Form (HFS 2249) is to be used in one of two circumstances:
- to correct any claim for which payment has been made, and the payment was more than or less than the amount which should have been received; or
- to void payment of a claim, which was submitted and paid, for an incorrect procedure code or the incorrect number of days or units. (After the voiding adjustment has been reported on a Remittance Advice, the service can be rebilled with the correct information).
The Payment Adjustment Form is always submitted after the recipient's claim has been processed and has been reported on the Remittance Advice as "Paid" or "Reduced." Several data items on this form must be completed using exact information as shown on the recipient's original claim. These items are included in the specific instructions given below.
When completed, make a copy of the adjustment prior to sending for processing. Submit the form to the following address:
- Illinois Department of Human Services
Division of Alcoholism and Substance Abuse
Harris Building, Harris II
100 South Grand Avenue East, Second Floor
Springfield, Illinois 62762
A copy of the completed adjustment will be returned to the provider with the Document Control Number of the adjustment made. When the adjustment has been processed, the remittance advice will show that the transaction has been completed.
- Item 1 - Document Control Number: Always leave blank.
- Item 2 - Provider Name and Address: Enter the provider name and address exactly as it appears on the Provider Information Sheet.
- Item 3 - Provider Number: Enter the Medicaid provider number exactly as it appears on the Provider Information Sheet.
- Item 4 - Payee: Always enter 1.
- Item 5 - Provider Reference (Optional): Enter the recipient's medical record number or patient control number utilized in your accounting system for identification purposes.
- Item 6 - Voucher Number: Enter the voucher number from the original paid claim as shown on the Remittance Advice.
- Item 7 - Document Control Number: Enter the Document Control Number from the original paid claim as shown on the Remittance Advice.
- Item 8 - Unlabeled: Always leave blank.
- Item 9 - Date of Service: Enter the last paid date of service from the original paid claim.
- Item 10 - Unlabeled: If the form is used to correct an erroneous prior payment, enter the procedure code that was used on the original claim.
- Items 11, 12 and 13 - Recipient Name, Number and Date of Birth: Enter the recipient name and recipient number exactly as it appears on the Remittance Advice. Enter the recipient's date of birth exactly as it was on the original claim submitted.
- Item 14 - Adjustment Type: Always enter 02.
- Items 15 and 16 - Unlabeled: Always leave blank.
- Item 17 - Charges: Enter the amount of the payment which was received as it appears on the Remittance Advice.
- Item 18 - TPL: If the recipient has insurance (third party liability or TPL), enter the three-digit code for the insurance company found in Chapter 100, General Appendix 9. If the adjustment is made for a change in the recipient's spend down amount, enter 906.
- Item 19 - TPL Amount: Enter the amount paid by the recipient's insurance or, if the recipient is subject to spend down requirements, enter the spend down amount the recipient has paid or for which the recipient has unpaid bills.
- Item 20 - Reason Adjustment Requested: Give the reason for which the adjustment is being requested, using as much specificity as possible. Include the name and telephone number of a provider contact person.
- Items 21 and 22 - Provider Signature and Date: The form must be signed and dated by the provider's authorized representative, using the date on which the form was completed.