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November 2025
Third-Party Billing Digest: The Thank-ful Edition
A Cornucopia of Information
As we head into a season of gathering and gratitude, we’re serving up the latest updates to support your third-party billing work across Illinois. This edition brings a fresh harvest of policy reminders, resources, and timely guidance to help your claims run smoothly through the end of the year. Settle in, fill your plate with insights, and stay current on all the essentials you need for accurate, efficient billing. And, as a matter of personal indulgence, I would like to share a hearty “THANK YOU” for your continued partnership and support of our Third-Party Billing Digest. I am most thankful to work with this community!
Common Working File (CWF) Errors Leading to Medicare Claim Denials for Non-Medicare Advantage (MA) Plan Patients
A discrepancy between the HIPAA Eligibility Transition Systems (HETS) and the claims processing system has been identified, resulting in claim denials due to conflicting MA plan enrollment. This is impacting both Part A and Part B provider types. CWF errors are incorrectly showing MA plan enrollment for patients who are not actually enrolled, causing these denials.
National Government Services (NGS) is holding claims related to this issue to prevent denials. No action required by providers at this time. NGS will temporarily hold claims related to MA plan enrollment to prevent denial. Once CMS resolves the issue and implements a correction, we will adjust the affected claims.
NCCI Alert: COVID-19 Vaccine Administration Edit Revision
Some providers may have 90480 claims denied when billed in conjunction with G0008, G0009, or G0010 as a result of a Procedure to Procedure edit released in the 2025 Quarter 4 National Correct Coding Initiative (NCCI) files. On October 14, 2025, CMS issued replacement NCCI files to remove this edit. Medicare Administrative Contractors (MACs) will reprocess claims with dates of service between July 1, 2025, and October 15, 2025, within approximately 30 business days, and Medicare providers don’t need to take any action. Alternatively, a provider may also choose to use the MAC appeals process if they don’t wish to wait for the automatic adjustment to occur, or they can wait to submit impacted claims until after CMS implements the change.
More information can be found here: MLN Connect 10.15.2025 newsletter
For additional information for COVID-19 billing and coding to Medicare, click here.
Abrysvo ® Act-0-Vial ® Presentation
After October 3, 2025, ABRYSVO will only be shipped in the ACT-O-VIAL presentation from Pfizer; no other presentations will be available for sale from Pfizer after this date. Customers using other presentations should consider transitioning to ACT-O-VIAL to allow for transition timing prior to the peak of the fall vaccination season. Please note updated NDC codes for electronic medical records and billing.
Look at this!
Using School-Based Services to Improve Access to Preventive Health Care for Children in Rural Areas. Children in rural communities often have less access to preventive services than their urban peers, due to fewer practicing pediatricians and long travel distances for care. Providing health care services in school settings is one way to increase sustainable access to health care services for children living in rural communities. Read the tip sheet
Promoting Health Foundations: Medicaid Opportunities to Support Community Health Workers in Child Health Care. Community health workers (CHWs) can be integrated into school-based health centers to support the health and well-being of students. This brief highlights the impact of CHWs on child health, shares examples of CHW models supporting children, and explores how Medicaid can strengthen pediatric care through CHW integration. Read the brief
Blue Cross Blue Shield of Illinois
Mandatory training due by end of year. Contracted providers serving members in Blue Cross Community Health PlansSM and/or Blue Cross Community MMAI (Medicare-Medicaid Plan)SM must complete required annual training by Dec. 31, 2025. The Centers for Medicare and Medicaid Services and/or Illinois Department of Healthcare and Family Services requires that we make training on MMAI and BCCHP topics available to you. Learn more.
Providers can take the modules at your own pace through the links on our website. After finishing the training, you can complete the attestation link below the module for your facility, group and/or individual providers.
If you’ve already completed the annual training for another insurer, please fill out this Attestation of Training Completion and select Submit to send it to us.
Blue Cross Blue Shield of Illinois offers free webinars and workshops for contracted providers. A list of On Demand trainings and Upcoming webinars can be found here.
Molina Healthcare of Illinois invites you to join the upcoming live webinars:
- CCBCH Program in Medicaid, November 20, 11:30am. Register Here
- HFS Revalidation Town Hall, November 20, 3:00pm. Register Here
- D-SNP Plan Introduction, November 21, 2:00pm. Register Here
- Lactation Consultant Billing, Thursday, December 11, 1:00pm. Register here
- Doula Billing, Tuesday, December 16, 1:00pm. Register here Live Provider Webinars on Upcoming DSNP Plan going into effect January 1, 2026. Details to register can be found here.
- Visit the HFS website for upcoming Revalidation Town Halls (2025).
- Looking for something else? Explore the 2025 schedule of live webinars exclusively for Illinois providers. Meanwhile, register for provider updates to receive notices for upcoming sessions.
