Illinois

To calculate an Illinois Medicaid claim at 100% of the state regulation rates, use the default settings. All fields are required.

  • Refer to the contract to determine the options to select and the values to enter.
  • Select Use EAPG for all outpatient hospital and ASTC claims.
    • Beginning 07/01/2014, all outpatient hospital and ASTC claims are grouped and priced through EAPG software.

Use the following steps to override the EAPG percentage default of 100%:

  • Enter the appropriate multiplier in the Percent Reimbursement field
  • Select the Use EAPG check box
  • Check the Cap line items at lesser of billed charges or Medicaid reimbursement check box so that the price is the lower of the billed charges or the expected payment.

Note: The following table describes the fields on the IL tab of the Medicaid - Facility reimbursement tool.

Field

Description

Override Provider Number

Preferred provider number. Up to ten alphanumeric digits.

Note: Enter the NPI number in this field if either the Use APR-DRG or Use EAPG check boxes are selected.

Override Service Date

Preferred service date. Use MM/DD/YYYY format. Overrides the service date on the claim with the date you enter. You may use the anchor date instead of this option.

State Code

This field defaults to IL, and it cannot be changed.

Do not consume charges

Provides the option not to consume charges. This is used for contract carve outs.

Do not consume units

Provides the option not to consume units. This is used for contract carve outs.

Percent Reimbursement

The three digit percentage amount.

Note: This option is disabled when the Use APR-DRG check box is selected.

OP

Use EAPG

Uses the EAPG groupers to group and price claims.

Note: Beginning 07/01/2014, all outpatient hospital and ASTC claims are grouped and priced using EAPG groupers.

Cap line items at lesser of billed charges or Medicaid reimbursement

This check box allows you to price the lower of the billed charges or the expected payment.

Price to zero on error

Enable (check) this option to include accounts that fail to price due to an error display with an expected reimbursement amount of zero ($0). When this check box is disabled (not checked), accounts price to 100% of billed charges.

IP

Use APR-DRG

Uses the APR-DRG groupers to group and price claims.

Disable cap

Provides the option to ignore the cap Illinois Medicaid places on either inpatient or outpatient claims. Typically, this option is only selected for managed care contracts that reimburse based on traditional Medicaid, but without the inpatient/outpatient cap.

Note: This option is disabled when either the Use APR-DRG or Use EAPG check boxes are selected.

IP Per Diem paid Hospital MC percentage

Inpatient per diem paid percentage.