Section 2017.10  Purpose

 

The purpose and intent of this Part is to promote the utilization of standardized forms in the billing and reimbursement of health care, which will reduce the number of forms used and increase efficiency in the reimbursement of health care through standardization.

 

Section 2017.20  Applicability and Scope

 

a)         Except as otherwise specifically provided, the requirements of this Part apply to health plans, health care practitioners and institutional health care providers.

 

b)         A health plan or provider of health care treatment shall not refuse to accept a claim or bill submitted on the uniform claim and billing forms defined in Section 2017.30 of this Part.

 

c)         The adoption of uniform claim forms and uniform billing forms by the Director under this Part does not preclude a health plan, hospital, medical, or dental service corporation, or other prepayment organization from obtaining any necessary additional information regarding a claim from the claimant, provider of health care or treatment, or certifier of coverage, as may be required.

 

(Source:  Amended at 20 Ill. Reg. 8497, effective June 5, 1996)

 

Section 2017.30  Definitions

 

CDT Codes means the current dental terminology prescribed by the American Dental Association.

 

CPT Codes means the current procedural terminology published by the American Medical Association.

 

HCFA means the Health Care Financing Administration of the U.S. Department of Health and Human Services.

 

HCFA Form 1500 means the current health insurance claim form published by HCFA, or its revision following the effective date of this Part, for use by health care practitioners.

 

HCPCS Codes means the HCFA's Common Procedure Coding System that is based upon the current American Medical Association's (AMA) Physician Current Procedural Terminology.

 

HCPCS Level 1 Codes means the AMA's current CPT codes with the exception of anesthesiology services.

 

HCPCS Level 2 Codes means the codes for physician and non-physician services that are not included in current CPT.

 

Health Care Practitioner means:

 

A chiropractor licensed under The Medical Practice Act of 1987, [225 ILCS 60] to treat human ailments without the use of drugs and without operative surgery.

 

A dentist licensed under The Illinois Dental Practice Act, [225 ILCS 25].

 

A nurse licensed under The Illinois Nursing Act of 1987, [225 ILCS 65].

 

An occupational therapist licensed under The Illinois Occupational Therapy Practice Act, [225 ILCS 75].

 

An optometrist licensed under The Illinois Optometric Practice Act of 1987, [225 ILCS 80].

 

A pharmacist licensed under the Pharmacy Practice Act of 1987, [225 ILCS 85].

 

A physical therapist licensed under The Illinois Physical Therapy Act, [225 ILCS 90].

 

A physician licensed under The Medical Practice Act of 1987, [225 ILCS 60] to practice medicine in all of its branches.

 

A podiatrist licensed under The Podiatric Medical Practice Act of 1987, [225 ILCS 100].

 

A psychologist licensed under The Clinical Psychologist Licensing Act, [225 ILCS 15].

 

A social worker licensed under The Clinical Social Work and Social Work Practice Act, [225 ILCS 20].

 

A speech-language pathologist and/or audiologist licensed under The Illinois Speech-Language Pathology and Audiology Practice Act, [225 ILCS 110].

 

Other Health Care Practitioners licensed by the Illinois Department of Professional Regulation.

 

A supplier of health care services not described herein, including but not limited to a physician assistant, nurses aide, or supplier of durable medical equipment.

 

Health Plan means an insurance company, fraternal benefit society, dental service plan, limited health service organization, pharmaceutical service plan, vision service plan, voluntary health services plans, health maintenance organization, workers' compensation insurance, third party administrator, third party prescription program administrator, and any other entity paying or reimbursing the costs of health care expenses.

 

ICD-CM Codes means the disease codes in the current International Classification of Diseases, clinical modifications published by the U.S. Department of Health and Human Services.

 

Institutional Health Care Provider means:

 

Ambulatory Surgical Treatment Center licensed under the Ambulatory Surgical Treatment Center Act, [210 ILCS 5].

 

Home Health Agency licensed under the Home Health Agency Licensing Act, [210 ILCS 55].

 

Hospice licensed under the Hospice Program Licensing Act, [210 ILCS 60].

 

Hospital licensed under the Hospital Licensing Act, [210 ILCS 85].

 

Skilled Nursing and Intermediate Care Facility licensed under the Nursing Home Care Act, [210 ILCS 45].

 

Trauma Center licensed under the Emergency Medical Services (EMS) Systems Act, [210 ILCS 50].

 

Other Institutional Health Care Providers licensed by the Illinois Department of Public Health.

