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CONSENT TO STERILIZATION FORM, HYSTERECTOMY FORM, and CLAIMS GUIDANCE

Date: 09/01/23

To ensure prompt and accurate payment, Meridian Medicaid Plan (Meridian) and YouthCare HealthChoice Illinois (YouthCare) have identified opportunities for claims corrections on denied claims and best practices for first-time claim submissions.

All completed and signed consent forms must be clear and legible in scanned attachments to the electronic claim 837i. Consent forms can also be attached to the CMS-1500/UB-04 in paper format.

A completed hysterectomy form (HFS 1977) is required in its entirety before a hysterectomy procedure. The sterilization form (HFS 2189) is required in its entirety before a sterilization procedure. Regardless of the clinical presentation of the patient, a form must be completed before a procedure.

A form is not considered complete unless it is signed and dated by the member and the physician. Forms received without the proper signatures will be denied as EXDD – signed consent form has not been received.

 

Billing Guidance

In accordance with ordinance 305 ILCS 5/3-1 et seq., the HFS 1977 hysterectomy acknowledgement form or the HFS 2189 sterilization form must be completed before a sterilization procedure is performed. Providers’ internal consent forms are not admissible as consent under this ordinance. Failure to use the appropriate form will be denied as EXNV – sterilization consent form not valid/missing information.

 

Completing Form HFS 1977

Part I must be completed in its entirety. The “Provider No.” is the Medicaid provider ID number. Leaving this or any other area blank will result in a claim denial.

Parts II and III must be signed and dated by the patient and the physician not later than the date of surgery. Forms dated after the date of surgery will be denied payment.

Part IV fill out as applicable, then sign and date.

 

Completing Form HFS 2189

Consent to sterilization must be completed and signed by the member before the procedure. Post-dated signatures on any section will not be accepted.

Interpreter statement must be completed and signed if an interpreter was utilized.

Statement of person obtaining consent must be completed, signed, and dated.

Physician statement must be completed, signed, and dated before treatment.

Additionally, the provider must cross out either paragraph one or two, whichever is NOT used. As an example, if a section used is circled, versus crossing out the section that is not used, the form is considered incomplete, and may result in a denial of claim payment.

 

The HFS hysterectomy (HFS 1977) form and the sterilization form (HFS 2189) are located on our website. Guidance can also be found on the IAMHP website.

Please login to the Meridian or YouthCare secure provider portal for updated claims information. You may also contact Meridian Provider Services at 866-606-3700, Monday through Friday, from 8 a.m. to 5 p.m., or YouthCare Provider Services at 844-289-2264, Monday through Friday, from 8 a.m. to 6 p.m.