MedicaidAdministrativeMedium impact
New UB-04 Override Request Form
Illinois Medicaid - HFS·IL·Provider Notice
Effective date
Sep 21, 2015
We identified it
Jun 20, 2026
Summary
Illinois Department of Healthcare and Family Services has introduced a new standardized form (HFS 1624A) that institutional providers must submit with UB-04 paper claim forms when requesting override of specific claim processing edits. The form must be mailed to a specific Springfield address for HFS staff review.
Action Required
Immediately: Institutional providers (hospitals, ambulatory surgical centers, hospice agencies, renal dialysis facilities, birth centers) must download HFS 1624A form from Illinois Medical Programs Forms Page. Complete this form for any UB-04 paper claims requiring override of processing edits. Mail completed override request form with paper claim to Illinois Department of Healthcare and Family Services, Bureau of Hospital and Provider Services, P.O. Box 19128, Springfield, Illinois 62794-9128. Contact 1-877-782-5565 for questions.