User Guide — IL Medicaid 1443 Form Instructions

athenaCollector

athenaOne supports the Medicaid-IL Claim Form DPA 1443. All claims that meet the criteria will use the DPA 1443 (R-0-04), according to Illinois Medicaid requirements.

Additional Fields for the DPA 1443 (R-0-04) form

Podiatrist Role

If supervising provider is a podiatrist, select A (Attending) or B (surgeon) in the custom claim format box. This value appears in Block 4 (Role) on the DPA 1443 (R-4-04).

TPL Status

This field is used for Medicaid-IL secondary claims. Select the applicable status reported on the primary insurer's EOB.

If the TPL Status field is not completed for a secondary claim, the secondary claim will be placed in CBOHOLD status for the completion of the TPL Status field.

TPL Date

This field is used for Medicaid-IL secondary claims. Enter the paid date reported on the primary insurer's EOB.

If the TPL Date field is not completed for a secondary claim, the secondary claim will be placed in CBOHOLD status for the completion of the TPL Date field.

Other requirements

For audiology claims, a referring provider name and referring provider's state license number are required.

The following instructions are from the Handbook for Therapy Services Chapter J-200 — Appendices (http://www.hfs.illinois.gov/assets/092905therapyappendices.pdf)

TECHNICAL GUIDELINE FOR PAPER CLAIM PREPARATION — FORM DPA 1443 (HFS 1443), PROVIDER INVOICE

Completion	#	Item Explanation and Instructions
Required	1.	Provider Name — Enter the provider's name exactly as it appears on the Provider Information Sheet.
Required	2.	Provider Number — Enter the Provider Number exactly as it appears on the Provider Information Sheet.
Required	3.	Payee — Enter the one-digit code of the payee to whom payment is to be sent. Payees are coded numerically on the Provider Information Sheet.
Not Required	4.	Role — Leave blank.
Not Required	5.	Emer — Leave blank.
Conditionally Required	6.	Prior Approval — Enter the unique number from the computer generated prior approval notification, when billing a service for which approval has been obtained
Optional	7.	Provider Street — Enter the street address of the provider's primary office. If the address is entered, the Department will, where possible, correct claims suspended due to provider errors. If address is not entered, the Department will not attempt corrections.
Conditionally Required	8.	Facility & City Where Service Rendered — This entry is required when Place of Service Code in Field 23 (Service Sections) is other than 11 (office).
Optional	9.	Provider City State ZIP — Enter city, state and ZIP code of provider.
Required	10.	Referring Practitioner Name — Enter the name of the physician who requested services to be provided.
Required	11.	Recipient Name — Enter the patient's name exactly as it appears on the MediPlan Card, Temporary MediPlan Card, KidCare Card or Notice of Temporary KidCare Medical Benefits. Separate the components of the name (first, middle initial, last) in the proper order of the name field.
Required	12.	Recipient No. — Enter the nine-digit number assigned to the individual as shown on the MediPlan Card, Temporary MediPlan Card, KidCare Card or Notice of Temporary KidCare Medical Benefits. Use no punctuation or spaces. Do not use the Case Identification Number.
Optional	13.	Birthdate — Enter the month, day and year of birth of the patient as shown on the MediPlan Card, Temporary MediPlan Card, KidCare Card or Notice of Temporary KidCare Medical Benefits. Use the MMDDYYYY format. If the birthdate is entered, the Department will, where possible, correct claims suspended due to recipient name or number errors. If the birthdate is not entered, the Department will not attempt corrections.
Not Required	14.	H Kids — Leave blank.
Not Required	15.	Fam Plan — Leave blank. .
Not Required	16.	St/Ab — Leave blank.
Required	17.	Primary Diagnosis Description — Enter the primary diagnosis which describes the condition primarily responsible for the patient's treatment.
Required	18.	Primary Diag. Code — Enter the specific ICD-9-CM code without the decimal for the primary diagnosis described in Item 17.
Required	19.	Taxonomy — Enter the appropriate ten-digit HIPAA Provider Taxonomy code. Refer to Chapter 300, Appendix 5.
Optional	20.	Provider Reference — Enter up to 10 numbers or letters used in the provider's accounting system for identification. If this field is completed, the same data will appear on Form DPA 194-M-1, Remittance Advice, returned to the provider.
Required	21.	Ref Prac No. — Enter the state license number, Social Security number or AMA number of the physician who requested services to be provided.
Not Required	22.	Secondary Diag Code — Leave blank.

