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Hospitals and Long Term Care facilities, ensure compliance with the Illinois Association of Medicaid Health Plans Billing Guidelines for value code 80 and 81 claim submissions

Date: 08/17/26

Provider billing reminder for hospitals and LTC facility providers on value code 80/81 rules

Meridian would like to remind hospitals and Long Term Care (LTC) facility providers that deliver services to Meridian Medicaid Plan and YouthCare members to validate claims to ensure compliance with Illinois Association of Medicaid Health Plans (IAMHP For Providers) Billing Manual.

Specific Value code Guidance

The Illinois Department of Healthcare and Family Services (HFS) requires hospital and Nursing home providers to follow the correct calculation for value code 80/81 claim submissions for covered and non-covered days.

Bill frequency “1” and “4” claims

If a provider bills an admission through discharge claim (claim frequency equal to 1) or final interim billing (claim frequency equal to 4) and the statement from and through period, discharge status code billed and room and board units do not align in the correct value codes 80/81 for the claim, the claim submission will deny as shown:

EX 8K - INPATIENT/LTC INCORRECT COVERED DAYS -DOS SPAN VALIDATION FINAL BILLS*

Below are HFS guidelines for these values as noted in the IAMHP Billing Guidelines

  • All inpatient claims must report the covered and non-covered days
  • The sum of covered and non-covered days must correspond to the statement covers period in FL 6 and should not reflect the day of discharge except as noted below.
    Example: From Date 3/1/26 to Thru Date 3/15/26 - Value code 80/81 = 14 days
  • If bill frequency type code (on CLM Segment) is a 1 or 4, include the day of discharge in covered/non-covered day calculations if the patient is deceased and utilize the following discharge status codes:
    • 20-29 Expired
    • 40 Expired at home
    • 41 Expired in a medical facility (e.g. hospital, SNF, ICF, or free-standing hospice)
    • 42 Expired – place unknown
    • Example: From date 3/1/26 to thru date 3/15/26 - value code 80/81 = 15 days
  • If the “statement from and “statement through” date are the same and a room and board revenue code is billed, the appropriate value code 80 or 81 can equal 1.
    • Example: From date 3/1/26 to thru date 3/1/26 - value code 80/81 = 1 day
  • When submitting claims that are reimbursed on a DRG basis, only report value code 80 as the total days of stay, even if all days are not approved via authorization
  • Claims paid by Per Diem reimbursement should have the appropriate covered and noncovered days reported to match the authorization.

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The following are some examples of claims denials with EX 8K

Example 1

In this example, the nursing facility did not add the additional day allowed for the day of death reimbursement:

Bill type is 214 and patient is deceased as denoted in Box 17 equal to “20”

The value code and room and board should be 6 based on the “Statement From and Statement Through” billed on this ‘final’ claim (Bill Type: 214). Claim is incorrecly billed with 5.

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Example 2

Hospital did not add the additional day allowed for the day of death reimbursement:

Bill type is 111 and patient is deceased as denoted in Box 17 equal to “41”

The value code and room and board should be 18 based on the “Statement From and Statement Through” billed on this incorrect final claim (bill type 111). Claim is incorrectly bill with 17.

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Example 3

Psychiatric hospital did not add the correct line room and board values

Bill type is 111 and patient is routinely discharged as denoted in Box 17 equal to “01”

The value code and room and board should be 8 based on the “Statement From and Statement Through” billed on this final claim (bill type 111).

The room and board units must balance to the “Value code 80/81” submission at the line level.

The day not covered should be denoted as it’s own line to balance the units of room and board (0124) to the value code 80/81 submission of 8.

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Interim Claims: Bill Frequency 2 and 3 Claims

If a provider bills an Interim-first claim (claim frequency equal to 2) or Interim-continuing claim (claim frequency equal to 3) and the statement from and through period, discharge status code billed and room and board units do not align in the correct value codes 80/81for the claim, your claim will deny:

EX 9M - INPATIENT/LTC INCORRECT COVERED DAYS -DOS SPAN VALIDATION INTERIM BILLS*

HFS guidelines for Interim claim are denoted in the IAMHP Billing Guidelines as follows:

Claims for inpatient services rendered and paid by per diem reimbursement methodology cannot be split unless the stay crosses calendar months.

Hospitals reimbursed with the DRG methodology cannot submit interim claims. A single claim for the entire period covering admission through discharge should be submitted, unless the category of service (COS) changes during the stay. If the COS changes during the inpatient stay, two claims would be submitted.

Guidelines for Interim Claims

  • Interim claims are defined by using bill frequency type code equal to 2 or 3 and a patient status 30
  • If bill frequency type code is 2 or 3 is used, include day of discharge in covered/non-covered day calculations

Descriptions for covered/non-covered day calculations (Value code 80/81)

  1. Bill frequency type code = 1: Admit through Discharge Claim = (DOS Thru Date – DOS from Date). This is NOT an interim claim.
    • bill frequency type code 1 can be billed with less than 30 days and CAN cross months.
  2. Bill frequency type code = 2: Interim-First Claim = (DOS To Date – DOS From Date) +1
    • bill frequency type code 2 can be billed for less than a full calendar month beginning with the admission date but CANNOT cross months. If the patient is admitted on the last day of the month, the last day of the month can be billed as 1 day, with the “Statement From” and “Statement To” dates both equal to the last day of the month.
  3. Bill frequency type code = 3: Interim-Continuing Claim = (DOS To Date – DOS From Date) +1
    • bill frequency type code 3 cannot be billed for less than a full calendar month and CANNOT cross months
  4. Bill frequency type code = 4: Interim-Final Claim = (DOS To Date – DOS From Date)
    • bill frequency type code 4 can be billed with less than a full calendar month ending with the discharge date but CANNOT cross months.

Example Claim

  • Psychiatric hospital did not follow interim billing guidance for Illinois Medicaid
  • Bill type is 112 and patient is still a patient as denoted in Box 17 equal to “30”
  • Since this is the first interim claim, it cannot cross months. The facility must bill 4/16/2026 – 4/30/2026 for 112 and then the month of May claim can be the remaining service on the bill. If the patient was discharged, the bill type should be 114 and then the value code calulations for that bill type must be adhered to and would not include the date of discharge as being eligible for the per diem (if the patient is not deceased)
  • The room and board units must balance to the “Value code 80/81” submission at the line level

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For questions, please contact Provider Services at 866-606-3700 or reach out to your Provider Engagement contact. For detailed billing requirements information, download the IAMHP Billing Guide.

*CARC 16/RARC MA32