Attachment F: Returned Claim Form (pdf)

Returned Claim Form

Early Intervention Central Billing Office
P.O. Box 19485
Springfield, IL 62794-9485

The attached bill s being returned because it does not include complete information as required by EI-CBO. 

Please provide additional details in teh areas as marked below and resubmit the original claim with the corrections made, along with this CBO dated request sheeet to the above address.  Please re-review the entire claim for completeness before resubmission.

Missing / Incomplete / Incorrect Information

  • Date(s) of service
  • Child's 6-digit EI number
  • Child's date of birth
  • Child's address
  • Length of session
  • Provider name
  • Provider address
  • FEIN / Social Security #
  • Place of service code
  • ICD-9 Code
  • Local HCPC / Procedure Code
  • Fee(s) charged for service
  • Enrolled Provider supervising Associate

Other Reason(s) for return

  • Child not known
  • Description of equipment is needed on claim
  • Therapist not known at this location
  • Physician not known
  • DHS billing form no longer accepted.  Use CMS 1500 or UB92 form
  • Only 6 lines of service per claim (in chronological order)
  • Services cannot be paid before they are rendered
  • Illegible claim / provider name
  • Provider not enrolled in EI system
  • Associate level provider not EI credentialed
  • Both providers on claim are EI creditentialed.  Identify provider who actually did services.
  • Discrepancy with EI # / Child's names / Address.  Please verify.
  • Only 1 discipline per claim
  • Other - See CBO Comments

CBO Comments:

[several lines for comments]

Provider Comments

[several lines for comments]

Date Returned to Provider

Processor Initials

7/01/05 MAL/sjm