23. Service Sections: Complete one Service Section for each item or service provided to the patient.
Required	Procedure Description/Drug Name, Form, and Strength or Size — Enter the description of the service provided or item dispensed.
Required	Proc. Code/NDC — Enter the appropriate CPT code.
Conditionally Required	Modifiers — Enter the appropriate two-byte modifier(s) for the service performed. The Department can accept a maximum of 4 two-byte modifiers per Service Section.
Required	Date of Service — Enter the date the service was provided. Use MMDDYY format.
Required	Cat. Serv. — Enter the appropriate two-digit category of service code. 11 Physical Therapy Services 12 Occupational Therapy Services 13 Speech Therapy/Pathology Services
Conditionally Required	Delete — When an error has been made that cannot be corrected enter an "X" to delete the entire Service Section. Only "X" will be recognized as a valid character; all others will be ignored.
Required	Place of Serv. — Enter the two-digit Place of Service code from the following list: 11 — Office 12 — Home 13 — Assisted Living Facility 14 — Group Home 21 — Inpatient Hospital 22 — Outpatient Hospital 31 — Skilled Nursing Facility 32 — Nursing Facility 33 — Custodial Care Facility
Required	Units/Quantity — Enter the units of time covered by the therapy session. Fifteen minute intervals equal one (1) unit. A maximum of four (4) units are allowed per date of service for therapy. A maximum of eight (8) units are allowed for children's evaluations.
Not Required	Modifying Units — Leave blank.
	TPL Code — If the patient's MediPlan or KidCare Card contains a TPL code, the numeric three-digit code must be entered in this field. If payment was received from a third party resource not listed on the patient's card, enter the appropriate TPL Code as listed in the Chapter 100, General Appendix 9. If more than one third party made a payment for a particular service, the additional payment(s) are to be shown in Section 25.
	Spenddown — Refer to Chapter 100, Topic 113 for a full explanation of the Spenddown policy. The following provides examples. When the date of service is the same as the "Spenddown Met" date on the DPA 2432 (Split Billing Transmittal) attach the DPA 2432 to the claim form. The split bill transmittal supplies the information necessary to complete the TPL fields.
	If Form DPA 2432 shows a recipient liability greater than $0.00 the Service Section should be coded as follows: TPL Code 906 TPL Status 01 TPL Amount The actual recipient liability as shown on DPA Form 2432. TPL Date The issue date on the bottom right corner of the DPA 2432. This is in MMDDYY format. If Form DPA 2432 shows a recipient liability of $0.00 the Service Section should be coded as follows: TPL Code 906 TPL Status 04 TPL Amount 0 00 TPL Date The issue date on the bottom right corner of the DPA 2432. This is in MMDDYY format.
Conditionally Required	Status — If a TPL code is shown in the previous item, a two-digit code indicating the disposition of the third party claim must be entered. No entry is required if the TPL code is blank. The TPL Status Codes are: 01 — TPL Adjudicated — total payment shown — TPL Status Code 01 is to be entered when payment has been received from the patient's third party resource. The amount of payment received must be entered in the TPL amount box. 02 — TPL Adjudicated — patient not covered — TPL Status Code 02 is to be entered when the provider is advised by the third party resource that the patient was not insured at the time services were provided. 03 — TPL Adjudicated — services not covered — TPL Status Code 03 is to be entered when the provider is advised by the third party resource that services provided are not covered. 04 — TPL Adjudicated — spenddown met — TPL status code 04 is to be entered when the patient's Form DPA 2432 shows $0.00 liability. 05 — Patient not covered — TPL Status Code 05 is to be entered when a patient informs the provider that the third party resource identified on the MediPlan Card is not in force. 06 — Services not covered — TPL Status Code 06 is to be entered when the provider determines that the identified resource is not applicable to the service provided. 07 — Third Party Adjudication Pending — TPL Status Code 07 may be entered when a claim has been submitted to the third party, 60 days have elapsed since the third party was billed, and reasonable follow-up efforts to obtain payment have failed. 10 — Deductible not met — TPL Status Code 10 is to be entered when the provider has been informed by the third party resource that non-payment of the service was because the deductible was not met.
Conditionally Required	TPL Amount — Enter the amount of payment received from the patient's third party for the service. A dollar amount entry is required if TPL Status Code 01 was entered in the "Status" box. For all other Status Codes, enter 0 00. If there is no TPL code, no entry is required.
Conditionally Required	TPL Date — A TPL date is required when any status code is shown. Use the date specified below for the applicable code: Status Code Date to be entered 01 Third Party Adjudication Date 02 Third Party Adjudication Date 03 Third Party Adjudication Date 04 Date from the DPA 2432, Split Billing Transmittal 05 Date of Service 06 Date of Service 07 Date of Service 10 Third Party Adjudication Date
Required	Provider Charge — Enter the total charge for the service, not deducting any TPL.
Sections 25 through 30 of the Provider Invoice are to be used: 1) to identify additional third party resources in instances where the patient has access to two or more resources and 2) to calculate total and net charges. If an additional third party resource was identified for one or more of the services billed in Service Sections 1 through 6 of the Provider Invoice, complete the TPL fields in accordance with the following instructions:

