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1 Iowa Medicaid Enterprise Welcome to FALL TRAINING 2006.

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Presentation on theme: "1 Iowa Medicaid Enterprise Welcome to FALL TRAINING 2006."— Presentation transcript:

1 1 Iowa Medicaid Enterprise Welcome to FALL TRAINING 2006

2 2 Agenda Medicaid Overview General Billing Guidelines Break! NPI and The Iowa NPI Verification Tool Provider-Specific Training Questions and Answers

3 3 Iowa Medicaid Iowa Medicaid provides health care coverage for financially-needy parents with children, children, people with disabilities, elderly people, and pregnant women. The goal is for Iowa Medicaid Members to live healthy, stable, and self-sufficient lives.

4 4 Iowa Medicaid In Fiscal Year 2006, the average monthly Medicaid enrollment was 297,000 members Growth of approximately 4 percent is projected for Fiscal Year 2007 The average Iowa cost per member is $2,200 a year. But costs vary widely

5 5 Iowa Medicaid More than half of Medicaid members are children, but they account for only 17% of the expenditures 10% are elderly, but they account for 25% of expenditures 16% are disabled, but they account for half of the expenditures

6 6 IME Facts Per month: –Average over 29,000 phone calls to Provider Services –Average 1,445 written inquiries –Respond to an average of 664 s –Process over 900 new provider enrollments, 1670 changes –Average 1.5 million claims processed 85% electronic 338,610 Medicaid members as of 7/31/06 36,000 Iowa Medicaid providers

7 7 3% Fee Increase FY 06 3% Increase Effective July 1, All processing of claims has occurred -Adjustment Reason 40 -Questions

8 8 3% Fee Increase FY 07 The 3% fee increase for Fiscal Year 2007 is still pending final approval of the State Plan Amendment that has been submitted to CMS. The IME will work together with CMS to ensure that the approval will occur as soon as possible. Due to the implementation of weekly payment cycles, the IME will be unable to give providers a separate remittance advice for the affected claims. However, we are researching methods of assisting provider in identifying the affected claims.

9 9 Top 10 Denial Reasons 1.Exact duplicate claim 2.Member not eligible 3.Missing or Invalid MediPass referral number 4.Third-party insurance should have been billed primary 5.Medicare should have been billed primary 6.Missing or Invalid member ID number 7.Procedure/Treating Provider conflict 8.Medicare paid amount is zero 9.Fragmented billing of medical services 10.Procedure/Provider Type conflict

10 10 Payment Cycles On August 7, 2006, the IME began weekly payment cycles Electronic Funds Transfer (EFT) Electronic Claims Submission

11 11 Contact Information What should you do if your claim denies? - Check your remittance advice for a specific denial reason. - Then, fix your claim and resubmit. What if you need additional assistance? Please call and let us assist you: or locally at us at:



14 14 ELVS Eligibility 24 hours a day, 7 days a week! Verify: Spend Down Lock-In Insurance Managed Health Care information NEW!! Vision and Dental Eligibility

15 15 How Can I Make the IME Work for Me? Use the IMEs internet based Web Portal Access Sign up for Electronic Funds Transfer (EFT) for your Medicaid Payments

16 16 IME Website


18 18 ELECTRONIC CLAIMS SUBMISSION All providers need to complete the appropriate EDI paperwork in order to submit electronic claims to the IME EDISS. The claims registration forms (837P, 837I, or 837D) along with the EDI Enrollment form must be completed. If using PC-ACE Pro32, complete the PC-ACE Pro32 Software Sublicense Agreement as well.

19 19 Claims Submission Issues Do not use red ink or any light-colored ink –Any light print will not show up on a scanned document Do not use high-lighters on any document –Highlighted documents will be blacked out by the scanner Position data in the center of each box Use the original Drop-out red and white CMS-1500 and UB-92 claim forms. Claims must include a valid Medicaid Provider number, member ID and dates of service in the correct boxes Diagnosis codes and procedure codes can not include descriptions On the 1500, do not use the diagnosis code in Column E On a UB, do not give the name of the attending physician On a UB, do not put your rate in Column 44 The dental form can not be used as a Prior Authorization form

20 20 Claim Submission Issues (cont) Indicate both the dollars and cents for the sub-charges and total charges The total charge box must be completed If the claim has multiple pages, total only the last page Do not staple or tape documents to the inside of envelopes Inquiry forms should not be used to submit claims Clear direction on Medicare EOBM SIQ forms must be updated at the IME prior to claim submission

