Family Health Network Clean Claim Definition: FQHC Professional Claims
“Clean Claim” means a claim for a Covered Services provided to a Member that
 is received timely by Plan
 has no defect, impropriety, or lack of substantiating documentation regarding Covered Services,
 includes all relevant information necessary for Plan to meet requirements of laws and Program Requirement for
reporting of Covered Services to Members to ensure timely processing and payment by Plan
PAPER CLAIMS
 Family Health Network accepts paper claims using CMS 1500 - OMB-0938-1197 Form 1500 (02-12) version
 The full instruction is available on the link provided below:
http://www.nucc.org/index.php?option=com_content&view=article&id=33&Itemid=114
ELECTRONIC CLAIMS
 Family Health Network prefers and accepts electronic claims in HIPAA 5010 – 837P format based on ASC X12 Implementation
Guide version 005010X222 and the ERRATA 005010X222A1 dated June 2010
 The instruction is available on the link provided below:
http://www2.illinois.gov/hfs/sitecollectiondocuments/837p.pdf
The following Claim Edits and Business Rules will be mandatory for claim acceptance –
NOTE: The list below provides the most common claim errors. It is not a comprehensive list of claim instruction and
business rules. For comprehensive list, please refer to links above
Address needs valid Street, City,
State and Zip Code
Telephone needs valid area
code
-
-
Claims should be free of syntax errors, symbols (i.e. commas (,) hyphens (-), asterisk (*) ) and must follow format as
indicated on CMS 1500 - OMB-0938-1197 Form 1500 (02-12) version when submitting paper claims and must follow
HIPAA 5010 – 837P format based on ASC X12 Implementation Guide version 005010X222 and the ERRATA
005010X222A1 dated June 2010 when submitting electronic claim.
Invalid date/time (i.e. the date is written as CCYY/MM/DD instead of CCYYMMDD on EDI submission)
(i.e. the date is written as MM/DD/CCYY instead of MM DD YY on paper submission)
Invalid telephone number (i.e. non-existing area code)
Invalid characters within an element (i.e. , -* &)
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Claims require valid ICD 9, CPT Codes,
Place of Service (i.e 50- FQHC, 11 –Office, etc.),
Date of Service must be on or after patient of date
of birth
T1015 and State assigned encounter rate is
required on the first line
EPSDT column needs
valid value of “Y” or “N”
Rendering Provider
needs NPI, Qualifier,
Taxonomy, and match IL
HFS Enrollment
Total Charge line items
equal to Total Charge
Amount
102014
Service Location and Billing Provider must provide valid
Name/Organization Name, Street Address, City, State, Zip Code, NPI,
Qualifier, Taxonomy Code, match IL HFS Enrollment and W9 Form
-
-
Patient date of birth cannot be after the date of service
Validates implementation guide-specific code set values, such as
For questions on your IL HFS enrollment
Place of service code
please call (217) 782-0538
CPT code
ICD-9 code
Billing provider taxonomy code is required on all claims
EPSDT needs a value “Y” if services fall under EPSDT services and a value of “N” if services do not fall under EPSDT
Services rendered by a billable provider must be submitted with the encounter CPT code (T1015) listed in the first service section along with the clinics
assigned encounter rate. If T1015 is not listed or listed outside of the first service line, the claims will reject.
Append appropriate modifiers
Bill the 99420 (post partum visit) with HD modifier
Bill the FP modifier with the EM CPT code for services related to Illinois Health Women/Family Planning
Bill T1015 with appropriate modifier for the following providers:
Licensed Clinical Social Worker – AJ
Licensed Clinical Psychologist – AH
Licensed Clinical Professional Counselor - HO
Services rendered by a non-billable provider must be submitted with the encounter CPT code (S5190) listed in the first service section
Claim Resubmission Requirement for Corrected Claim or Void/Cancel Claims
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QUESTIONS: Please call or email your Network Management Specialist
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