Provider Notice issued 11/16/05

To: Participating Local Education Agencies

Date: November 16, 2005

Re: Revision of the DPA 1443, Provider Invoice

The purpose of this bulletin is to announce a revised claim form, DPA 1443 (R-4-04), Provider Invoice. The claim form has been revised to accommodate various processing mandates resulting from the federal Health Insurance Portability and Accountability Act (HIPAA). Effective October 1, 2005, providers may begin submitting claims to the department on the revised DPA 1443. To allow for a transition period, mandatory use of the revised form will not be required until January 1, 2006. All DPA 1443 (R-1-91) claims submitted after January 1, 2006, will be returned to the provider.

To reduce copying and mailing cost, the department may not always include hardcopies of attachments referenced in notices and bulletins. Web site links are identified so providers may view and print the material from the Internet.

A facsimile of the revised claim form and the billing instructions referenced in this provider bulletin have been added to the Handbook for Local Education Agencies, Chapter U-200 and are available on the department’s Web site at: <http://www.hfs.illinois.gov/handbooks/ >. If you do not have access to the Internet, or need a paper copy, printed copies are available upon written request. You need to specify a physical street address to ensure delivery. Submit your written request or fax to:

Healthcare and Family Services
Provider Participation Unit
Post Office Box 19114
Springfield, Illinois 62794-9114
Fax Number: 217-557-8800
E-mail: HFSwebmaster@illinois.gov

A supply of the DPA 1443 (both R-1-91 and R-4-04) are available and may be requested on our Web site http://www.hfs.illinois.gov/forms/ or by submitting a 1517 Provider Forms Request or 1517A, Provider Forms Request (only for the following Illinois Counties – Cook, DuPage, Kane, Kankakee, Lake, Will and Winnebago) as explained in Chapter 100, General Appendix 10. When ordering the 1443 form, please indicate the revision date following the form number, i.e., DPA 1443 (R-4-04) or DPA 1443 (R-1-91).

As you may be aware, effective July 1, the name of the Department of Public Aid (DPA) changed to Healthcare and Family Services (HFS). You will see the new name on forms, letters and the Internet. Either version of documents should be considered official regardless of the name they bear.

The DPA 1443 (R-4-04) is currently being revised to reflect the new agency name. The form control number for this form will be HFS 1443 (R-7-05). However, until existing form supplies are exhausted, we will continue to use the DPA 1443 (R-4-04). It is anticipated that the HFS 1443 (R-7-05) will become available during the transition period.

• HFS’s programs, staff, office locations, mailing addresses and phone numbers remain the same as DPA’s. We believe our new name more clearly reflects our mission of service to the State of Illinois including providing access to health care for over two million Illinoisans. We deeply appreciate your participation in our programs and we hope this change poses no inconvenience for you.

Providers wishing to receive e-mail notification, when new provider information is posted by the department, may register at the following HFS Web site at:

                                                    http://www.hfs.illinois.gov/provrel

If you have questions regarding this notice, please contact the Bureau of Comprehensive Health Services at 1-877-782-5565.

INSTRUCTIONS FOR UPDATING HANDBOOK

Appendix U-1 – Technical Guidelines for Paper Claim Preparation, Form DPA 1443 (HFS 1443), Provider Invoice

Remove pages July 2001 IDPA Appendix U-1 (1-8) and insert new pages September 2005 HFS Appendix U-1 (1-8)

Appendix U-1a – Reduced Facsimile of DPA 1443, Provider Invoice

Remove pages July 2001 IDPA Appendix U-1a (1-2) and insert revised claim form, DPA 1443 (R-4-04).

Appendix U-1 attachments (pdf)