Date: July 5, 2022
To: Participating Hospitals: Chief Executive Officers, Chief Financial Officers; and Patient Accounts Managers
Re: Hospital Outpatient Claims for Sexual Assault Treatment Services per Public Act 102-0699
This notice outlines the minimum $1,000.00 reimbursement for sexual assault outpatient hospital treatment services in accordance with Public Act 102-0699. This Act amends the Sexual Assault Survivors Emergency Treatment Act.
The Illinois Department of Healthcare and Family Services (HFS), the Illinois Sexual Assault Emergency Treatment Program under HFS, or the appropriate HealthChoice Illinois (HCI) managed care organization (MCO) is required to reimburse a hospital providing outpatient medical forensic services to a sexual assault survivor a rate of at least $1,000.00 beginning with dates of service on or after July 1, 2022.
Hospital Outpatient Billing Instructions to Capture the Increased Rate Effective July 1:
- The provider submitting the claim must be approved by the Illinois Department of Public Health (IDPH) to provide these services. Approved hospitals are identified on the IDPH website.
- The claim must contain a sexual assault diagnosis code from Attachment A of this notice in any diagnosis code field.
- The claim must contain a CPT code in the range of 99201-99295 to indicate an Evaluation & Management (E & M) service was provided.
- The E & M service must contain Modifier 32 to indicate "Mandated Services", identifying a forensic examination, for dates of service beginning July 1, 2022. Claims must contain this modifier for new pricing logic to apply to these claims. When the total amount priced in the Enhanced Ambulatory Procedure Grouping (EAPG) system is below $1,000.00, new pricing logic will ignore the EAPG total payment and instead price the claim at $1,000.00 if the conditions above are met.
- A new informational edit is being created to identify claims on the Remittance Advice that priced at $1,000.00 for a forensic service. The J97 message, "Payment Increased to $1,000.00 for Forensic Services", will appear on the Remittance Advice for applicable claims.
For Medicaid-eligible FFS sexual assault survivors, providers must submit all claims and attachments electronically as outlined in the November 24, 2021, provider notice. HFS will no longer return paper UB-04 claims to the provider. At this time, HFS asks hospitals to hold applicable electronic FFS claims until they are notified that system pricing updates have been completed.
For non-Medicaid eligible sexual assault survivors, providers must submit claims on a UB-04 to:
Illinois Department of Healthcare and Family Services
Sexual Assault Emergency Treatment Program (ISAETP)
P.O. Box 19129
Springfield, Illinois 62794-9129
ISAETP does not accept electronic claims. UB-04 claims for the non-Medicaid eligible population may continue to be submitted without delay.
For the MCO covered population, hospitals should contact the appropriate HCI MCO for specific billing information.
Questions regarding this notice may be directed to the Bureau of Professional and Ancillary Services at 877-782-5565 for FFS claims or to the applicable HCI MCO plan.
Kelly Cunningham, Administrator
Division of Medical Programs
Attachment A - Diagnosis Codes for Sexual Assault Survivor Claims
|O9A411||Sexual abuse complicating pregnancy, first trimester|
|O9A412||Sexual abuse complicating pregnancy, second trimester|
|O9A413||Sexual abuse complicating pregnancy, third trimester|
|O9A419||Sexual abuse complicating pregnancy, unspecified trimester|
|O9A42||Sexual abuse complicating childbirth|
|O9A43||Sexual abuse complicating the puerperium|
|T7421XA||Adult sexual abuse, confirmed, initial encounter|
|T7421XD||Adult sexual abuse, confirmed, subsequent encounter|
|T7421XS||Adult sexual abuse, confirmed, sequela|
|T7422XA||Child sexual abuse, confirmed, initial encounter|
|T7422XD||Child sexual abuse, confirmed, subsequent encounter|
|T7422XS||Child sexual abuse, confirmed, sequela|
|T7621XA||Adult sexual abuse, suspected, initial encounter|
|T7621XD||Adult sexual abuse, suspected, subsequent encounter|
|T7621XS||Adult sexual abuse, suspected, sequela|
|T7622XA||Child sexual abuse, suspected, initial encounter|
|T7622XD||Child sexual abuse, suspected, subsequent encounter|
|T7622XS||Child sexual abuse, suspected, sequela|
|Z0441||Encounter for exam and obs following alleged adult rape|
|Z0442||Encounter for exam and obs following alleged child rape|
|Z62810||Personal history of physical and sexual abuse in childhood|
|Z91410||Personal history of adult physical and sexual abuse|