronological order and only one discipline of service per billing form:
    • Date of Service: MM/DD/YY
    • Procedure Code
    • POS
    • Departure Address
      • Address
      • Departure Code (D=Medical Services, R=Residence)
      • Departure Time
    • Destination Address
      • Address
      • Departure Code (D=Medical Services, R=Residence)
      • Departure Time
    • Loaded Mileage
      Mileage to and from each location where Early Intervention Services are provided while child is in the vehicle.
    • Charge
  • Billed Charges
  • Total Charges

  • This form can be used to bill for Early Intervention transportation services only.
  • Services must be provided by an enrolled transportation provier or driver employed by the transportation provider
  • Must bill CBO no later than nine (9) months following completion of services.
  • Incomplete billing forms will be returned to the provider

I certify that I provided the services identified above, or a driver employed under my supervision provided the services.

Signature Lines: Name of Enrolled Provider or Transportation Company (Printed)
Date of Signing


Please forward ALL billings and explanations of benefits ertaining to this authorization to:
Illinois Department of Human Services
Central Billing Office
3430 Constitutional Dr
Suite 118
P.O. Box 19485
Springfield, IL 62794-9485
CBO Phone Number 1-800-634-8540

Billing Authorization Information

  • Must have authorization in hand prior to providing billing for Early Intervention services in orderto ensure payment for service.
  • Billings may be submitted to the Central Billing Office by completing the DHS Transportation Billing form.
  • The Central Billing Office requires all provider billings related to this authorization be received no later than nine (9) months following the completion of services.
  • Billings for authorized services must be billed using the Nation Level II HCPCS Procedure Codes.
  • The authorization is limited to the time period, provider, services, supplies or equipment specified on the authorization.
  • The Central Billing Office uses a schedule of allowable fee reimbursement for all authorized services.
  • By accepting the service authorization, the provider agrees not to seek further payment from the child or the child's family for such authorized services beyond the amounts available from the Central Billing Office.
  • By accepting the service authorization, the provider agrees to maintain records which include at a minimum:
    • Client information including name, address and IDPA Recipient identification number an
    • Copy of transportation invoice, including type of vehicle used, license plate number and name of provider

Parental Rights

For Early Intervention parents shall be informed in their native language or normal mode of communication that they have the right to:

  • A timely, multidisciplinary evaluation and assessment
  • Appropriate early intervention services for the child and family if eligibility is determined;
  • Refuse evaluations, assessments and services, and may decline such a service after first accepting it, without jeopardizing other early intervention services;
  • Written prior notice before provider proposes, or refuses, to initiate or change the identification, evaluation or placement of the child, or the provision of services;
  • Confidentiality of personally identifiable information
  • Review and correct records relating to evaluations and assessments, eligibility determinations, development and implementation of Individual Family Service Plans, individual complaints dealing with their child, and any other area under these rules involving records about the child and child's family;
  • Use an advocate in any and all dealings with the early intervention system; and
  • Use administrative and judicial processes to resolve complaints.

State of Illinois Certifications

Affirmative Action / Nondiscrimination: The Provider/Vendor certifies they comply with all Federal and State nondiscriminatory equal opportunity affirmative action orders and regulations. The Provider/Vendor will not engage in discrimination or harassment against any person because of race, color, religion, sex, national origin, ancestry, age, marital status, handicap, unfavorable discharge from the military, or status as a disabled veteran or veteran from the Vietnam era. This certification applies to admission, employment, access to and treatment in the Provider/Vendor programs and activities.

Americans With Disabilities Act (ADA): The Provider/Vendor certifies they are in compliance with Title I through V of the Americans With Disabilities Act signed into law July 26, 1990.

Bribery Clause: The Provider/Vendor certifies that they have not been convicted of bribery or attempting to bribe and officer or employee of the State of Illinois, nor has the Provider/Vendor made an admission of guilt of such conduct which is a matter of record.

Drug Free Workplace Act: The Provider/Vendor certifies that they are in compliance with Public Act 86-1459 and will not engage in the unlawful manufacture, distribution, dispensation, possession, or use of a controlled substance.

Health Care Professionals: The Provider/Vendor certifies they are not involuntarily sanctioned from participating in and/or are not inappropriately being reimbursed under the Title XVII (Medicare) Program, the Title V (Maternal and Child Health) Program or any other section of the Social Securities Act. Health care professionals excluded from programs of federal and state agencies shall also be excluded from participation in this program.

Maintaining of Records: The Provider/Vendor agrees to maintain and make available for a minimum of 6 years after the completion of the services adequate books, records, and supporting documents that support each date of service billed to the DHS/CBO, including daily documentation of services related to the authorization.

Health Insurance Portability and Accountability Act (HIPAA): The Provider/Vendor certifies that they will comply with HIPAA Standards 45 CFR Parts 160, 162, and any additional part that may be finalized in the future where appliance.

The Vendor Certifies that they have:

  1. Not been delinquent in paying a child support order as specified in section 10-65 of the Illinois Administrative Procedure Act (5 ILCS 100/10-65);
  2. Not been in default of an educational loan in accordance with Section 2 of the Education Loan Default Act (5 ILCS 385/2),
  3. Not have served or completed a sentence for a conviction of any of the felonies set for in 225 ILCS 45/25(a) and (b) within the preceding five years (see 30 ILCS 500/50-10); and
  4. Not been indicated as a perpetrator of child abuse or neglect in an investigation by Illinois or another state for at least the previous five years.