E-200
Audiology Services
E-200 Basic Provisions
For consideration of payment by the Department for audiological or hearing aid services, such services must be provided by an audiologist or a hearing aid retailer enrolled for participation in the Department’s Medical Programs via the web-based system is known as Illinois Medicaid Program Advanced Cloud Technology (IMPACT).
Services provided must be in full compliance with applicable federal and state laws, the general provisions contained in the Chapter 100, Handbook for Providers of Medical Services, General Policy and Procedures and the policy and procedures contained in this handbook. Exclusions and limitations are identified in specific topics contained herein.
The billing instructions contained within this handbook apply to participants enrolled in traditional fee-for-service, Accountable Care Entities (ACEs) and Care Coordination Entities (CCEs) and do not apply to patients enrolled in Managed Care Organizations (MCOs) and Managed Care Community Networks (MCCNs).
Providers submitting X12 electronic transactions must refer to Chapter 300, Handbook for Electronic Processing. Chapter 300 Handbook identifies informationspecific to conducting Electronic Data Interchange (EDI) with the Illinois Medical Assistance Program and other health care programs funded or administered by the Illinois Department of Healthcare and Family Services.
E-201 Provider Enrollment
E-201.1 Enrollment Requirements
An audiologist who is licensed by the Illinois Department of Professional Regulation or their state of practice is eligible to be considered for enrollment and participation in the Department’s Medical Programs.
A certified hearing instrument dispenser who is not an audiologist but is registered by the Illinois Department of Public Health to dispense hearing aids is eligible to be considered for enrollment to participate in the Department’s Medical Programs.
If enrollment is granted, the non-audiologist certified hearing instrument dispenser is enrolled as a medical equipment provider who may provide hearing aids, and hearing aid-related services such as accessories, supplies and repairs.
An audiologist or certified hearing instrument dispenser who provides hearing aids and hearing aid related services such as accessories, supplies and repairs must also comply with requirements set forth in Chapter M-200, Handbook for Providers of Medical Equipment and Supplies.
To comply with the Federal Regulations at 42 CFR Part 455 Subpart E - Provider Screening and Enrollment, Illinois has implemented a new electronic provider enrollment system. The web-based system is known as Illinois Medicaid Program Advanced Cloud Technology (IMPACT).
Illinois IMPACT is a multi-agency effort to replace the Department’s Medicaid Management Information System (MMIS) with a web-based system that meets federal requirements. IMPACT is more convenient for providers and increases efficiency by automating and expediting state agency processes.
Under the IMPACT system, category of service(s) (COS) is replaced with Specialties and Subspecialties. When enrolling in IMPACT, a Provider Type Specialty must be selected. A provider type subspecialty may or may not be required. Refer to IMPACT Provider Types, Specialties and Subspecialties for additional information.
E-201.2 Enrollment Approval
When participation is approved, the provider will receive a computer-generated notification, the Provider Information Sheet, listing certain data on the Department’s computer files.
The provider is to review this information for accuracy immediately upon receipt. For an explanation of the entries on the form, refer to Appendix E-5. If all information is correct, the provider is to retain the Provider Information Sheet for subsequent use in completing claims (billing statements) to ensure that all identifying information required is an exact match to that in the Department files. If any of the information is incorrect, refer to Topic E-201.4.
E-201.3 Enrollment Denial
When participation is denied, the provider will receive written notification of the reason for denial. Within ten (10) calendar days after the date of this notice, the provider may request a hearing. The request must be in writing and must contain a brief statement of the basis upon which the Department's action is being challenged.
If such a request isnot received within ten (10) calendar days, or is received, but later withdrawn, the Department's decision shall be a final and binding administrative determination. Department rules concerning the basis for denial of participation are in 89 Ill. Adm. Code 140.14. Department rules concerning the administrative hearing process are in 89 Ill. Adm. Code 104 Subpart C.
E-201.4 Provider File Maintenance
The information carried in the Department’s files for participating providers must be maintained on a current basis. The provider and the Department share responsibility for keeping the file updated.
Provider Responsibility
Information contained on the Provider Information Sheet is the same as in the Department’s files. Each time the provider receives a Provider Information Sheet, it is to be reviewed carefully for accuracy.
The Provider Information Sheet contains information to be used by the provider in the preparation of claims; any inaccuracies found must be corrected and the Department notified immediately via IMPACT. Failure of a provider to properly update the IMPACT with corrections or changes may cause an interruption in participation and payments.
Department Responsibility
When there is a change in a provider's enrollment status or the provider submits a change, the Department will generate an updated Provider Information Sheet reflecting the change and the effective date of the change. The updated sheet will be sent to the provider’s office address and to all payees listed if the payee address is different from the provider address.
