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  2. Medical Providers
  3. Electronic Data Interchange (EDI)
  4. FAQs
  5. Problems Encountered on the EDI-Formatted Claims

Problems Encountered on the EDI-Formatted Claims 

Listed below are the most common problems encountered on the HIPAA-formatted claims that HFS is receiving. Select the Frequently Asked Question to view answer.
  1. Taxonomy

    An appropriate taxonomy code must be provided for both Institutional and Professional 837 claims. For further details see 837I or 837P Companion Guides.

  2. Subscriber
    The patient is always the subscriber. See 837I or 837P Companion Guides.
  3. Payer

    The destination payer must be 'Illinois Medicaid'. See 837I, 837P or EDI Control Companion Guides.

  4. Outpatient Series Claim

    For 5010, the number of series days for which outpatient services were provided must be reported in Loop 2300, HI Segment. See 837I Companion Guide (pdf).

  5. TPL/Status Code

    The 3-digit TPL code followed by the 2-digit Status Code assigned by HFS to other payers, must be reported in Loop 2330B, REF02. In addition, the TPL Date is required in Loop 2330B, DTP03. See 837P Companion Guide (pdf).

  6. How do you bill Physician fee-for-service claims when services are rendered outside the FQHC setting?

    Physicians who bill fee-for-service, under their own name and NPI and designate the FQHC, RHC, or ERC as their payee, must report their name and NPI as the Rendering Provider in Loop 2310B. The NPI linked to the physician's appropriate 16-digit payee number must be reported as the Billing Provider in Loop 2010AA. The Billing NPI reported in Loop 2010AA must not be linked to the FQHC's, RHC's, or ERC's provider number. Please contact the Provider Participation Unit to initiate any NPI Link to Payee changes at: 217-782-0538.

    Example:

    Loop 2010AA, NM1*85 – Billing Provider
    NPI associated to the 16-digit payee number

    Loop 2310B, NM1*82 - Rendering Provider
    Physician NPI