• Medical Interest Penalties Request Form HFS 3805 (pdf)

INSTRUCTIONS for Requesting Interest under the Prompt Payment Act for interest alleged to be due from proper bills received by the Department of Healthcare and Family Services on or after July 1, 2002, for which the Department of Healthcare and Family Services is responsible for payment. "Proper bills received" include "Prepayment Reports" for Long Term Care Facilities which are generated by the Department. These instructions are subject to change based on the final "Joint Rules of the Comptroller and the Department of Central Management Services: Prompt Payment" 74 Ill. Adm Code 900.10 et seq.

1. Requests must be addressed as follows:
   Department of Healthcare and Family Services
   Interest Request
   Post Office Box 19127
   Springfield, IL 62763
   
2. Requests must be submitted by the provider who billed the Department or the payee who received the payment. Only requests from Provider or Payee stated on Remittance Advice will be accepted.
   
3. A request should be submitted within 90 days of the issue date of the warrant.
   
4. A separate request for each individual proper bill or invoice (Document Control Number or DCN) must be submitted to include the following information:

Requester's Name and Address For Providers, the name and address shall be the same as appears on the Provider's enrollment application with the Department. For Alternate Payees, the name and address shall be the same as appears on the Voucher for which the request is made.

Voucher Number (Pursuant to 74 Ill. Adm Code 900.90 (b)(3))

Warrant Date (Pursuant to 74 Ill. Adm Code 900.90 (b)(3)(provides estimate of the date upon which the interest penalty begins to accrue)) (By Julian or Calendar ) (Convert both this date and the Date of DCN to the same format, either Julian or Calendar.)

Payee Number Named on the Warrant (Pursuant to 74 Ill. Adm Code 900.90 (b)(2)) Regardless of the identity of the requestor, payment of any interest due will only be paid to the payee who was listed on the original voucher.)

(The above four elements do not need to be repeated for multiple requests for interest for separate DCNs for the same Requestor from the same voucher if the request is submitted in one document (multiple request document). If a multiple request document is more than one page in length then each page beginning with page 2 should be identified as "Interest request for DCNs per Voucher No. ___________, Page ___ of ___. Multiple page request documents should not be stapled, but should be paper clipped or rubber-banded.)

Document Control Number (DCN) (Pursuant to 74 Ill. Adm Code 900.90 (b)(2)(provides description of original transaction)) (10-digit number prior to 1/1/02, 12 digits after 1/1/02 - first column on voucher) Each DCN shall be stated separately, in the same order as they appear on the remittance advice, and individually numbered, 1, 2, 3 etc.

DCN Date (74 Ill. Adm Code 900.90 (b)(3) provides date a proper bill or invoice was presented to agency) (By Julian or Calendar) (The Calendar Date of DCN is determined by converting the first four digits of the DCN from its Julian representation to the regular calendar date. The first number indicates the last digit of the year and the next three numbers indicate the day of the year. (For example, DCN 2105123456 has the Julian date of 2105 which is April 15, 2002.)

Number of Days Interest Owed See CALCULATION OF ESTIMATED INTEREST DUE, below.

Total Amount Allowed for DCN (Pursuant to 74 Ill. Adm Code 900.90 (b)(2)(provides "Invoice amount") (dollar amount total for all paid services for the DCN - 7th column on voucher.)

Estimated Interest Owed (Pursuant to 74 Ill. Adm Code 900.90(b)(3), provides other information necessary to verify interest payment penalty, and 900.90(c) interest must be $5.00 or greater)) Include Estimated Amount of interest. (See CALCULATION OF ESTIMATED INTEREST DUE, below)

Certification

Each request or multiple request document shall contain a certification statement, meeting the requirements of the Department, signed and dated by an authorized representative of the requestor (contact signature).


If the certification is omitted from the request or unsigned, the request will not be processed and will be returned to the requestor.

Attach copy of page(s) from the remittance advice with the requested DCN(s) circled in black ink. For photocopying purposes, highlighted copies will not be accepted.

CALCULATION OF ESTIMATED INTEREST DUE

The interest request will be denied unless the Number of Days between Issue Date of Warrant and the Date of DCN is greater than 61 days. No interest accrues on date of payment (74 Ill. Adm. Code 900.100 (e)). Pursuant to 5 ILCS 70/1.11: The time within which any act provided by law is to be done shall be computed by excluding the first day and including the last, unless the last day is Saturday or Sunday or is a holiday as defined or fixed in any statute now or hereafter in force in this State, and then it shall also be excluded. If the day succeeding such Saturday, Sunday or holiday is also a holiday or a Saturday or Sunday then such succeeding day shall also be excluded.

Any interest determination made by the Department resulting in an amount less than $5.00 will be not be paid. (74 Ill. Adm. Code 900.90 (c))

Requestors should determine prior to submitting a request whether the request might result in an interest payment of $5.00 or more. To save administrative resources for both the requestor and the Department, requests estimated to result in less than $5.00 in interest for a DCN should not be submitted. To determine if the request computes to less than $5.00 for a DCN, the following formula may be used:

1. Issue Date of Warrant minus Date of DCN minus 61 equals interest payment days. (Example: 4/2/2003 minus 1/26/2003 equals 66 days minus 61 equals 5 interest payment days).
   
2. Multiply the interest payment days by 0.00033 (daily interest factor) to obtain the accrued interest factor. ((Example: 5 days times 0.00033 equals 0.00165 (accrued interest factor)).
   
3. Multiply the accrued interest factor by the Total Amount Allowed for DCN to obtain the amount of Estimated Interest Due. (Example: 0.00165 times $3,000 equals $4.95).