E-202 Reimbursement
When billing for services or materials, the claim submitted for payment must include a diagnosis and the coding must reflect the actual services provided or materials dispensed. Any payment received from a third-party payor or other persons applicable to the provision of services must be reflected as a credit on any claim submitted to the Department for those services or items.
E-202.1 Charges
Charges billed to the Department must be the provider’s usual and customary charge billed to the general public for the same service or item. Providers may only bill the Department after the service has been provided.
Covered services must be billed to the Department using the Current Procedural Technology (CPT) codes or alphanumeric HCPCS codes.
An audiologist may only charge for services he or she personally provides. A certified hearing instrument dispenser may only charge for the equipment dispensed. Providers may not charge for services provided by another provider, even though one may be in the employ of the other.
Charges for services and items provided to participants enrolled in a Managed Care Entity (MCE) must be billed to the MCE according to the contractual agreement with the MCE. Information regarding MCE’s can be found on the HFS Care Coordination web page.
E-202.2 Electronic Claims Submittal
Any services that do not require attachments or accompanying documentation may be billed electronically. Further information concerning electronic claims submittal can be found in the Chapter 100 Handbook or Chapter 300, Topic 302.
Providers billing electronically should take special note of the requirement that Form HFS 194-M-C, Billing Certification Form, must be signed and retained by the provider for a period of three years from the date of the voucher.
Failure to do so may result in revocation of the provider’s right to bill electronically, recovery of monies or other adverse actions. Form HFS 194-M-C can be found on the last page of each Remittance Advice that reports the disposition of any electronic claims.
Please note that the specifications for electronic claims billing are not the same as those for paper claims. Please follow the instructions for the medium being used.
If a problem occurs with electronic billing, providers should contact the Department in the same manner as would be applicable to a paper claim. It may be necessary for providers to contact their software vendor if the Department determines that the service rejections are being caused by the submission of incorrect or invalid data.
E-202.3 Claim Preparation and Submittal
The Department will not accept paper claim forms hand-delivered to HFS office buildings by providers or their billing entities. HFS will return hand-delivered claims to the provider identified on the claim form. All services for which charges are made must be coded on the appropriate claim form.
For general information on billing Medicare covered services provided and submittal of claims for participants eligible for Medicare Part B, refer to the Chapter 100 Handbook.
Form HFS 3797, Medicare Crossover Form, is to be used to submit Medicare allowable crossover charges. Detailed instructions for completion are included in Appendix E-2.
Form HFS 1443, Provider Invoice, is to be used to submit charges for audiological services provided to a Department’s Medical Programs participant. Detailed instructions for completion are included in Appendix E-1.
Form HFS 2210, Medical Equipment /Supplies Invoice, is to be used to submit charges to the Department for a hearing aid, hearing aid accessories, supplies, equipment, hearing aid repairs and the dispensing fee. Detailed instructions for completion are included in Appendix E-3.
The Department uses a claim imaging system for scanning paper claims. The imaging system allows efficient processing of paper claims and also allows attachments to be scanned. Refer to Appendix E-1 for technical guidelines to assist in preparing paper claims for processing.
The Department offers a claim scanability/imaging evaluation. Turnaround on a claim scanability/imaging evaluation is approximately seven to ten working days and providers are notified of the evaluation results in writing. Please send sample claims with a request for evaluation to the following address.
Healthcare and Family Services
201 South Grand Avenue East
Second Floor - Data Preparation Unit
Springfield, Illinois 62763-0001
Attention: Vendor/Scanner Liaison
E-202.4 Payment
Payment made by the Department for professional services and for hearing aid accessories, supplies and hearing aid repairs will be made at the lower of the provider’s usual and customary charge or the maximum rate as established by the Department. Refer to the Chapter 100 Handbook, for payment procedures utilized by the Department and General Appendix 8 (pdf) for explanations of Remittance Advice detail provided to providers.
Audiological services in a hospital are covered depending on the setting. Inpatient charges are included in the Department’s reimbursement to a hospital and are not to be billed fee for service. Outpatient services rendered by a salaried audiologist may be billed fee for service by the hospital. If a salaried audiologist is enrolled, the audiologist may bill fee for service. In no circumstance, should the audiologist and the hospital bill for the same service.
E-202.5 Fee Schedule
A fee schedule of allowable procedure codes by provider type is available on the Department’s website.
For DME providers and audiologists who provide hearing aids and hearing aid supplies, there is a listing by HCPCS code. The DME fee schedule lists the maximum rates, quantity limitation, whether the item is covered for residents of Long Term Care facilities and prior approval requirements for each item. For an audiologist’s professional services there is an Audiology fee schedule which lists CPT codes used for diagnostic testing.
Providers will be advised of major changes via an electronic notice. Providers should sign up to receive electronic notification of new releases on the Department’s website. Please mark “All Medical Assistance Providers” as well as each specific provider type for which notification is requested.
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