Illinois Administrative Code
Title 89 - SOCIAL SERVICES
Part 140 - MEDICAL PAYMENT
Subpart B - MEDICAL PROVIDER PARTICIPATION
Section 140.20 - Submittal of Claims
Universal Citation: 89 IL Admin Code ยง 140.20
Current through Register Vol. 48, No. 38, September 20, 2024
a) When claims for payment are submitted to the Department, providers shall:
1) Use Department designated billing forms or
electronic format for submittal of charges; and
2) Certify that:
A) They have personally rendered the services
and provided the items for which charges are being made;
B) Payment has not been received, or that
only partial payment has been received;
C) The charge made for each item constitutes
the complete charge;
D) They have
not, and will not, accept additional payment for any item from any person or
persons;
E) They will not make
additional charges to, nor accept additional payment from, any persons if the
charges they present are reduced by the Department to conform to Department
standards; and
F) Starting June 1,
2019, in the case of providers of medical equipment, supplies, prosthetic
devices and orthotic devices, the provider is accredited by a healthcare
accrediting body approved by the federal Centers for Medicare and Medicaid
Services and recognized by the Department under Section
140.475(g).
b) Statement of Certification
1) All billing statements shall
contain a certification statement that must remain unaltered, and must be
legibly signed and dated in ink by the provider, his or her designated
alternate payee, or his or her authorized representative. A rubber stamp or
facsimile signature is not acceptable.
2) An "authorized representative" may only be
a trusted employee over whom the provider has direct supervision on a daily
basis and who is personally responsible on a daily basis to the provider. The
representative must be specifically designated and must sign the provider's
name and his or her own initials on each certification statement.
3) An alternate payee must be specifically
designated by the provider and must sign the provider's name and alternate
payee's authorized representative's initials on each certification
statement.
c) Effective July 1, 2012, to be eligible for payment consideration, a provider's vendor-payment claim or bill, either as an initial or resubmitted claim following prior rejection, that can be processed without obtaining additional information from the provider of the service or from a third party, must be received by the Department, or its fiscal intermediary, no later than 180 days after the date on which medical goods or services were provided, with the following exceptions:
1) The Department must
receive a claim after disposition by Medicare or its fiscal intermediary no
later than 24 months after the date on which medical goods or services were
provided.
2) In the case of a
provider whose enrollment is in process by the Department, the 180-day period
shall not begin until the date on the written notice from the Department that
the provider enrollment is complete.
3) In the case of errors attributable to the
Department or any of its claims processing intermediaries that result in an
inability to receive, process or adjudicate a claim, the 180-day period shall
not begin until the provider has been notified of the error.
4) In the case of a provider for whom the
Department initiates the monthly billing process.
5) For claims for rendered during a period
for which a recipient received retroactive eligibility, claims must be filed
within 180 days after the Department determines the applicant is
eligible.
6) For claims for which
the Department is not the primary payer, claims must be submitted to the
Department within 180 days after the final adjudication by the primary payer.
A) For purpose of this subsection (c)(6), a
primary payer is a payer that can reasonably be expected to make payments
within 120 days after the date of service; for example, other medical insurance
or a group health plan, when the patient is the insured party. Primary payer
does not include payers who are not reasonably expected to pay within 120 days;
for example, liability insurance and workers' compensation, when the patient is
not the insured party.
B) During
the 180 day period beginning November 15, 2014, providers may submit claims and
request a time override from the Department for claims with dates of service on
and after July 1, 2012 not filed because of the provider's belief that it could
file after final adjudication by an insurer when the patient was not the
insured party. A provider asking for such a time override shall also provide a
copy of the request for time override to the Department's Bureau of
Collections, with a written notification to the Bureau indicating the names and
addresses of other parties, insurers or attorneys involved in attempting to
recover, defend or settle possible damages to the patient that resulted in the
services provided. Failure to provide the required information to the Bureau
shall result in a denial of the request for time override.
7) In the case of long term care facilities,
admission documents shall be submitted as provided in Section
140.513.
Confirmation numbers assigned to an accepted transaction shall be retained by a
facility to verify timely submittal. Once an admission transaction has been
completed, the Department will generate a monthly billing statement (remittance
advice) for the services rendered to the admitted Medicaid eligible resident
from date of admission through date of discharge. Any disputes regarding
payment for services provided from the date of admission through date of
completion of the admission transaction must be submitted to the Department for
Payment Review Request (HFS Form 3725) no later than 180 days after the date of
completion of the admission transaction. For any disputes regarding payment for
services rendered after the date of completion of the admission transaction,
the Payment Review Request must be submitted to the Department within 180 days
after the:
A) date of the remittance advice
that initially shows the adjudication for the date or dates of service that are
disputed;
B) date of the remittance
advice that rejects a previously adjudicated claim, if rejection is the basis
for the disputed payment; or
C)
date of the remittance advice that adjusts a previously adjudicated claim, if
the adjustment is the basis for the disputed payment.
8) For hospital inpatient claims, the 180
days is measured from the date of discharge.
9) Per Public Act 98-104, in the case of a
provider operated by a unit of local government with a population exceeding
3,000,000, when local government funds finance federal participation for claims
payment, a claim must be received by the Department or its fiscal intermediary
no later than one year after the date on which medical goods or services were
provided.
d) Claims that are not submitted and received in compliance with the foregoing requirements will not be eligible for payment under the Department's Medical Assistance Program, and the State shall have no liability for payment of the claim.
Disclaimer: These regulations may not be the most recent version. Illinois may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
