Provider Notice issued 09/19/14

Ambulance Quantities and Rate Adjustments

Illinois Administrative Rules at 89 Adm. Code 140.492 authorized an increase in rates for certain ambulance services effective July 1, 2013. The department completed the system programming necessary to implement the rate increase, and began paying claims at the increased rates beginning with claims received on and after April 10, 2014. On June 16, 2014, the department initiated systematic adjustments to certain previously paid claims with dates of service on and after July 1, 2013 that were not paid at the increased rate when processed.

In the process of researching the claims subject to adjustment, an overpayment was found to have been paid on mileage code, A0425 in certain circumstances. The department is continuing to research the issue. Two problems with processing claims have been identified:

• Some paper claims that were billed with a decimal were not read accurately by the department’s scanner. For example, a claim billed with a quantity of 67.3 miles was read by the scanner as 673 miles. Per the instructions on how to complete the HFS 2209 (pdf), Transportation Invoice, providers should round up to the nearest mile when billing miles. Decimals should not be used when billing. The system has now been programmed to require manual review any time more than one digit is reported in the total loaded miles field on a paper claim.

• Inaccurate miles were reported on emergency claims that did not require prior approval. HFS reminds providers who use a billing vendor that miles are reported in CR106 with a qualifier of DH. If loop 2300, CR106 is populated, the quantity will be applied to each service line including the base rate unless overridden at the line level, loop 2400. The base rate should always be a quantity of one at the service line level.

The department is processing the systematic adjustments in batches. The first batch of adjustments includes:

• All emergency claims, category of service 50, billed with quantities less than 10 miles

• All emergency claims that were billed electronically with quantities between 10-99 miles

• All rotary helicopter claims, category of service 50

All other claims will be adjusted after they have been reviewed. Providers should access the System Issues page for continuing updates on the adjustments as the department will not be issuing additional notices.

It is the provider’s responsibility to ensure claims are billed correctly and that the payment received is accurate.

If previously paid claims must be adjusted, the department encourages providers to utilize the 837P void/re-bill process through MEDI or through a vendor. This is a one-step process for voiding a previously paid claim and replacing the original claim. If a void/re-bill is submitted within 12 months from the original paid voucher date, a timely filing override will not be required. Electronic void/re-bills can be processed whether the original paid claim was billed on paper or electronically.

Providers can also complete a paper HFS Form 2292, Adjustment NIPS, to void a paid service or claim. After the void has been processed, a paper 2209, Transportation Invoice, must be completed within 90 days of the adjustment voucher date with a request for a timely filing override. Mail to:

HFS – Transportation Billing Consultant

P.O. Box 19115

Springfield, IL 62794-9115

Submitting an 837P Void/Re-bill:

The department will accept an 837P transaction to replace a paid or pending-payable claim. Providers can replace a single service line or an entire claim.

In order to process the void, the following data elements must match the original claim:

HFS Document Control Number (DCN)

Provider NPI

HFS Recipient ID Number

If these elements match, the original service section or claim will be replaced with the new claim. If all three elements do not match, the transaction will be rejected.

Required Elements:

Loop 2300, REF 02, Payer Claim Control Number, use the Document Control Number (DCN) of the original paid claim or service line to be replaced.

Loop 2300, CLM05-3, Claim Frequency, use Bill Type Code 7.

Replacement of a Prior Claim (Bill Type “7”)

To replace a single service line or an entire claim, enter Claim Frequency "7" in CLM05-3.

If the DCN of the original paid or pending-payable claim, plus a Service Section of "00" is entered in REF02 of the 2300 Loop, the original claim will be voided and replaced with the information contained in the resubmitted 837.

• Replace entire claim for DCN: 201025522123456

  REF02: 20102552212345600

If the DCN of the original paid or pending-payable claim, plus a Service Section number greater than "00" from the original paid or pending-payable service line is entered, only that service line will be replaced with the new information contained in the resubmitted 837.

• Replace Service Line 2 only for DCN: 201025515123456

  REF02: 20102551512345602

Submitting a Void/Replacement Claim through MEDI :

Select Claim Frequency Code : 7 to replace a claim

Enter the original DCN as stated in the above instructions in the Claim Tab.

Enter the new claim information in the Service Line Tab.

Any questions regarding this notice may be directed to the Bureau of Professional and Ancillary Services at 1-877-782-5565 option 3 and then option 3.

Theresa A. Eagleson, Administrator

Division of Medical Programs