Provider Notice issued 04/08/2026

HealthChoice Illinois (HCI) Managed Care Claim Submission Member Edits

This notice informs all providers about the launch of the Illinois Department of Healthcare and Family Services’ (HFS) Advanced Communication Engine (ACE) Member Edits for claims submitted to a HealthChoice Illinois (HCI) Managed Care Organization (MCO). Implementation of these edits is designed to streamline claim submission processes across the Medicaid MCOs. These edits do not apply to the Medicaid Fee for Service program. 

HFS will stagger the launch of the member edits by MCO beginning April 23, 2026. The tentative schedule is as follows.

• Meridian April 23, 2026. 

• Aetna May 7, 2026.

• BCBS May 21, 2026.

• CountyCare June 4, 2026.

• Molina June 18, 2026. 

The member edits focus on three common target areas that correspond to the top MCO member rejection reasons: 

• Member (subscriber ID) not found.

• Medicaid Recipient Identification number (RIN) does not match a Medicaid ID.

• Incorrect member (subscriber) date of birth (DOB).

• Member’s DOB does not match 

• Invalid (subscriber) eligibility dates on the date of service (DOS).

• Member is not Medicaid eligible during DOS.

ACE member edits will use the following information on the claim to verify a member’s Medicaid eligibility before sending to the MCO for processing. 

• Medicaid RIN. 

• DOB.

• DOS.

If a member’s Medicaid eligibility cannot be verified through ACE, the claim will be rejected and sent back to the provider’s clearinghouse for correction and resubmission. 

NOTE: The Department has implemented a temporary bypass edit that will allow claims received with the MCO’s subscriber ID or other nonMedicaid ID to bypass ACE eligibility validation and route directly to the MCO for processing. This will allow all providers to update their internal process to include the members’ Medicaid RIN on all claims going forward. 

The launch of the ACE member edits does not require any registration or clearinghouse updates from the provider. This is only a process flow change. Providers will notice the following changes: 

• Claims will be rejected for Medicaid eligibility prior to being sent to the MCO. 

• Providers are encouraged to check MEDI to verify the following member information before submitting the claim to reduce rejections. 

• • RIN
  •  
  • DOB
  •  
  • Eligibility during DOS

Rejection messaging for Medicaid eligibility identified through ACE will appear differently on the 277 Claim Acknowledgement report. 

• STC*A3:21:40**U*********uRECIPFE-Subscriber ID does not match the State of IL - HFS Subscriber/Recipient file.~

• STC*A3:21:40**U*********uRECIPFE1-Subscriber Date of Birth does not match the State of IL - HFS Subscriber/Recipient file.~

• STC*A3:21:40**U*********uRECIPFE2-Subscriber Eligibility dates do not match the State of IL - HFS Subscriber/Recipient file.~

MCOs will not have access to claims rejected by ACE. 

Providers must 

•  
• Use MEDI to verify member eligibility data.
•  
• Work with their clearinghouse to identify rejected claims and resubmit corrected claims.

ACE customized member edits will be implemented as part of the ACE project, created in response to Illinois Public Aid Code 305 ILCS 5/5-30.12  (305 ILCS 5/ Illinois Public Aid Code), referred to as the Pipeline project. 

HFS has prepared a FAQ document regarding the ACE launch that is attached to this notice. 

Sincerely,

Laura Phelan, Administrator
Division of Medical Programs

                                                                                Illinois Advanced Communication Engine (IL ACE)

                                                                                                     Member Edits Launch

Frequently Asked Questions (FAQ) 

What is the IL ACE Member Edits Launch?

The IL ACE Member Edits Launch is an initiative to implement customized member edits for providers, aimed at improving data accuracy and reducing claim rejections supported by the Illinois Department of Healthcare and Family Services (HFS), the Bureau of Managed Care (BMC), and Optum Government Solutions.

The launch does not require any registration or clearinghouse updates from providers.

The implementation of member edits will begin on April 23, 2026, based on the following Managed Care Organization (MCO) go live dates at 12am CST:

• Meridian - April 23, 2026

• Aetna – May 7, 2026 

• BCBS - May 21, 2026

• CountyCare – June 4, 2026

• Molina – June 18, 2026

What are the member edits focused on?

The member edits focus on three key areas to achieve member eligibility verification for the State of Illinois. The three areas below correspond to the top member reject reasons that are occurring with the MCO rejections. 

• Member not found

Medicaid Recipient Identification Number (RIN) does not match

• Incorrect member date of birth (DOB)

Member’s DOB does not match 

• Invalid eligibility dates on the date of service

Member is not Medicaid eligible during date of service

What information will the member edits use on the claim to verify the member’s Medicaid eligibility before sending it to the MCO for processing?

• Medicaid RIN

• DOB

• Date of Service

Will the clearinghouse process or workflow change? 

No, there will not be any changes.  The process and workflow will remain the same.

How will providers receive responses from the IL ACE system on submitted claims?

There are no changes to current processes. Providers receive communication though the 277 Claim Acknowledgment (277CA) response for claims submitted in the 837.

How will providers receive 277CAs?

The 277CA will come through their clearinghouse. A 277CA should be expected for their 837 file submission.  

Will the format of the 277CA change due to the member edit message? 

No, the format will be the same. There is a STC12 segment in 277CA Loop 2200D that will provide the reject message and the reason for the claim being returned by the IL ACE system. 

What are some key things in the 277CA to look for?

Some key things to look for in the 277CA include the claim status code, claim status category code, and STC12. Claim Status Category Codes | X12     Claim Status Codes | X12

Example:

STC*A3:21:40**U*********uRECIP1-Subscriber Date of Birth does not match the State of IL - HFS Subscriber/Recipient file. ~

A3 – Claim Status Category Code

21 – Claim Status Code

WQ – Accepted

U – Rejected

• The reject message will be in 277CA Loop 2200D STC12 – “uRECIP1-Subscriber Date of Birth does not match the State of IL - HFS Subscriber/Recipient file”

Will a claim be forwarded to the MCO after being returned by Optum Intelligent Electronic Data Interchange (iEDI)?

No, if a claim is returned by Optum iEDI due to member eligibility the claim will not be forwarded to the MCO.

Who should providers contact for questions?

Please follow your current communication protocols.

Please note: In case of IL ACE system outages, claims may bypass the IL ACE system. In these cases, the claims will be forwarded to the MCO even though the recipient information is not correct. There will not be any impact on the claim submission process.