IlliniCare Health
QUICK BILLING GUIDE
This guide explains how to submit a claim online using IlliniCare Health’s
secure provider portal, as well as examples of paper claims. This guide
should be used by supportive living facilities. In order to submit claims
online, you must create an account. To access IlliniCare Health’s secure
provider portal, visit www.IlliniCare.com.
QUESTIONS? CONTACT US!
Provider Services: 866-329-4701
IlliniCare.com
STEP 1: Click
Claims on the
top navigation
bar
STEP 2:
Click Create
Claim
STEP 6:
Enter in prior
authorization number.
This information will
be provided to you by
our Integrated Care
Team.
STEP 7:
Enter in the
diagnosis code.
This will be provided
to you by our
Integrated Care
Team.
STEP 4: You will
then be prompted
to choose a claim
type. Choose CMS
1500, Professional
Claim.
STEP 3:
Enter the
member’s ID
Number or their last
name, and their
birth date. Click
find.
STEP 5: Enter
in the Patient’s
Account Number.
This would be the
number you associate
with this member’s
record in your
system.
STEP 8:
Click Next.
STEP 9:
Enter in
the dates of
service.
STEP 11:
Enter in procedure
code T2033. If entering
in a temporary absence,
enter in procedure
code T2033 with the
modifier U1.
STEP 10:
Enter in the
place of service;
for SLFs, enter
in 13 - Assisted
Living.
STEP 12:
Place a check
mark next to
the diagnosis
code.
STEP 13:
Enter in the
TOTAL charges for
this service, as well
as the number of
days.
STEP 14:
Select Save/
Update. This will
add this service line to
your claim. If you have
additional services to
include for this specific
member, repeat
steps 10-15.
STEP 15:
Once you have
completed adding
service lines to this
claim, click Next.
STEP 16:
Search for rendering
provider information
using your Tax ID
Number. Choose the
correct provider, and
it will appear under
Selected Provider.
STEP 17:
If the billing provider
and service facility location
are the same as the rendering
provider, select that option to
fill in the relevant information.
If not, enter in the information
for the billing provider and
service facility location.
FINAL STEPS:
19. Upload any necessary attachments.
20. Review your claim to ensure it is correct.
21. Press submit!
STEP 18:
Click Next.
CMS 1500 Form Billing Instructions
The instructions below explain the fields required on a CMS 1500 form for
Supportive Living Facilities.
Item
Field
Required?
Description/Instructions
1
Required
Indicate the type of health insurance for which the claim is being submitted. For
members of the Integrated Care Program, check “Medicaid”.
1a
Required
Enter the member’s Medicaid ID number in this field.
2
Required
Enter in the member’s full name. Enter last name, first name and middle initial.
3
Required
Enter in the member’s date of birth and sex. For the date of birth, follow this format:
MMDDYYYY. Check the appropriate box indicating the member’s gender.
5
Optional
Enter in the member’s address. This information is not used in claims processing, but
can be entered if desired.
6
Required
Checkmark “self”.
21
Required
Enter in diagnosis code of member. If you have a diagnosis code available, you can use
the code you have for that member. If you do not have the diagnosis code, the Integrated
Care Team can provide it for you.
23
Optional
Enter in the prior authorization number. All Supportive Living Facility stays require prior
authorization. When services are setup for a member, the Integrated Care Team will
provide this number to you.
Introduction
Section 24: This section is comprised of six service lines. The six service lines have been
divided horizontally. A valid claim must have at least one completed service line. The
instructions for each field on the service line (24A-G) apply to all six lines.
24A
Required
Enter in the dates of service. A “from” date of service must be entered. If a “to” date of
service is not entered, the “from” date of service will be used as the “to” date of service
as well. All dates must be entered in the MMDDYYYY format. All dates of service must
have occurred after the date the claim is submitted.
24A-G
24B
Required
A two-digit place of service is required; for SLFs, enter in 13: Assisted Living.
24D
Required
Enter in the appropriate procedure/service code. For SLFs, this will be T2033.
24E
Required
Enter “1” in this field. This points to the diagnosis code you placed in field 21. Diagnosis
codes will be provided by the Integrated Care Team.
24F
Required
Enter in the total charges for the service. Enter in the dollars to the left of the dashed line
and cents to the right of the dashed line. Services with no charges will be denied.
24G
Required
Enter in the amount of units of service being billed as appropriate.
For SLFs, units are days.
25
Required
Enter in provider Tax ID Number. Also check the box to determine which type of Tax ID
Number is being used.
26
Optional
This is your reference number for the member. This is an optional field.
Item
Field
Required?
Description/Instructions
27
Required
Check mark “Yes”.
28
Required
Enter in the total of all service line charges. The total charge amount MUST equal the
same of all service line charges.
31
Required
A signature and date are required. The signature can be an original signature, a
stamped signature, a typewritten signature, or a printed signature, but it MUST be the
name of a person. It cannot be “signature on file” or the name of a facility. Enter date in
MMDDYYYY format.
32
Required
Enter in the service location name and address.
33
Required
Enter in the billing provider’s name, address and phone number in this field.
CMS 1500 Form Billing Instructions - Continued
The next page shows a blank CMS 1500 form, so you can see where the fields
described in these instructions are on the form. After that page, please find an
example claim form. This includes dummy fields to show a properly filled out form.
BILLING – DOS
Submit your claim within 180 days of the date of service
Submit on a proper original form – CMS 1500
Mail to the correct PO Box number
Submit all claims in a 9” x 12” or larger envelope
Type all fields completely and correctly
Use typed black or blue ink only at 9-point font or larger
Include all other insurance information (policy holder, carrier name,
ID number and address) when applicable
BILLING – DON’TS
Submit handwritten claims
Use red ink on claim forms
Don’t circle data on claim forms
Don’t add extraneous information to any claim form field
Don’t use highlighter on any claim for field
Don’t submit photocopied claim forms (no black and white claim forms)
Don’t submit carbon copied claim forms
Don’t submit claim forms via fax
EXAMPLE PAPER CLAIM
X
123456789
Member, Joseph, M.
05
1000 W. Illinois Street
X
SAME
X
Westmont
60559
25 1950
SAME
IL
555 555-5555
SIGNATURE ON FILE
SIGNATURE ON FILE
0123456789
10 01 12 10 28 12
13
T2033
10 29 12 10 31 12
13
T2033
0123456789
X
James Provider
55555555555
U1
X
Supportive Living Facility, Inc
1000 W. Oakdale Ave
11152012 Orland Park IL 60462
1
2090 48
28
1
223 98
3
2314 46
555 555-5555
Supportive Living Facility, Inc
1000 W. Oakdale Ave
Orland Park IL 60462