The Provider Information Sheet is produced whenever a provider is enrolled in the Illinois Medicaid Management Information System (MMIS). It will also be generated every time there is a change or update to the provider record. This sheet is mailed back to the provider and serves as a record of all the data that appears on the Provider Database.
The following information will appear on the Provider Information Sheet. An explanation of the field follows the field name.
- Provider Key: This number uniquely identifies the provider at HFS. This Medicaid provider number is used for processing claims.
- Provider Name and Address: Name and address of the provider as it appears on the Provider Database.
- Provider Type: A three-digit code and the corresponding narrative indicating the provider's classification.
- Organization Type: A two-digit code and the corresponding narrative indicating the legal structure of the environment, in which the provider primarily performs services. For A/SA treatment providers, code 01 will always be used.
- Enrollment Status: A one-digit code and the corresponding narrative indicating whether or not the provider is currently an active participant in the Illinois Medical Assistance Program. The possible codes are:
B = Active
I = Inactive
R = Rejected
- Begin (Enrollment Status): Date indicating when the provider was most recently enrolled in Illinois MMIS.
- End (Enrollment Status): Date indicating the end of the provider's most current enrollment period. If currently enrolled, the word "active" will be shown.
- Exception Indicator: A one-digit code and the corresponding narrative indicating that the provider claims will be reviewed manually prior to payment. The possible codes are:
- Exception Requested by Audits
- Pseudo Number Abuse
- No Exception
- Exception Requested by Provider Services
- Tax Levy
- Begin (Exception Indicator): Date indicating the first day the provider's claims are to be manually reviewed.
- End (Exception Indicator): Date indicating the last day the provider's claims are to be manually reviewed.
- Certificate/License Number: A unique number identifying the certificate issued authorizing a provider to become enrolled in the Illinois Medicaid Program.
- Ending (of Certificate/License Number): Date indicating when the certificate will expire.
- County: The three-digit code identifying the county, in which the provider maintains its primary office location. It is also used to identify a state if the provider's primary office location is outside of Illinois.
- DEA # (Drug Enforcement Agency Number): A number assigned by the Federal Drug Enforcement Administration as a means of identifying practitioners or other prescribers and dispensers of drugs and controlled substances.
- Telephone Number: The telephone number of the provider's primary office.
Last Transaction: A three-digit code indicating the last type of update made to the provider's record.
The possible codes are:
ADD = Add
CHG = Change
DEL = Delete
COR = Correct
- As-of (Last Transaction): Date of last update made to Department records.
- Medicare Number: The number assigned to the provider by Medicare. (This does not apply to A/SA treatment providers at this time).
Facility Control/Affiliation: A two-digit code and the corresponding narrative indicating the ownership of the health and medical services facilities.
The possible codes are:
01 = Public (State, County, Federal)
02 = Charitable or Religious Organization
03 = Proprietary (Privately owned)
04 = Other
- Social Security Number: Does not apply for A/SA providers.
- Fiscal Year End: Date on which the provider's fiscal year ends.
- Pharmacy Affiliation: Does not apply to A/SA treatment providers.
- Eligibility Category of Service: A three-digit code and the corresponding narrative indicating the types of service a provider is authorized to render to a recipient. The code for A/SA services is 035.
- Begin-Elig-End: Begin and end dates during which the provider has been approved to render services.
Termination Reason: A one-digit code and the corresponding narrative indicating the reason for a provider's termination of eligibility to render a service to a recipient.
The possible codes are:
- 1 = Voluntary Termination
- 2 = Termination by HFS
- 3 = License Decertification
- 4 = Death
- 5 = Financial Disclosure Not on File
- 6 = Medicare Termination
- 7 = Closed Due to Inactivity
- 8 = Other
- 9 = Dis-enrolled
- R = Closed due to expired license
- Payee: List of payees authorized to receive warrants on behalf of the provider.
- Payee Name: The name of the person or entities designated to receive payment on behalf of the provider.
- Payee Street: The street of the mailing address of the designated payee.
- Payee City: The city of the mailing address of the designated payee.
- Payee State: The two-digit postal abbreviation of the state of the mailing address of the designated payee.
- Payee Zip: The zip code of the mailing address of the designated payee.
- Payee ID Number: Sixteen-digit identification number assigned to each payee to whom warrants may be issued. This is not the Medicaid provider number
- Effective Date: Date indicating the effective date when payment can be made to the payee on behalf of the provider.
If, after review, the provider notes that the Provider Information Sheet does not reflect accurate data, line out the error and note the correct information in the space below the error and return the document to DASA to the attention of the DASA Medicaid Liaison. If all the information on the sheet is correct, the provider is to keep the document for reference when completing Medicaid adjustment forms. (HFS 2249)