Dear Transportation Providers:
The enclosed enrollment application for the Illinois Medical Assistance Program has been designed for use by all providers with specific sections relating to different provider types. Please read the enclosed instructions prior to completing the forms.
Your enrollment request will be processed, upon completion and receipt of the enclosed: Medical Provider Enrollment Application Form (HFS 2243 pdf), Transportation Provider Agreement Form (HFS 1413T pdf) and Enrollment Disclosure Statement Form (HFS1513 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 of the entity to which payments are to be made on their behalf. Enclosed for your convenience is a Request for Taxpayer Identification Number and Certification Form (W-9) to be completed and returned with your enrollment request. Please Note: The HFS 1413T Transportation Provider Agreement requests names, social security number and percentage of ownership of owners/stock holders who own 5% or more of the stock/shares. If not applicable, please write none to indicate.
The HFS 1413T Transportation Provider Agreement also requests names, Social Security number and position within the company of every partner in a partnership, the sole proprietor and each officer, manager, dispatcher and all individuals in charge of day-to-day operations.
All individuals that are listed on the HFS 1413T Transportation Provider Agreement may have to submit to a fingerprint-based criminal background check. See the Criminal Background Checks section below for more information and exclusions from this requirement.
Drivers and employee attendants of Medicar and Service Car providers who transport participants of the Department’s Medical Assistance programs must complete a safety-training program approved by the Department in order to be eligible for reimbursement. See the attached form for a listing of current Certified Safety Training Programs. For additional information regarding Safety Training requirements, see April 1, 2008, Informational Notice Safety Training Certification Requirement.
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 will be mailed to the participating provider at both the office and payee location(s) listed on the enrollment application. The Provider Information Sheet 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 Provider Information Sheet and mailed to the address below. An updated Provider Information Sheet 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 Web page.
The Illinois Department of Healthcare and Family Services appreciates your interest in enrolling in the Illinois Medical Assistance Program. If you have any questions regarding the completion of the enclosed forms, please contact the Provider Participation Unit.
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 Non-Emergency Transportation Fingerprint Form (ORI: IL920600Z) must be completed by each individual listed on the HFS 1413T Transportation Agreement when submitting for the Criminal Background Check.
Timeframe for submitting fingerprints: All individuals identified must submit their fingerprints within thirty (30) days of the submission of a provider application.
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.
AFingerprinting US Photo
125 South Clark Street, Ground Floor Lobby
Chicago, Illinois 60603
Phone 312-782-8143 and 312-782-8144
Web site: www.FingerprintingChicago.com
Accurate Biometrics - (formerly Art’s Investigations)
4849 North Milwaukee Avenue, Suite 101
Chicago, Illinois 60630-5100
Phone 866-361-9944 Fax 773-685-5433
Web site: www.accuratebiometrics.com
L-1 Identity Solutions
1650 Wabash, Suite D
Springfield, Illinois 62704
Web site: www.identix.com/iis/
206 South Sixth Street
Springfield, Illinois 62701-9929
Phone 217-753-1190 Fax 217-525-1271
Web site: www.verifyinc.com
Digby’s Detective & Security Agency, Inc.
2630 South Wabash Avenue
Chicago, Illinois 60616
Web site: www.digbysecurity.com
Security Partners International, Inc
P.O. Box 5392
River Forest, Illinois 60305
Phone 877-774-7266 Fax 630-629-4916
Web site: www.1877spgs.com
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 Road, Suite AC
Chicago Heights, Illinois 60411
Phone 708-754-2900 Fax 708-754-2999
Web site: www.traceidentitysi.com
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 West 140 Butterfield Road, Suite 105
Warrenville, Illinois 60555
Phone 630-873-2201 Fax 630-657-1801
Web site: www.backgroundresources.com
Rich Wooten & Associates South Side
547 East 75th Street
Chicago, Illinois 60619
Web site: richwooten.org
Rich Wooten & Associates North Side
676 N LaSalle Street, Suite 211
Chicago, Illinois 60654
Web site: richwooten.org
Fact Finders Group, Inc
4747 Lincoln Mall Drive, Suite 300
Matteson, Illinois 60443
Web site: www.factfindersgroup.com
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
Web site: infotrackinc.com
Kevin W. McClain Investigations, Ltd
202 South Broadway Street, P.O. Box 1434
Centralia, Illinois 62801
Phone 618-532-1152 Fax 618-545-0375
Web site: www.mcclaininvestigations.com
188 West 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 Illinois State Police and the FBI. The Department suggests that those NET provider applicants who must be fingerprinted contact a local police authority in their state of residence to obtain classifiable prints. 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
The Illinois Department of Healthcare and Family Services (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 Web site.
Contact: Jimmie Hamp
Business telephone: 773-856-5055
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-C 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