Dear Transportation Providers:
Illinois’ Healthcare and Family Services (HFS) enrollment application for participation in the Medical Assistance Program has been designed for use by all providers with specific sections relating to different provider types.
Your enrollment request will be processed, upon completion and receipt of the: Medical Provider Enrollment Application Form (HFS 2243)(pdf), Provider Agreement Form (HFS 1413) (pdf) and Enrollment Disclosure Statement Form (HFS 1513)(pdf). Before your enrollment is approved, your application to become a Medicaid provider will be investigated by the Office of Inspector General. This may include an onsite physical inspection of your office, equipment, record keeping and other areas related to your operation.
Each provider is required to report the Name and Federal Employee Identification Number or Social Security Number of the entity to which payments are to be made on their behalf. In addition, the Request for Taxpayer Identification Number and Certification Form (W-9) is to be completed and returned with your enrollment request. If using a Federal Employee Identification Number, the IRS letter validating this number and the name of your company must also accompany the enrollment request. In addition to the requirements above entities not registered with the Secretary of State must submit confirmation of registration with their local Circuit Clerk.
All individuals that are listed on the HFS 1513 Enrollment Disclosure Statement Form may have to submit to a fingerprint-based criminal background check. See the attached form on Criminal Background Checks for more information and exclusions from this requirement.
Drivers and employee attendants of Medicar and Service Car providers who transport Medicaid participants must complete a safety-training program approved by HFS in order to be eligible for reimbursement. See below for a listing of current Certified Safety Training Programs. For additional information regarding Safety Training requirements, see the Safety Training Certification Requirement Informational Notice (pdf). Training certificates must accompany the initial enrollment documents for all drivers and employee attendants who will be transporting Medicaid participants.
The initial enrollment application must also include the vehicle registration for all vehicles transporting Medicaid participants copies of the driver licenses of all drivers who will be transporting.
No enrollment will be effective until the department approves the application. No service should be provided prior to notification of enrollment approval. Payment will not be made for services rendered prior to the effective date of enrollment. Change in ownership or corporate structure necessitating a new Federal Tax Identification Number terminates the participation of the enrolled provider. Participation is not transferable.
Once enrolled, a Provider Information Sheet (PIS) will be mailed to the participating provider at both the office and payee location(s) listed on the enrollment application. The PIS is to be reviewed for accuracy and used as a reference in preparing claim forms. Reporting of discrepancies or changes to the information originally submitted to HFS are to be noted on the PIS and mailed to the address below. An updated PIS will then be mailed to both the office and payee location(s). The Handbook for Providers of Transportation Services, containing coverage and billing policies for all transportation services, is available on the HFS Medical Providers Handbook webpage.
HFS appreciates your interest in enrolling in the Illinois Medical Assistance Program. If you have any questions regarding the completion of the enrollment forms, please contact the Provider Participation Unit at 217-782-0538.
Illinois Department of Healthcare and Family Services
Provider Participation Unit
P. O. Box 19114
Springfield, Illinois 62794-9114
Criminal Background Check Information
Criminal background checks are required for all Non-Emergency Transportation (NET) Providers except the following: Ambulance providers (including helicopters), private automobiles and all NET providers that are owned or operated by governmental agencies.
The HFS 3819 Non-Emergency Transportation Fingerprint Form (ORI: IL920600Z) must be completed by each dispatcher as well as each individual listed on the HFS 1513 Enrollment Disclosure Statement Form when submitting for the Criminal Background Check.
Timeframe for submitting fingerprints: All individuals identified must submit the fingerprint receipt with their initial enrollment documents.
Providers shall be responsible for the payment of the costs of fingerprint-based criminal background checks. Information regarding fees may be obtained from the respective fingerprint vendors. The following is a list of the fingerprint vendors currently providing this service for the Illinois State Police (ISP).
