HFSMedical ProvidersClaims Processing System Issues

Claims Processing System Issues

HFS is experiencing the following system problems. Once the system problems have been resolved, we will notify the providers by updating this Web site.

If your question is not answered by the HFS Claims Processing System Issues informational pages, please send your question to us via: E-mail HFS Claims Processing System Issues.

The links below will provide you with the most current system issues that the department is experiencing as well as information regarding resolutions.

HFS System Issue

HFS System Issue Problem Begin Date Problem Fix Date    

Hospital outpatient fee-for-service physical therapy and occupational therapy services are either paying inappropriately or rejecting in error when billed by hospitals under the same provider number.

​July 2012

​June 13, 2017

A timely filing override for impacted claims will be allowed for 180 days from the provider notification date of 09/28/17. Instructions for the paper override process are explained in detail on the Department's Non-Institutional Providers Resources webpage.

Claims submitted to the Department via MEDI/DDE using Place of Service code 02 for the Telehealth distant site service are not processing. Claims are being accepted when submitted, but are not showing claim status. Claims with dates of service on or after January 1, 2017 May 19, 2017
MEDI/DDE has been modified to allow for entry of the Place of Service code 02 at the claim and service line levels.  Providers have always had the option to submit claims on paper or via batch 837P upload as an alternative. If a provider did not have this option, a timely filing override for impacted claims will be allowed 180 days from the fix date of 5/19/17.  Instructions for the paper override process are explained in detail on the Department’s Non-Institutional Providers Resources webpage. 
Claims submitted to the Department by enrolled Licensed Clinical Psychologists (LCPs) and Licensed Clinical Social Workers (LCSWs), for dates of service on/after January 1, 2017, are rejecting P83/Provider Type Not Valid For Claim.
Effective January 1, 2017, the Department’s policy changed to allow fee-for-service (FFS) reimbursement for certain services provided by individual LCPs and LCSWs.  Programming to accept claims submitted by these provider types is not yet implemented.  As a result, all claims submitted by LCPs and LCSWs are rejecting P83/provider Type Not Valid For Claim.  
 ​January 1, 2017
May 18, 2017
 
Claims with dates of service between 1/1/17 and 5/17/17 that have previously rejected P83/Provider Type Not Valid For Claim must be resubmitted to the Department.  Timely filing override for impacted claims will be allowed 180 days from fix date of 5/18/17.  Instructions for the paper override process are explained in detail on the Department’s Non-Institutional Providers Resources webpage. 
​​ICG claims for FY’16 dates of service are rejecting with the C17/Illogical Place of Service and C33/Procedure Illogical for Role error codes.  Additionally, please note ICG claims for FY’17 dates of service will reject if billed at this time.  ​July 2016  ​2/7/17
Claims rejecting incorrectly with error code A82, for a participant who is an IDOC/IDJJ Inmate, when a provider (Non-Institutional providers billing both electronically and paper claims) is billing for services that were rendered in the hospital, inpatient, outpatient or emergency room setting  ​June 2016 April 6, 2017
Resolution for Impacted Claims:
Claims must be rebilled.  For claims past the 180 day timely filing deadline, providers must re-bill the Department on paper and request a time override using the HFS 1624, Override Request Form.  Instructions for the paper override process are explained in detail on the Department’s Non-Institutional Providers Resources webpage.  Providers will have 180 days from the fix date to qualify for an override. 

Participant eligibility was not properly coded for some participants in the Department’s systems.   Participants were coded as Title 21 when they should have been coded as Title 19. On December 21, 2016, the eligibility was corrected to Title 19.  Depending on when claims were received for processing, this change may have affected private stock vaccine procedure code reimbursements.

 
If private stock vaccines were administered when the participants were in Title 21 status and claims were processed after the eligibility status had been changed to Title 19, the Department reimbursed the Unit Price rate on the Practitioners Fee Schedule based on the participant’s eligibility on the date the claim was received. 
 
