Home care billing in Illinois

Split by enrollment. HealthChoice Illinois covers families and children, adults eligible under the Affordable Care Act, seniors and adults with disabilities who are not eligible for Medicare, special needs children including youth in care and former youth in care, and the MLTSS population: dual Medicare-Medicaid eligible adults receiving certain long term services and supports. MLTSS customers receive some long term services and supports, along with some mental health and transportation services, from their HealthChoice Illinois plan, and customers in a nursing facility or an HCBS waiver who opted out of MMAI were required to participate in HealthChoice Illinois under MLTSS.¹⁰ The Medicare-Medicaid Alignment Initiative ended December 31, 2025 and its members moved to fully integrated dual eligible special needs plans on January 1, 2026. The HFS page does not spell out which waiver services a plan pays for each population, so the member's plan assignment in MEDI and the plan's own provider manual decide where a waiver claim goes.

Hybrid. HHAeXchange is the state's EVV vendor and aggregator; an agency can use any qualified EVV vendor, but the visit data must still be submitted to HHAeXchange. EVV applies to personal care services under six HCBS waivers (Persons with Disabilities, Brain Injury, HIV/AIDS, Elderly, Adults with Developmental Disabilities, and Children and Young Adults with Developmental Disabilities Support) and to home health care services under the State Plan or a waiver, including the Medically Fragile Technology Dependent waiver.⁹ Dates on the HFS page: September 1, 2023 for the developmental disabilities waivers, December 31, 2023 for home health services, and March 2, 2026 for data integration for DRS and Department on Aging providers. Each visit must capture the type of service, the recipient, the date, the location, the provider and the start and end times.

Services under EVV⁹

• Personal care services under the Persons with Disabilities waiver
• Personal care services under the Brain Injury waiver
• Personal care services under the HIV/AIDS waiver
• Personal care services under the Elderly waiver
• Personal care services under the Adults with Developmental Disabilities waiver
• Personal care services under the Children and Young Adults with Developmental Disabilities Support waiver
• Home health care services under the State Plan or a waiver, including the MFTD waiver: nursing, physical therapy, occupational therapy and speech therapy provided in the home

Home health under the HFS Handbook for Home Health Agencies (Chapter R-200) needs a direct order from an MD, DO, APN or PA and a plan of care on the CMS 485, reviewed by the practitioner at least every 60 days, and the participant does not have to be homebound. One skilled nurse home assessment visit may be made without prior approval and is billed with modifier U2; skilled nursing and home health aide services at daily frequency or less are exempt from prior approval for the first 60 days after discharge from an acute care or rehabilitation hospital when care starts within 14 days of discharge; physical and occupational therapy always need prior approval, speech therapy needs it for adults 21 and older, and all in-home shift nursing needs prior approval.¹¹ The initial therapy evaluation visit is exempt from prior approval and billed with U2, and continuation past the first 60 days or past the approval period, exhausted Medicare benefits and more than one visit a day all require approval. A prior approval never decides eligibility, ends when the participant enrolls in an MCO (requests then go to the plan), and is rejected on the claim if it was not obtained. The face-to-face encounter must occur within 90 days before or 30 days after the start of care, may be done by telehealth, is submitted with the plan of care for services that need prior approval and kept in the record either way, and does not apply to recertifications or aide-only services.

Fee-for-service home health claims go to HFS as 837P electronic transactions when no attachment is needed, and all claims, including corrected and resubmitted claims, must be received within 180 days of the date of service; a claim adjudicated first by Medicare or its fiscal intermediary has 24 months from the date of service.¹¹ Paper HFS 2212 Health Agency Invoices with an HFS 1624 Override Request are still used in four cases: Medicare denied the visit for homebound status (attach the EOMB or demand denial), the participant entered or left a long term care facility on the day of the visit, the participant lives in a residential facility that is not paid for skilled services, or eligibility was backdated, with 180 days from the date eligibility was approved. The HFS 194-M-C Billing Certification Form on each remittance advice must be signed and kept for three years. In-home shift nursing bills the approved hourly rate times hours per day, rounding a partial hour up as a unit while reducing the charge to the actual time.

Palmetto GBA, the home health and hospice contractor for A/B MAC Jurisdiction M, processes Medicare home health and hospice claims for Illinois agencies, not the A/B MAC that handles Illinois physician claims.¹⁹ On the licensing side, IDPH's home health page explains that Illinois licenses home health agencies under the Home Health, Home Services, and Home Nursing Agency Licensing Act (210 ILCS 55), administered by the Illinois Department of Public Health under Administrative Code Part 245. A home health agency is a public agency or private organization that provides skilled nursing services and at least one other home health service under a plan of treatment for illness or infirmity prescribed by a physician, podiatrist or health care professional, and the same page carries the Medicare certification process references for agencies that bill Medicare. The Act licenses home services agencies (non-medical) and home nursing agencies as separate types, so an agency that adds skilled care or drops it changes license category.