 

J510, J511 or J512 Form means the current uniform dental claim form or its revision following the effective date of this Part, approved by the American Dental Association for use by dentists.

 

Medicare means the Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965, as then constituted or later amended.

 

Medical Assistance or Medicaid means Title XIX of the federal Social Security Act (42 U.S.C. 1396, et seq.) as then constituted or later amended.

 

Revenue Codes means the current codes established for use by institutional health care providers by the National Uniform Billing Committee and the Illinois Uniform Billing Committee.

 

UB92/HCFA Form 1450 means the current health insurance claim form, or its revision following the effective date of this Part, developed by the National Uniform Billing Committee for use by institutional health care providers.

 

(Source:  Amended at 20 Ill. Reg. 8497, effective June 5, 1996)

 

Section 2017.40  Requirements for Use of HCFA Form 1500

 

a)         Health plans shall accept an appropriately completed HCFA Form 1500 from health care practitioners.  Health care practitioners, other than dentists, shall use the HCFA Form 1500 when filing claims with health plans for professional services.

 

b)         Health plans shall not require health care practitioners to use any coding system for the filing of claims for health care services other than the following:

 

1)         current HCPCS Codes or current CPT Codes;

 

2)         current ICD-CM Codes; and

 

3)         For anesthesia services, current HCPCS Level 1 Codes.

 

c)         Health plans shall not require health care practitioners to use any other descriptor with a code or to furnish additional information with the submission of an HCFA Form 1500 except under the following circumstances:

 

1)         When the procedure code used describes a treatment or service that is not otherwise classified; or

 

2)         When the procedure code is followed by the CPT modifier 22, 52 or 99.  Health care practitioners may use Box 19 of the HCFA Form 1500 to explain multiple modifiers.

 

d)         Health care practitioners may use Box 19 of the HCFA Form 1500 to indicate the form is an amended version of a form previously submitted to the health plan by inserting the word "amended" in the space provided.

 

e)         Health care practitioners billing for services based on the amount of time involved shall define in Box 19 the time interval in Box 24 G of the HCFA Form 1500.  If not defined, units will be assumed to be days of treatment.

 

(Source:  Amended at 20 Ill. Reg. 8497, effective June 5, 1996)

 

Section 2017.50  Requirements for Use of UB92/HCFA Form 1450

 

a)         Institutional health care providers shall use the UB92/HCFA Form 1450 when filing claims with health plans for health care services.

 

b)         Health plans shall accept the UB92/HCFA Form 1450 from institutional health care providers when completed in accordance with instructions provided by the National Uniform Billing Committee and the Illinois Uniform Billing Committee.

 

c)         Health plans shall not require institutional health care providers to use any coding system for the filing of claims for health care services other than the following:

 

1)         ICD-CM Codes;

 

2)         Revenue Codes;

 

3)         HCPCS Codes or CPT Codes.

 

            The ICD-CM Codes, Revenue Codes, HCPCS and CPT Codes must be used in accordance with the instructions provided by the National Uniform Billing Committee and the Illinois Uniform Billing Committee.

 

d)         Institutional providers may use the HCFA Form 1500 to supplement a UB92/HCFA Form 1450 if necessary.

 

(Source:  Amended at 20 Ill. Reg. 8497, effective June 5, 1996)

 

Section 2017.60  Requirements for Use of J510/J511/J512 Form

 

a)         Dentists shall use the J510/J511/J512 Form and instructions provided by the American Dental Association for use of the J510/J511/J512 Form for filing claims with health plans for professional services.

 

b)         Health plans shall accept the J510/J511/J512 Form from dentists when completed in accordance with instructions provided by the American Dental Association.

 

c)         Health plans shall not require a dentist to use any code other than the CDT codes for the filing of claims for dental care services or to routinely furnish additional information with the submission of a J510/J511/J512 Form, unless the use of supplemental codes is defined and permitted in a written contract between the issuer and dentist.

 

(Source:  Amended at 20 Ill. Reg. 8497, effective June 5, 1996)

 

Section 2017.70  General Provisions

 

a)         Nothing in this Part shall preclude the filing of a claim electronically.

 

b)         Health plans shall accept forms submitted in compliance with this Part for the processing of claims.

 

c)         Health care practitioners, institutional health care providers and health plans shall use and accept the most current editions of the HCFA Form 1500, UB92/HCFA Form 1450 or J510/J511/J512 Form.

 

(Source:  Amended at 20 Ill. Reg. 8497, effective June 5, 1996)