If private stock vaccines were administered and billed while the participants were still in Title 21 status, the Department reimbursed the appropriate rate. 
 
​10/1/2016 12/21/2016
The Department will initiate adjustments.   
 
When adjusted, claims will be identified on the Form HFS 194-M-1, Remittance Advice with the following message:  Adjustment Reason Code 3450 Vaccine Adj/Eligibility Update
 
Providers should not process adjustments.  
 
For claims processed through Managed Care plans, providers must work with the individual plans for reimbursement.
When the new VFC policy was implemented on 10/1/2016, the system did not process certain vaccine service lines correctly.  Vaccines administered to Title 19 participants were paid at the State Max rate (private stock rate) and vaccines administered to Title 21 participants were paid at the Unit Price rate (VFC $6.40 rate) on the Practitioner Fee Schedule
 
The discrepancy affected service lines and not the whole claim.  For example, a provider may have billed five vaccine procedure codes on one claim and all vaccine procedure codes paid correctly except one.
10/1/2016
11/18/2016 
The Department will initiate adjustments.   
 
When processed, adjustments will be identified on the HFS on Form HFS 194-M-1, Remittance Advice with the following message:  Adjustment Reason Code 3450 Vaccine Adj/Eligibility Update
 
Claims that were paid $6.40 instead of the State Max rate (private stock) will be adjusted to pay the State Max rate plus the Unit Price ($6.40) rate.  
 
The system issue did not affect Managed Care Plan claims.
DHS/DMH and SASS claims submitted by Community Mental Health Centers are either paying incorrectly or rejecting with the A59 - Procedure/Modifier/POS Combination Invalid - error code.
Additionally, some DHS/DMH claims submitted by Community Mental Health Centers for FY’17 dates of service are receiving the D04 - Suspended for Department Review - error code.  This is an informational only error message and claims will continue to process and adjudicate once the hold edit is lifted.
Incorrect payments or A59 rejections - July 2016
D04/Suspended for Department Review – July 1, 2016 for FY’17 claims with dates of service on or after 7/1/16
A59 rejection or incorrect payment – September 1, 2016.
D04 – contractual funding information was loaded on September 29, 2016.  All held claims were released into processing for re-editing and final adjudication on September 30, 2016.
Claims with dates of service April 01, 2015 through December 31, 2015
February 24, 2016
September 2015

