Form hfs 2390-2026

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The document is an Abortion Payment Application form from the Illinois Department of Healthcare and Family Services, which is used to request medical assistance payment for abortion services. It requires detailed information about the recipient, the procedure performed, and the physician involved, including reasons for the abortion. The form must be completed accurately to avoid rejection.

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Click ‘Get Form’ to open the HFS 2390 in the editor.
Begin by entering the recipient's first and last name in the 'Recipient Name' field. Ensure accuracy as this is crucial for processing.
Fill in the 'Recipient Address' with the complete address of the recipient, ensuring all details are correct.
Input the 'Case Identification No.' which corresponds to the recipient’s case number.
Enter the 'Recipient Identification No.' that matches what is on the invoice.
In the 'Location' section, provide the facility name and address where the abortion was performed. If done in an office, include that physician's or clinic's details.
Specify the date when the service was performed in the designated field.
Select one reason for the abortion by circling only one code from the options provided.
Print and enter the full name of the physician performing the abortion in that section.
Provide either a Medicaid provider number or state license number for verification purposes.
Complete with street address, city, state, and zip code of the provider’s office.
Ensure that there is an original signature from the physician performing the abortion in black ink.
Finally, enter today's date next to where you signed to confirm completion of this application.

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Can you submit Medicare claims on paper?

The Administrative Simplification Compliance Act (ASCA) requires that Medicare claims be sent electronically unless certain exceptions are met. Providers meeting an ASCA exception may send their claims to Medicare on a paper claim form.

What is the timely filing limit for IL Medicaid?

Timely filing is 180 days from the discharge date. Medicare/Medicaid combination claims are allowed 24 months from the date of service. If you have an exception to the 180 days filing limit, submit the claim on paper with an HFS 1624A override request form.

What are healthcare paper claims?

An \u201celectronic claim" is a paperless patient claim form generated by computer software that is transmitted electronically over the telephone or computer connected to a health insurer or other third-party payer (payer) for processing and payment, while A \u201cmanual claim\u201d is a paper claim form that refers to either the ...

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What is the TFL for Medicaid claim submission?

If a provider is unable to submit a claim within three-hundred sixty-five (365) days from the date of service due to retroactive beneficiary eligibility, claims must be submitted within sixty (60) days of the eligibility determination.

Does Medicaid cover abortion pill in Illinois?

As a freedom of choice state, Illinois is one of only 16 states that go beyond federal Medicaid limits and use state funds to cover abortions for people enrolled in Medicaid. The department covers both surgical and medical abortion services.

Does IL Medicaid accept paper claims?

As a step toward paperless billing, the Department will only accept paper claims if an attachment is required. Claims that do not require an attachment should be filed electronically. The Department encourages paperless billing through these mediums: Medical Electronic Data Interchange (MEDI) System.

Form hfs 2390-2026

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