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                Get Hfs 1443 Form
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How to fill out the Hfs 1443 Form online
The Hfs 1443 Form is essential for providers to submit billing claims efficiently. This guide provides clear, step-by-step instructions for completing the form online, ensuring that all necessary information is correctly captured.
Follow the steps to successfully complete the Hfs 1443 Form online.
- Click ‘Get Form’ button to obtain the form and open it in your online editor.
- Enter the provider’s first and last name in the 'Provider Name' field, ensuring accurate spelling.
- Fill in the 'Provider Number' field with the provider's NPI (National Provider Identifier).
- Enter the one-digit code of the payee to whom payment is to be sent in the 'Payee' field.
- Leave the 'Role' and 'Emer' fields blank, as they are not required.
- If applicable, enter the street address of the provider’s primary office in the 'Provider Street' field. Note that this entry is conditionally required.
- Fill in the 'Facility & City Where Service Rendered' field if the Place of Service Code in Field 23 is other than 11 (office) or 12 (home).
- Enter the patient's name in the 'Recipient Name' field exactly as it appears on the patient's MediPlan Card.
- In the 'Recipient Number' field, input the nine-digit number from the patient's MediPlan Card without any punctuation or spaces.
- Provide the patient's birth date in the format MMDDYYYY in the 'Birth Date' field.
- Complete the 'Primary Diagnosis Description' and 'Primary Diag. Code' fields with the appropriate information for the patient’s condition.
- Fill in the 'Date of Service' field using the MMDDYY format to indicate when the service was provided.
- Ensure you complete the 'Claim Summary Fields' at the bottom of the form, including Total Charge, Total Deductions, and Net Charge.
- Review all information for accuracy, then save your changes, download, print, or share the completed form.
Complete your Hfs 1443 Form online for efficient processing of your claims.
In Illinois, the state Medicaid program is officially known as the Medical Assistance Program. This program provides essential health coverage for low-income individuals and families. For applicants, completing the Hfs 1443 Form is an integral step, as it helps determine eligibility and benefits. Understanding this program can empower you to make informed health decisions.
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