Provider Notice Issued 11/01/2019

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Date:   November 1, 2019

To:       Enrolled Physicians; Advanced Practice Nurses; and Hospitals

Re:      Changes to Claim Submittal Process and Rates for Abortion Procedures

This notice informs providers of several changes regarding claim completion, claim submission, and rates for abortion services.

Claim Submission for Practitioner and Hospital Claims Beginning November 1, 2019

The HFS 2390 Abortion Payment Application is being obsoleted and the Department will no longer require it for claims received on and after November 1, 2019. Per the October 17, 2019 informational notice, paper claims without an attachment required for processing will be returned to the provider. Therefore, claims containing abortion procedures must be billed electronically beginning November 1, 2019.

All abortion services for both fee-for-service and managed care participants will be state-only funded beginning November 1, 2019. With this change, all claims, regardless of the date of service, that contain abortion procedures must be billed directly to the Department beginning November 1, 2019. This applies to claims submitted for participants covered under a HealthChoice Illinois managed care plan as well as traditional fee-for-service.  

837 Professional: Providers must identify the abortion procedure code in Loop 2400, Segment SV101. The Department will no longer require the use of specific procedure code modifiers on practitioner claims.

837 Institutional: Hospitals must identify the abortion procedure code in Loop 2300, Reference HI*BG*AH~. The Department will no longer require the use of specific condition codes on hospital claims.

Rates and Procedure Coding for Practitioner Claims Effective with Dates of Service Beginning December 1, 2019

Surgical abortion:  The Department will continue a global rate reimbursement structure. No ancillary services are billable.

Medication-assisted abortion:  The Department is changing procedure code billing requirements from procedure code H0033 to S0199 to initiate a global rate reimbursement structure under the protocol for the use of Mifepristone. No ancillary services are billable.

• S0199 will be opened to allow for the global reimbursement of the required visits, laboratory services, and ultrasounds. S0199 by definition specifically excludes reimbursement for drugs.

• Current reimbursement methodology for the medications will continue:  S0190 – Mifepristone,1^st pill, at $68.33 and S0191 – Misoprostol, four pills at $1.35 per pill.

Questions regarding this notice may be directed to a billing consultant in the Bureau of Professional and Ancillary Services or the Bureau of Hospital and Provider Services at

877-782-5565.

Doug Elwell

Medicaid Director