23. Service Sections: Complete one Service Section for each item or service provided to the patient.

Required

Procedure Description/Drug Name, Form, and Strength or Size — Enter the description of the service provided or item dispensed.

Required

Proc. Code/NDC — Enter the appropriate CPT code.

Conditionally

Required

Modifiers — Enter the appropriate two-byte modifier(s) for the service performed. The Department can accept a maximum of 4 two-byte modifiers per Service Section.

Required

Date of Service — Enter the date the service was provided. Use MMDDYY format.

Required

Cat. Serv. — Enter the appropriate two-digit category of service code.

11 Physical Therapy Services

12 Occupational Therapy Services

13 Speech Therapy/Pathology Services

Conditionally

Required

Delete — When an error has been made that cannot be corrected enter an "X" to delete the entire Service Section. Only "X" will be recognized as a valid character; all others will be ignored.

Required

Place of Serv. — Enter the two-digit Place of Service code from the following list:

11 — Office

12 — Home

13 — Assisted Living Facility

14 — Group Home

21 — Inpatient Hospital

22 — Outpatient Hospital

31 — Skilled Nursing Facility

32 — Nursing Facility

33 — Custodial Care Facility

Required

Units/Quantity — Enter the units of time covered by the therapy session. Fifteen minute intervals equal one (1) unit. A maximum of four (4) units are allowed per date of service for therapy. A maximum of eight (8) units are allowed for children's evaluations.

Not Required

Modifying Units — Leave blank.

TPL Code — If the patient's MediPlan or KidCare Card

contains a TPL code, the numeric three-digit code must be entered in this field. If payment was received from a third party resource not listed on the patient's card, enter the appropriate TPL Code as listed in the Chapter 100, General Appendix 9. If more than one third party made a payment for a particular service, the additional payment(s) are to be shown in Section 25.

Spenddown — Refer to Chapter 100, Topic 113 for a full explanation of the Spenddown policy. The following provides examples.

When the date of service is the same as the "Spenddown Met" date on the DPA 2432 (Split Billing Transmittal) attach the DPA 2432 to the claim form. The split bill transmittal supplies the information necessary to complete the TPL fields.

If Form DPA 2432 shows a recipient liability greater than $0.00 the Service Section should be coded as follows:

TPL Code 906

TPL Status 01

TPL Amount The actual recipient liability as shown on DPA Form 2432.

TPL Date The issue date on the bottom right corner of the DPA 2432. This is in

MMDDYY format.

If Form DPA 2432 shows a recipient liability of $0.00 the

Service Section should be coded as follows:

TPL Code 906

TPL Status 04

TPL Amount 0 00

TPL Date The issue date on the bottom right

corner of the DPA 2432. This is in

MMDDYY format.

Conditionally

Required

Status — If a TPL code is shown in the previous item, a two-digit code indicating the disposition of the third party claim must be entered. No entry is required if the TPL code is blank.

The TPL Status Codes are:

01 — TPL Adjudicated — total payment shown — TPL Status Code 01 is to be entered when payment has been received from the patient's third party resource. The amount of payment received must be entered in the TPL amount box.

02 — TPL Adjudicated — patient not covered — TPL Status Code 02 is to be entered when the provider is advised by the third party resource that the patient was not insured at the time services were provided.

03 — TPL Adjudicated — services not covered — TPL Status Code 03 is to be entered when the provider is advised by the third party resource that services provided are not covered.

04 — TPL Adjudicated — spenddown met — TPL status code

04 is to be entered when the patient's Form DPA 2432 shows $0.00 liability.

05 — Patient not covered — TPL Status Code 05 is to be entered when a patient informs the provider that the third party resource identified on the MediPlan Card is not in force.

06 — Services not covered — TPL Status Code 06 is to be entered when the provider determines that the identified resource is not applicable to the service provided.

