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Elizabeth M. Whitehorn, Director

Provider Notice issued 09/21/15

New UB-04 Override Request Form

 

To:​ Enrolled Hospitals:  Chief Executive Officers, Chief Fiscal Officers, and Patient Accounts Managers; Ambulatory Surgical Treatment Centers; Hospice Agencies; Renal Dialysis Facilities; and Birth Centers          ​
Date:​ September 21, 2015​
Re:​ New UB-04 Override Request Form ​

The department has prepared a standardized form for institutional providers to use when requesting paper claim review and override of specific department claim processing edits.

The HFS 1624A, UB-04 Override Request Form, has been designated for use by institutional providers and must be submitted with the provider’s UB-04 paper claim form for review by HFS staff. The HFS 1624A is available on the department’s Medical Programs Forms Page. A completed override request form and claim form should be mailed for review to the following address:

 

Illinois Department of Healthcare and Family Services

Bureau of Hospital and Provider Services

P.O. Box 19128

Springfield, Illinois 62794-9128

 

Any questions regarding this notice may be directed to a UB-04 billing consultant in the Bureau of Hospital and Provider Services at 1-877-782-5565.

 

 

Felicia F. Norwood

Director