MedicaidAdministrativeLow impact
Discontinuation of Payment Review Request Form (LTC) HFS 3725 for Dates of Service 12/01/16 and After
Illinois Medicaid - HFS·IL · Geriatrics·Provider Notice
Effective date
Dec 1, 2016
We identified it
Jun 20, 2026
Summary
Illinois Medicaid has discontinued the Payment Review Request Form (LTC) HFS 3725 for long-term care claims with dates of service on or after December 1, 2016. This form should only be used for pre-12/1/16 dates of service, and providers must submit disputes within 180 days of the relevant remittance advice.
Action Required
Immediately: Long-term care billing staff must stop using Payment Review Request Form (LTC) HFS 3725 for any claims with dates of service 12/01/16 and after. Continue using this form only for pre-12/01/16 dates of service disputes, ensuring submission within 180 days of the relevant remittance advice. Direct billing questions for dates of service 12/01/16 and after to the Bureau of Long Term Care at 1-844-528-8444.