07 — Third Party Adjudication Pending — TPL Status Code 07 may be entered when a claim has been submitted to the third party, 60 days have elapsed since the third party was billed, and reasonable follow-up efforts to obtain payment have failed.

10 — Deductible not met — TPL Status Code 10 is to be

entered when the provider has been informed by the third party resource that non-payment of the service was because the deductible was not met.

Conditionally

Required

TPL Amount — Enter the amount of payment received from the patient's third party for the service. A dollar amount entry is required if TPL Status Code 01 was entered in the "Status" box. For all other Status Codes, enter 0 00. If there is no TPL code, no entry is required.

Conditionally

Required

TPL Date — A TPL date is required when any status code is shown. Use the date specified below for the applicable code:

Status

Code Date to be entered

01 Third Party Adjudication Date

02 Third Party Adjudication Date

03 Third Party Adjudication Date

04 Date from the DPA 2432, Split Billing Transmittal

05 Date of Service

06 Date of Service

07 Date of Service

10 Third Party Adjudication Date

Required

Provider Charge — Enter the total charge for the service, not deducting any TPL.

Sections 25 through 30 of the Provider Invoice are to be used: 1) to identify additional third party resources in instances where the patient has access to two or more resources and 2) to calculate total and net charges.

If an additional third party resource was identified for one or more of the services billed in Service Sections 1 through 6 of the Provider Invoice, complete the TPL fields in accordance with the following instructions:

Conditionally Required	25.	Sect. # — If more than one third party made a payment for a particular service, enter the service section number (1 through 6) in which that service is reported. If a third party made a single payment for several services and did not specify the amount applicable to each, enter the number 0 (zero) in this field. When 0 is entered, the third party payment shown in section 25C will be applied to the total of all Service Sections on the Provider Invoice.
Conditionally Required	25A.	TPL Code — Enter the appropriate TPL Code referencing the source of payment (Chapter 100, General Appendix 9). If the TPL Codes are not appropriate enter 999 and enter the name of the payment source in section 35.
Conditionally Required	25B.	Status — Enter the appropriate TPL Status Code. See the Status field in Item 23 above for correct coding of this field.
Conditionally Required	25C	TPL Amount — Enter the amount of payment received from the third-party resource.
Conditionally Required	25D.	TPL Date — Enter the date the claim was adjudicated by the third party-resource. (See the TPL Date field in Item 23 above for correct coding of this field.)
Conditionally Required	26.	Sect. # — (See 25 above).
Conditionally Required	26A.	TPL Code — (See 25A above).
Conditionally Required	26B.	Status — (See 25B above).
Conditionally Required	26C.	TPL Amount — (See 25C above).
Conditionally Required	26D.	TPL Date — (See 25D above).
Conditionally Required	27.	Sect. # — (See 25 above).
Conditionally Required	27A.	TPL Code — (See 25A above).
Conditionally Required	27B	Status — (See 25B above).
Conditionally Required	27C.	TPL Amount — (See 25C above).
Conditionally Required	27D.	TPL Date — (See 25D above).

Claim Summary Fields: The three claim summary fields must be completed on all Provider Invoices. These fields are Total Charge, Total Deductions, and Net Charge. They are located at the bottom far right of the form.
Required	28.	Tot Charge — Enter the sum of all charges submitted on the Provider Invoice in Service Sections 1 through 6.
Required	29.	Tot Deductions — Enter the sum of all payments submitted in the TPL Amount field in Service Sections 1 through 6. If no payment was received, enter zeroes (0 00).
Required	30.	Net Charge — Enter the difference between Total Charge and Total Deductions.
Required	31.	# Sects — Enter the total number of Service Sections completed in the top part of the form. This entry must be at least one and no more than six. Do not count any sections which were deleted because of errors.
Not Required	32.	Original DCN — Leave blank.
Not Required	33.	Sect. — Leave blank.
Not Required	34.	Bill type — Leave blank.
Conditionally Required	35.	Uncoded TPL Name — Enter the name of the third-party resource. The name must be entered if TPL code 999 is used.
Required	36-37	Provider Certification, Signature and Date — After reading the certification statement, the provider or their designee must sign the completed form. The signature must be handwritten in black ink. A stamped or facsimile signature is not acceptable. Unsigned Provider Invoices will be rejected. The signature date is to be entered in MMDDYY format.

© 2024 athenahealth, Inc. All rights reserved. These materials constitute Confidential Business Information of athenahealth, Inc. subject to the non-disclosure provisions of the athenahealth Services Agreement, and are provided for the internal use of athenahealth customers only.