Aetna Better Health of Illinois
Quarter 4 Provider summits: Aetna Better Health of Illinois (ABHIL) wants to continue to grow and strengthen relationships with their valued provider partners. ABHIL has heard your concerns and is gearing up for some exciting and informative Provider Summits, both virtual and in-person upon request, in 2025. Be on the lookout for a calendar of events! Register Here for an upcoming Summit: https://www.surveymonkey.com/r/RNCFFS9
Aetna Better Health® of Illinois Provider claim reconsideration, member appeal and provider complaint/grievance instructions (UPDATED INSTRUCTIONS 9/11/25):
Provider claim reconsideration, member appeal and provider complaint/grievance instructions (PDF)
The Fall Newsletter can be found here.
Contact your Provider Relations representative with any questions.
BlueCross BlueShield of Illinois
A few common billing errors typically cause most denials of claims for members of Blue Cross Community Health Plans. For resources to help your claims process more smoothly and avoid delays in payment for service dates prior to August 1, 2025, visit Avoid Many Denials of Medicaid Claims with Help from New Resources | Blue Cross and Blue Shield of Illinois
The November 2025 issue of Blue Review is available here. If you have not already subscribed to receive this publication, you may sign up here.
To contact your Provider Network Consultant, visit Provider Network Consultant Assignments for more information.
The Q4 2025 issue of Humana Physician News is available here. If you have not already subscribed to receive publications from Humana, you may sign up here.
Humana’s Resource Sheet for Healthcare Providers is a one-stop resource containing essential information on a variety of important topics for providers.
Humana’s Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP) in Illinois. Illinois Department of Healthcare and Family Services is transitioning its Medicare-Medicaid Alignment Initiative (MMAI) demonstration program to a FIDE-SNP effective January 1, 2026. Find more information here.
November 2025 Monthly Provider Check-In can be found here.
Meridian recently updated Resolving Common Claims Rejections, a resource providing tips on resolving and avoiding rejected claims.
Contact your assigned Provider Engagement Administrator or representative for support. For those without an assigned representative, complete this intake form or contact Meridian using the information here.
Molina Healthcare of Illinois (MHIL)
MHIL announces an upcoming change in dental vendors for our Medicaid plan and our upcoming D-SNP plan. Beginning January 1, 2026, Molina will terminate the relationship with DentaQuest and begin a relationship with SKYGEN Dental. For more information, see the MHIL Provider Memo from November 10, 2025.
See what you missed! Molina is sharing a summary of recent news pertinent to your practice/facility. Check out their Monthly Memo Roundup.
The Fourth Quarter Provider Newsletter, Illinois Edition, can be found here.
Contact your dedicated Provider Relations Manager or email the Provider Relations team at MHILProviderNetworkManagement@MolinaHealthcare.com. To help identify your dedicated Provider Relations Manager, visit Molina's Service Area map.
The November 2025 issue of Network News contains important notifications and updates for healthcare providers and can be found here.
The November 2025 Reimbursement Policy Update can be found here.
The News Your Way feature allows you to customize your subscription to receive information and updates specific to your role, specialty, and state. Click here to subscribe or update your preferences.
Upcoming HHAeXchange Illinois Informational Sessions
Illinois Department on Aging (IDoA) and Illinois Department of Human Services – Division of Rehabilitation Services (IDHS-DRS) have recently distributed Welcome Letters to Homemaker and Home Health Care Service (HHCS) provider agencies serving Community Care Program (CCP) and Home Services Program (HSP) customers. These letters outline a March 2, 2026, HHAeXchange (HHA) go-live date and upcoming Informational sessions hosted by HHA.
Welcome letters and additional onboarding information for CCP and HSP provider agencies may also be viewed at HHA’s Illinois Information page for IDoA and DRS.
CCP and HSP Homemaker and HHCS provider agency administrators should register for the November 18, 2025, and December 2, 2025, HHA Informational sessions as soon as possible.
CCP and HSP Homemaker and HHCS provider agency administrators should ensure completion of HHA’s Provider enrollment form prior to January 19, 2026.
EVV Policy questions should be posed to IDoA at Aging.EVV.Support@Illinois.gov and IDHS-DRS at DHS.EVV@illinois.gov.
Medicaid Technical Assistance Center (MTAC)
MTAC is working to create, collect, and disseminate educational resources to help Illinois health care providers of all types, sizes, and levels of business ability successfully engage with the Illinois Medicaid program. Whether you’re already serving Illinois Medicaid customers or only starting to explore the Medicaid possibilities, MTAC is at work to provide you with:
- One-on-one technical assistance and education
- Easy-to-use and up-to-date web resources
- Stakeholder learning collaboratives
To contact MTAC or sign up for MTAC Email Updates, you can do that here.
A complete list of HFS Provider Notices can be found here.
If you have not already subscribed to receive email notifications from HFS when new Provider Notices are posted, you may subscribe here. To learn more about the many helpful resources available to healthcare providers, please visit the HFS Provider website.
If you have not already subscribed to receive email notifications from HFS when new Provider Notices are posted, you may subscribe here. To learn more about the many helpful resources available to healthcare providers, please visit the HFS Provider website.
If you have any questions or suggestions for topics that you would like to see covered in future issues of the IPHA Billing Digest, please email your suggestions and/or requests to insurancebilling@ipha.com. Your feedback is valuable and appreciated.
Thank you!