AFingerprinting US Photo
125 S. Clark St., Ground Floor Lobby
Chicago, IL 60603
Phone 312-782-8143 and 312-782-8144
Accurate Biometrics - (formerly Art’s Investigations)
4849 North Milwaukee Avenue, Suite 101
Chicago, Illinois 60630-5100
Phone 866-361-9944 Fax 773-685-5433
L-1 Identity Solutions
1650 Wabash, Suite D Springfield, Illinois 62704
206 South Sixth Street
Springfield, IL 62701-9929
Phone 217-753-1190 Fax 217-525-1271
Digby’s Detective & Security Agency, Inc.2630 South Wabash Avenue
Chicago, Illinois 60616
Security Partners International, Inc
PO Box 5392
River Forest, Illinois 60305
Phone 877-774-7266 Fax 630-629-4916
Big River Investigation
301 Oak Street, Suite 2-42
Quincy, Illinois 62301
Phone 217-228-9114 Fax 217-228-9116
Trace Identity Services Inc
222 Vollmer Rd, Suite AC Chicago Heights, Illinois 60411
Phone 708-754-2900 Fax 708-754-2999
AP Private Detective & Security Agency
17100 Dixie Highway, Suite F Hazel Crest, Illinois 60429
Phone 708-922-3500 Fax 708-992-3533
Background Resources Inc
29 W 140 Butterfield Rd, Ste 105
Warrenville, Illinois 60555
Phone 630-873-2201 Fax 630-657-1801
Rich Wooten & Associates South Side
547 East 75th St
Chicago, Illinois 60619
Rich Wooten & Associates North Side
676 N LaSalle St., Suite 211
Chicago, Illinois 60654
Fact Finders Group, Inc
4747 Lincoln Mall Dr, Suite 300
Matteson, Illinois 60443
Infotrack Information Services
111 Deerlake Road, Suite 105
Deerfield, Illinois 60015
Illinois Phone 847-444-1177 Fax 847-444-1166
Outside Illinois Phone 800-275-5594
Kevin W. McClain Investigations, Ltd
202 S Broadway St, PO Box 1434
Centralia, Illinois 62801
Phone 618-532-1152 Fax 618-545-0375
Web site: www.mcclaininvestigations.com
188 W. Industrial Drive, Suite 208
Elmhurst, Illinois 60126
Web site: http://www.biometricimpressions.com/
Criminal Background Check Information (Out of State Applicants)
Individuals who reside outside the State of Illinois and do not have an opportunity to submit their fingerprints to one of the electronic fingerprint facilities specified above must submit fingerprint cards for the ISP and the Federal Bureau of Investigation. HFS suggests that those NET provider applicants who must be fingerprinted contact a local police authority in their state of residence to complete the approved HFS fingerprint card. Fingerprint cards available at local police stations will not be accepted, nor will copies of cards. Please send your request for the HFS approved fingerprint cards to:
Illinois Department of Healthcare and Family Services
Office of Inspector General
Administrative Services Unit
404 North 5th Street
Springfield, Illinois 62702
Certified Safety Training Programs
HFS has certified the following safety training programs:
Classroom training available at the following locations: Triton College, River Grove and Wilbur Wright College, Chicago
Medicarsafety.com Inc. continues to provide alternate classroom availability throughout the greater Chicago area. Medicarsafety.com Inc. also provides for those who are unable to travel to one of our fixed classroom locations, the option of our (trainers) traveling to your location for training services. They also provide safety training certification through the Train the Trainer format. Training program content may be viewed on the MedicarSafety website.
Contact: Jimmie Hamp
Business telephone: 773-856-5055
Email: jhamp@MedicarSafety.com or Service@medicarsafety.com
Rural Transit Assistance Center at Western Illinois University
Offering classroom sessions throughout Illinois, our trainers will come directly to your facilities for a fee. Specific details will be worked out between the trainer and your agency.
Contact: Mable Kreps
Southern Illinois University, Carbondale
SIU-Carbondale can provide information on Illinois Community Colleges throughout the state that offer classroom sessions for drivers and attendants.
Contact: Jackie Welch or Dale O. Ritzel
Mashelle A. Rose, Acting Bureau Chief
Bureau of Comprehensive Health Services