Il444 4198 Form PDF Details

Understanding the complexities and requirements of the IL444 4198 form, utilized by the Illinois CMS Department of Central Management Services Risk Management Division, is crucial for managing medical bill transmittals within the state's risk management framework. This form serves as a critical conduit for the payment process of medical bills related to worker's compensation, claims management, and other medical services necessitating state oversight. It meticulously outlines the need for client and vendor information, detailed account and service data, and a comprehensive record of the service period. Additionally, the form categorizes types of services to streamline the payment processing procedure. It emphasizes the significance of accompanying documentation – such as discharge summaries, radiology reports, and medical tests results – without which, the submission will be returned unprocessed. A distinctive feature is the dual acknowledgment section for payment approval or denial, signed off by an adjuster, ensuring a clear decision pathway. The IL444 4198 form embodies the state's commitment to a structured and transparent process, mandating thorough documentation to facilitate the timely and effective reimbursement of medical services.

QuestionAnswer
Form NameIl444 4198 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesmedical bill form pdf, medical bill fillable, il444 4198, fillable medical invoice

Form Preview Example

ILLINOIS

CMS DEPARTMENT OF CENTRAL

MANAGEMENT SERVICES

Risk Management Division

MEDICAL BILL TRANSMITTAL FORM

Re: Client Name: _________________________________

CF#: _______________ D/A: _____________

Vendor Name:

_________________________________

SS#: ________________________________or

Address:

_________________________________

FEIN: ________________________________

 

_________________________________

ACCOUNT#: __________________________

Received: ___________________

Dates of Service: From: __________________ To: __________________

Total Amount of Bill:

$_______________________

 

 

 

Type of Service:

 

 

 

 

 

 

 

 

Facility #: _______________

 

 

WC 02 Medical

 

WC 08 IME

 

WC 11 Rehabilitation

 

 

 

 

 

 

 

 

WC 12 Claims Management

 

 

 

 

 

 

 

 

NOTE: When submitting a bill for payment, supporting documentation and attachments are required. If any of the information is missing, this transmittal form will be returned.

MEDICAL BILLS WILL BE RETURNED IF YOU HAVE NOT SUBMITTED THE PAPERWORK TO ESTABLISH A CLAIM.

In order for the office to process the above-mentioned bill, we must have the following:

_____ Discharge Summary

_____ Radiology Report

_____ Emergency Room Report

_____ CT Scan Results

_____ Medical Report

_____ Prescription Names

_____ Test Result

 

 

Approved for Payment: ______________________________________________________________________

 

(Adjuster Signature)

(Date)

Denied for Payment:

______________________________________________________________________

 

(Adjuster Signature)

(Date)

IL444-4198 (R-06-04)

 

 

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The right way to complete il444 4198 part 1

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Filling out section 2 in il444 4198

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