July 18, 2016

November 2015

December 4, 2015

July 2012
To be announced.  Continue to monitor this page for updates.
Adjustments were over-recouped. First recoupment: Vouchers generated April 27, 2015, identified by Voucher Number beginning with numbers 5117.
Second recoupment: Vouchers generated April 28, 2015, identified by Voucher Number beginning with numbers 5118.
Claims for Screening, Assessment and Support Services (SASS) were processed incorrectly.
Updated September 29, 2015
The issue began with claims received on and after November 8, 2014 May 7, 2015
Certain services are assessed a co-pay. Co-pay deductions are reported with an informational comment on the HFS paper remittance advice. Claims with dates on or after May 1, 2015 were placed on hold beginning May 1, 2015. Claims that were previously on hold were released May 26, 2015. Claims received after May 26, 2015 are processing correctly.    
Non-emergency claims require prior approval. Claims denied whether or not they had prior approval. Claims with service dates on or after May 1, 2015 were placed on hold beginning May 1, 2015. Claims that were previously on hold were released May 26, 2015. Claims received after May 26, 2015 are processing correctly. 
Non-emergency transportation claims that were previously suspended with code D04, rejected G55, 180-Day Timely Filing Limit, when they were rebilled. HFS posted a webpage on April, 27, 2015 stating the claims would be rebilled, and they would bypass the timely filing edit for error code, G55, 180-day timely filing. See System Issue Page, Non Emergency Transportation Claims Suspended, D04, Pricing Problem. Claims rebilled on and after April 27, 2015. The claims affected were previously submitted between December 27, 2012 and July 11, 2014. May 20, 2015
Non-Emergency transportation claims were suspended. Providers received information on the remittance advice stating the claims were suspended with code D04, pricing problem. Claims submitted between December 27, 2012 and July 11, 2014 March 19, 2015
Oxygen procedure codes should be reimbursed at a monthly flat rate. See Provider Notice dated September 27, 2012, Oxygen Reimbursement Changes Effective December 1, 2012. Claims received for dates of service after 12/01/2012 To be announced. Continue to monitor this page for system fix updates.
Podiatric claims denying G51, Podiatric Service Inappropriate for Diagnosis Claims received on or after 10/1/2014. - 11/06/2014 for claims with dates of service on/after 10/1/2014
- 12/23/2014 for claims with dates of service prior to 10/1/2014
Update January 21, 2015 - Overpayment of Transportation Claims (A0120, A0130, A0422, A0426, AO428 and T2005) Claims received:  12/04/12 Claims received:  03/05/13
Preventive Visit Claims Denied with Error Code X11 - Procedure Conflicts with Program Limits. Claims received on or after 11/1/2012. 9/15/2014
Home Health Claims with dates of service on or after 07/01/14 are temporarily placed on hold. At this time, the Department is requesting providers who bill for In-Home Shift Hourly Nursing Services do not submit claims to the Department for dates of service on or after July 1, 2014. Claims with dates of service on or after 07/01/14 August 25, 2014
D17 Quantity Billed Requires Prior Approval Claims received on or after 9/11/14. 10/1/14
Copayments may be taken incorrectly for office visits when billed for Family Planning Services. October 1, 2014 To be announced.
T4521 is denying R09, Requires Prior Approval, inappropriately. Claims with dates of service on or about 7/21/14 August 4, 2014
MEDI Affecting Medicare Crossovers June 3, 2014 Claims submitted through MEDI after June 26, 2014, 4:07 p.m.
Ambulance Rate Changes Update – Second Batch Claims with dates of service on or after 07/01/13 Claims received on and after April 9, 2014 for dates of service on or after 7/1/13
Ambulance Rate Changes Claims with dates of service on or after 07/01/13 Claims received on and after April 9, 2014 for dates of service on or after 7/1/13
The 340B dispensing fee add-on is not being applied to claims submitted by Provider Type 52, Local Health Department. Claims received 02/04/2014 and after May 23, 2014
Local Health Department claims rejecting incorrectly for G61, Service Not Covered Without Modifier. June 9, 2014 August 5, 2014
SMART Act Ambulance Services Claims with dates of service on or after 07/01/13 Claims received on and after April 9, 2014 for dates of service on or after 7/1/13
The 340B dispensing fee add-on is not being applied to claims submitted by Provider Type 52, Local Health Department Claims received 02/04/2014 and after May 23, 2014
Copayments were being applied incorrectly for the new ACA adult population January 1, 2014 April 14, 2014
Copayments were being taken on services rendered to pregnant women July 16, 2012 April 29, 2014
SMART Act 2.7% reimbursement rate reduction no longer applies to ambulance services Claims Received: July 1, 2013 April 9, 2014
Expansion of Telehealth Services – Payment of the Q3014 Telehealth Originating Site Fee to Community Mental Health Providers for SASS eligible participants Claims received: January 29, 2010 March 25, 2014
Recoupment of Affordable Care Act (ACA) Primary Care Increased Payments January 1, 2013 November 18, 2013
Potential Overpayment of Transportation Claims (A0120, A0130, A0422, A0426, AO428 and T2005) Claims received: December 04, 2012 Claims received: March 05, 2013
Expansion of Telehealth Services – Added Telehealth Originating Site Facility Fee (Q3014) to Medicaid/MCD benefits package for Medicaid eligible DMH clients receiving distant site physician services via telemedicine Bill date: July 1, 2011 Bill date: December 16, 2013

Claims Processing System Issues

 

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