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Elizabeth M. Whitehorn, Director

Provider Notice issued 12/16/05

Medicare Crossover Invoice – HFS 3797

​To; ​All Enrolled Providers
​Date: ​December 16, 2005
​Re: Medicare Crossover Invoice – HFS 3797​

The department is pleased to announce that, for claims submitted on or after January 1, 2006, two new billing procedures for submitting Medicare Crossover claims will be available.

Direct Data Entry (DDE)

Medicare crossover claims can be submitted through the department’s Medical Electronic Data Interchange, Internet Electronic Claims (MEDI/IEC) System.  This new electronic feature allows you to submit claims directly to the department through your Internet browser software.  No additional hardware or special software is needed.

Electronic claim submission via the Internet is available by registering on the department’s MEDI/IEC System at:

Providers currently registered to submit claims via the MEDI/IEC system will be given a new claim form link titled “Medicare Crossover Invoice.”  Providers not currently registered to submit claims via the MEDI/IEC System may do so by going to the Web site mentioned above.

The MEDI/IEC System is available to enrolled providers and their authorized staff, claim submitting agents and payees.  During the registration process, you will be given access to specific claim formats based upon your enrollment status with the department.  

HFS 3797

In addition to electronic submission, the department has developed a new single page claim form, HFS 3797, Medicare Crossover Invoice.  

The use of the MEDI IEC System or the paper HFS 3797 will eliminate the need to submit the following documents and attachments when billing a crossover claim to the department:

    • DPA 2360 Health Insurance Claim Form

    • HCFA 1500 Health Insurance Claim Form

    • HCFA 1491 Request for Medicare Payment – Ambulance

    • Explanation of Medicare Benefit (EOMB)

    • Medicare Remittance Advice

Attachments required for special processing, such as the DPA 2189, Sterilization Consent Form or the DPA 2432, Split Billing Transmittal, will still be required and must be submitted with a paper HFS 3797.  A facsimile of the new claim form and the billing instructions are attached.  The HFS 3797 should be mailed to the department in a pre‑addressed mailing envelope, Form HFS 824MCR, provided by the department. 

To allow for a transition period, mandatory use of the paper HFS 3797 or electronic submission through MEDI/IEC will not be required until April 1, 2006.  Any Medicare crossover claims on forms other than the HFS 3797 submitted after the 90-day transition period will be returned to the provider.  The introduction of the HFS 3797 does not affect electronic crossover claims received directly through the Medicare intermediary or providers submitting charges on the UB92.

A supply of the HFS 3797 and HFS 824MCR are available and may be requested on our Web site at http://www.illinois.gov/hfs/MedicalProviders/Forms%20Request/Pages/default.aspx or by submitting a DPA 1517, Provider Forms Request or DPA 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. 

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

 

Anne Marie Murphy, Ph.D.

Administrator

Division of Medical Programs