Medical Benefits, All Kids and Family Care Billing Requirements
All provider sites and services eligible for the Medical Benefits, All Kids and Family Care reimbursement must be certified by DHS/DASA and enrolled with the Illinois Department of Healthcare and Family Services. The certification must specify which services are for adult or youth. Certification is granted by DASA according to criteria specified in Part 2090.
Each Medical Benefits, All Kids and Family Care certified provider must enroll each site with the Illinois Department of Healthcare and Family Services (HFS) prior to billing.
- All services at one certified site should be enrolled under one provider number. As such, reimbursement is linked to the enrollment number and all reimbursement for all services at this site are contained on one voucher and one remittance advice.
In order to enroll, the provider must complete an enrollment package that is supplied at the time of certification. Upon completion, the enrollment package and a copy of the provider's certification should be returned to DASA. Once the enrollment package is reviewed and accepted by DASA, it is forwarded to HFS with a memo indicating the certified procedure codes and corresponding rates.
In the event a provider requests to relocate an enrolled site, the following information will be required by DASA:
- A copy of the revised DASA license/certificate;
- Address of the previous site; and
- Unit and program numbers involved in the relocation.
Enrollment Certification - Provider Information Sheet
Upon enrollment, HFS will send the provider a "Provider Information Sheet," which lists all data carried on HFS's computer files relative to enrollment. The provider should review this information for accuracy immediately upon receipt, especially the provider name and address. For an explanation of all entries on the form, see Appendix A. This information must be kept current and the provider and HFS share this responsibility.
- Provider Responsibility: Information contained on the Provider Information Sheet is the same information which is carried on HFS files. Each time the provider receives a Provider Information Sheet, it is to be reviewed carefully for accuracy.
- Procedure: The provider should enter the correct data in the space below the error and forward the corrected Provider Information Sheet to:
Illinois Department of Human Services
Division of Alcoholism and Substance Abuse
Attention: Medicaid Liaison
Harris Building, Harris II
100 South Grand Avenue East, Second Floor
Springfield, Illinois 62762
Failure of a provider to properly notify the Department of corrections and/or changes maycause an interruption in participation and a delay in payments.
- HFS Responsibility: Whenever there is a change in a provider's enrollment status, an updated Provider Information Sheet will be generated and sent to the provider indicating the change and the effective date.
Providers should ensure that they are billing only for covered services or for those services identified in their award agreement (contract) with DASA.
Diagnosis and Procedure Codes
All claims require specific procedure codes and at least one diagnosis code as listed in the International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM). If the patient is identified as a Mentally Ill/Substance Abuse (MISA) patient, one of the diagnosis codes must relate to MENTAL HEALTH.
Service Data Reporting (Billing)
Billing is accomplished electronically utilizing the Department's Automated Reporting and Tracking System (DARTS). Appropriate software containing this system is provided free of charge. A flow chart outlining the steps in the billing process is included with this manual as Appendix B.
Providers may report DARTS and third party service data on a weekly basis but must report data at least monthly. Providers shall also report any other data so requested by DASA by the prescribed time lines. The preferred method of reporting service data is through software supplied by the Department. The Department assumes no responsibility for late, incomplete or inaccurate data produced by any software.
DASA may conduct random reviews to determine accuracy of provider's service data. The provider shall be able to verify data entries upon request.
The provider agrees to notify DASA immediately through a written request to the Help Desk at: DHS.DASAHELP@ILLINOIS.GOV upon discovery of any problem relative to the submission of any required service or financial data.
All services submitted for payment will appear on a DHS accepted/rejected report. All rejected services will have an error message associated with the rejection. These reports should be reviewed and reconciled upon receipt.
Services submitted for reimbursement can also be rejected during processing at HFS. In these instances, rejections are identified on a remittance advice with an error code and a descriptive error message.
In all instances, if an error occurs and the service can be rebilled, the service should be resubmitted utilizing DARTS. Providers should remember that services must be resubmitted in a timely manner.
If an adjustment is necessary to a paid claim, it is necessary to complete a HFS Hospital Adjustment form 2249. Instructions for completion are contained in Appendix C. A specific listing of error codes and procedures are specified in Appendix D.
Late Payment/Services Submission
DASA has two established billing periods:
- Medicaid Funds: Medicaid funds can be paid if accepted for payment and processed within 12 months of the date of service and if the bill does not exceed the established fiscal year obligation.
- All Other DASA Funds: Any other DASA funds can be paid if they are delivered within the applicable state fiscal year, accepted for payment before annually established dates relative to the end of the lapse period and do not exceed the established fiscal year amount of funding contained in the contract.
Payment or Acceptance of Services Beyond Established Billing Periods:
- Requests for payment or service acceptance beyond established billing periods are allowable if the delay in submission was due to DASA or Healthcare and Family Services (HFS) processing.
- Requests for service acceptance or reimbursement from DASA funds other than Medicaid may only be submitted for the prior state fiscal year. Requests for reimbursement from Medicaid may only be submitted up to two years from the date of service. All requests shall be in writing and include the reason the established billing period was exceeded.Supporting documentation must be attached. All requests must also adhere to the conditions specified in the DASA contract, applicable manuals and/or letter of agreementor memorandum of understanding. If the request is for reimbursement from a federal project fund, it must reference the federal grant fiscal year funding as specified in the DASA contract. All other requests for reimbursement shall be for the same type of program funds identified in the DASA contract.
If the request is denied, it will be for one of the following reasons:
- It is determined that the delay in submission is not the fault of DASA or HFS.
- Insufficient funds to satisfy the request in the specific project or program area.
- No availability of funds within DASA's appropriation authority.
If the request is approved, DASA will apply the appropriate service credit or approve the services for reimbursement from the Illinois Court of Claims. All such approvals are subject to on-site and/or electronic audit. All requests will be responded to in writing and will specify the reason for the denial or acceptance.