For FCRC use only. Place an X in this box when correcting a past segment with new information.
When information must be corrected for a past segment, 2 transactions must be processed.
Example: MMIS LTC system shows the current patient credit segment has an effective date of 01/01/97 and the end date is open. The FCRC finds a correction of the patient credit is required for the period 06/01/96 through 12/31/96. The
MMIS LTC system shows a past segment covers the period 01/01/96 through 12/31/96. The 2 transactions are:
Complete Form 2449 to correct the end date of the past segment 01/01/96 through 12/31/96. Put an X in Item 6 - Correction. Line through the information in Item 24 - Income Beginning Date and print 01/01/96 above the old entry. Enter 05/31/96 in Item
25 - Income End Date. Enter the appropriate patient credit amount for this past segment under Item 26 - Amount. This corrects the end date of this segment. When the first transaction is completed, the new information (patient credit) can be entered
immediately into the system as the 2nd transaction.
Immediately complete a 2nd Form 2449 for an Add Action to enter the new information and create a past segment for the new information. Enter an X in Item 4 - Add. Line through the information in Item 24 - Income Beginning Date. Print 06/01/96 above
the old entry. Enter 12/31/96 under Item 25 - Income End Date. Place the new patient credit amount for this past segment in Item 26 - Amount. This enters the new information and creates a past patient credit segment for the period 06/01/96 through
12/31/96. An adjustment of a future payment to the facility is centrally processed.
When information must be corrected and the segment to be corrected remains unchanged, only a Correction Action is processed. For example, using the previous example it is found the level of care must be corrected for the entire period
covered by this past segment. Complete Form 2449 and enter an X in Item 6 - Correction. Line through the information in Item 28 - Level of Care Effective Date. Print 01/01/96 above the old entry. Enter 12/31/96 in Item 29 - Level of Care End Date. Line
through the information in Item 30 - Category of Service and print the 2-digit code for the specific category of service above the old entry.
NOTE: Items 16, 17, 20, 21, and 22 can only be updated centrally using Form 552. Items 18, 19, and 23 cannot be changed by the FCRC.
*Private facility only
**State institution entered only by DHS
***Private facility or state institution.
Illinois Department of Human ServicesJB Pritzker, Governor · Grace B. Hou, Secretary
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