Provider Notice issued 08/15/2023

This notice announces new billing requirements for maternity care services, effective October 1, 2023, which impacts all customers under both Medicaid fee-for-service (FFS) and the HealthChoice Illinois (HCI) managed care organization (MCOs).

The Department of Healthcare and Family Services (HFS) is updating the method of reimbursement for maternity services to align with Third Party Liability (TPL) requirements established by the Bipartisan Budget Act of 2018. Section 53102(a)(1) of the Bipartisan Budget Act of 2018 amends section 1902(a)(25)(E) of the Social Security Act to require states to use standard coordination of benefits cost avoidance when processing claims for prenatal services, thereby eliminating the “pay and chase” methodology that HFS has had in place for billing of antepartum care. Consequently, practitioners rendering services to women with a diagnosis of pregnancy will be required to bill a customer’s private insurance carrier, when applicable, prior to billing the Department for all maternity services.

This requirement prompts a change in the way HFS reimburses maternity services. When a customer has TPL, this will allow providers to submit claims using the same coding methodology used in billing the primary payer source(s), specifically a global maternity billing and reimbursement methodology if that is the requirement of the primary payer(s).  

For customers with no primary insurance, HFS will continue to reimburse maternity care by individual maternity care coding only, though providers should take note of coding changes and use of two new modifiers. 

To assist providers in this billing transition, HFS has prepared a detailed ‘Billing Guidelines for Changes to Maternity Care Reimbursement’ document that is linked on the Non-Institutional Providers webpage. Language in the Handbook for Practitioners Rendering Medical Services regarding prenatal care, delivery, and postpartum visits will be updated. The ‘Billing Guidelines for Changes to Maternity Care Reimbursement’ document will also be included in a future update of the Handbook Supplement.

Rates are still being finalized and HFS will notify providers of those rates as soon as possible.

Questions regarding this notice or the billing guidelines may be directed to the Bureau of Professional and Ancillary Services at 877-782-5565 for FFS claims, or to the applicable HCI MCO plan.

Kelly Cunningham, Administrator
Division of Medical Programs