Form Hfs 2249 PDF Details

In the complex landscape of healthcare administration, the HFS 2249 form plays a pivotal role, particularly for hospitals in Illinois. Crafted by the Illinois Department of Healthcare and Family Services, this document serves as a formal request for adjustments to previously submitted claims. It demands meticulous attention to detail, covering everything from the provider's information, including name, address, and various identification numbers, to the specific details about the service provided, such as the date of service, patient details, and the reason for the requested adjustment. Each section, including voucher and provider reference numbers, payee and provider numbers, as well as specific codes related to the adjustment, has been thoughtfully designed to ensure clarity and precision in the adjustment process. Providers must complete this form with accurate and complete information, as any failure to do so could lead to unfavorable actions by the department. The form also includes space for both the provider's and an authorized Illinois Department of Healthcare and Family Services employee's signatures, making it a critical step in the formal process of adjusting healthcare claims. Approval from the Forms Management Center underscores the form's importance and legitimacy in the administrative procedures of healthcare services in Illinois.

QuestionAnswer
Form NameForm Hfs 2249
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesHFS, PAYEE, seq, unfavorable

Form Preview Example

State of Illinois

Illinois Department of Healthcare and Family Services

ADJUSTMENT (HOSPITAL)

1. DOCUMENT CONTROL NUMBER (Dept Use Only)

AAH

2. PROVIDER NAME, ADDRESS, CITY,STATE, ZIP

61

3.PAYEE NUMBER

4.PROVIDER NUMBER

5.PROVIDER NPI NUMBER

ADJUSTMENT TO

6.VOUCHER NUMBER

7.DOCUMENT CONTROL NUMBER

8. COS 9. DATE OF SERVICE

10. PROVIDER REFERENCE NUMBER

11.RECIPIENT NAME (FIRST, MI, LAST)

12.RECIPIENT NUMBER

13.DATE OF BIRTH

FOR PROVIDER USE ONLY

14. REASON ADJUSTMENT REQUESTED

Completion Mandatory, 305 ILCS 5/1-1 et seq. Failure to This is to certify that the information above is true, accurate and complete complete may result in the department taking unfavorable

action. Form has been approved by the Forms Management Center.

 

 

 

 

 

 

15. PROVIDER SIGNATURE

 

 

16. DATE

 

 

 

 

 

 

 

 

 

 

 

 

FOR ILLINOIS DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES

 

 

 

 

 

 

 

17. PROCESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TYPE

18. CAT SERVICE

19. CREDIT AMT

20. DEBIT AMT

21. REASON CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

22. REASON ADJUSTMENT MADE OR DENIED

 

 

23. EMPLOYEE

 

 

24. DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

25. AUTHORIZED HFS SIGNATURE

HFS 2249 (R-8-11)

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1. Begin completing the hfs 2249 form with a group of necessary blanks. Gather all of the required information and make certain not a single thing omitted!

How to complete Illinois part 1

2. After filling in this section, go on to the subsequent step and fill in the essential particulars in these fields - REASON ADJUSTMENT REQUESTED, Completion Mandatory ILCS et seq, This is to certify that the, FOR ILLINOIS DEPARTMENT OF, PROCESS TYPE, CAT SERVICE, CREDIT AMT, DEBIT AMT, REASON CODE, PROVIDER SIGNATURE, DATE, REASON ADJUSTMENT MADE OR DENIED, EMPLOYEE, DATE, and HFS R.

Step number 2 in filling in Illinois

You can potentially make errors when completing the This is to certify that the, thus make sure that you take a second look before you finalize the form.

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