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Provider Notice Issued 04/21/2021

Date:   April 21, 2021                                                                                  


To:      Long Term Care Providers - Nursing Facilities (NF), Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID), Medically Complex for the Developmentally Disabled Facilities (MC/DD), Supportive Living Program (SLP) Providers, and Specialized Mental Health Rehabilitation Facilities (SMHRF)


Re:      Provider Responsibility for Completing Applications


This notice is to remind long term care providers that all forms and applications submitted on behalf of a resident need to be correct and complete. As enrolled Medicaid providers, long term care facilities must submit Medicaid applications, the 3654 form (Additional Financial Information for Long Term Care Applicants) and all MEDI TAN submissions with accurate information.

Providers need to exercise due diligence to obtain the requested data and ensure its accuracy prior to applying for Medicaid on behalf of a resident. Since three months backdating is available when submitting a Medicaid application, providers have additional time to collect the information needed for completion.  

When completing an application or the 3654 form: 

  • The family, POA (Power of Attorney), guardian and resident should be consulted in order to collect the most accurate information and determine when a question should be marked yes, no or left blank for unknown.
  • Answering a question “no” and leaving an answer blank because the information is unknown are different responses. 
    • A response should only be marked “no” if it is determined that the answer is actually “no” to one of the questions. For example, the provider determined that a client does not have a bank account.
    • If the answer is unknown, then the response should be left blank as unknown.  For example, you are not able to determine if a client has a bank account.

All information submitted on behalf of a resident by a provider must be correct and complete. 

The following list contains examples of forms and applications which are not considered complete and/or correct:

  •  Submitting Medicaid applications with incorrect information.
  • Selecting “no” to questions on an application without making an effort to obtain the data prior to submission.
  •  Submitting TANs with incorrect screening information.
  •  Falsifying TAN information on an admission record.

o   Data fields cannot be edited after submission in MEDI (TAN digits, Screening Info, Provider Name and Number)

o   Updating TAN data fields require a new TAN submission.

  • Selecting that an applicant is private pay when they are not.
  •  Failing to report the death or discharge of a recipient.
  •  Failing to identify a spouse when they are known or reasonably should be known.

When submitting an application on behalf of a resident, providers and staff should be mindful of the following attestation in ABE. 

Long term care providers, like all enrolled providers, are expected to act in accordance with all laws, regulations, provider handbooks, guidance, their provider enrollment agreement, and other applicable provisions. Failure to do so may subject the provider to referral to the HFS OIG or other authorities for sanction or further actions. 

Please review the below resources for more information on provider expectations.

  • OIG Code of Conduct for Nursing Home Providers


  • CMS Nursing Home Provider Booklet



Questions regarding this bulletin may be directed to the Bureau of Long Term Care at




Kelly Cunningham, Administrator

Division of Medical Programs



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Illinois Department of Healthcare and Family Services

JB Pritzker, Governor • Theresa Eagleson, Director