21 21 Credit/Adjustment Request When to request a Credit or an Adjustment? Request a Credit if you want the IME to take back an entire payment on a claim. Request an Adjustment when there is a correction to be made on a claim (date of service, number of units, primary payment, late insurance payments, etc). Where do I find the form? (click on Providers, then Forms) Provider Manual

22 22 Credit/Adjustment Request Continued The Credit/Adjustment Request Form has three sections that must be completed. In Section A, choose Credit or Adjustment. In Section B, note the 17-digit TCN number found on the remittance advice. In Section C, sign and date the request. Do not submit a Credit/Adjustment Request if the claim is denied. Requests must be submitted one year or sooner after the date of original payment.


24 24 Provider Inquiry How can I get an answer in writing? Use the Provider Inquiry Form or the Provider Manual Submit a Provider Inquiry when you have a question regarding a claim and need to receive the answer in writing. Attach the Provider Inquiry Form to a claim and any documentation required. Fill the form out completely- include the 17-digit TCN number found on the remittance advice, describe the situation, and note your provider number, address, and phone number. Also, be sure to sign and date the form.

25 25 Provider Inquiry Continued When to use: –To initiate an investigation into a claim denial When not to use: –To add documentation to a claim –To update/change/correct a paid claim Mail Provider Inquiries to: IME PO Box Des Moines, IA 50315


27 27 Third-Party Liability Medicare Other Insurance Updating to the IME Using the SIQ form

28 28 Guidelines for Medicare Crossovers Coinsurance and deductibles only Information needed on the EOMB copy TPL payment

29 29 Prior Authorization Mail your requests to: Iowa Medicaid Enterprise Medical Prior Authorizations PO Box Des Moines, IA Questions? (Local) (Fax)

30 30 Timely Filing Guidelines Initial Filing Must be filed within 12 months of the first date of service The date of submission must be shown beside the signature on paper claims Medicare crossovers must be filed within 24 months of the first date of service Exceptions Exceptions to the 12 month filing limit are considered in only two cases: Retroactive Eligibility Third-party related delays

31 31 Timely Filing Guidelines Continued Resubmissions If a claim is filed timely but denied, an additional 12 month follow up period is allowed. These claims must be submitted on paper with the original filing date noted. Claim Adjustments Requests for claim adjustments must be made within 12 months of the payment date. Claim credits or partial refunds are not subject to a time limit.

32 32 Iowa Administrative Code (4) Recipients must be informed before the service is provided that the recipient will be responsible for the bill if a non-covered service is provided. The member must be informed of the date and procedure that will not be covered by Medicaid. This information must be noted in the patients file.

33 33 Iowa Medicaid Eligibility Cards Green Card: Traditional fee-for-service Medicaid members. Also Medically Needy Members who have met their spenddown Pink Card: Managed Health Care members (MediPASS and HMO) Blue Card: Lock-in recipients Violet Card: Qualified Medicare Beneficiaries (QMB), as well as Alien-Status individuals with limited benefits IowaCare Card: Members are covered if seen at the University of Iowa Hospitals and Clinics, Broadlawns Medical Center, and the States four Mental Health Institutions at Cherokee, Clarinda, Independence, and Mt. Pleasant Notice of Decision: Presumptively eligible women. Coverage is for: Women who have or may have breast or cervical cancer. Applies to all Medicaid covered services Pregnant women. Applies to ambulatory prenatal care only

34 34 For information about the Iowa Plan, members may call Providers may call the ELVS line for Iowa Plan eligibility at or For information regarding the Iowa Plan, providers should call Magellan at Iowa Plan for Behavioral Health

35 35 Managed Health Care Comprised of MediPASS and any HMO contracted with DHS. Primary Care Providers can be one of the five provider types that provide primary care services. Managed Care is mandatory in many counties in the State of Iowa. Providers of care must obtain a referral from the provider listed on the members Medicaid Eligibility Card.

36 36 The Medically Needy Program This program provides medical coverage to people who incur high medical expenses but have too much income or resources to qualify for regular Medicaid. Enrolled members are eligible for payment of all services covered by Medicaid except: –Care in a nursing facility –Care in an intermediate care facility for the mentally retarded –Care in an institution for mental disease

37 37 The Medically Needy Program Spenddown If a members income exceeds a set amount, the individual will be required to spenddown some of their income by paying for a portion of outstanding medical expenses before receiving a Medicaid Card. Submitting Claims If a member has not met spenddown, he/she will not have a Medicaid card. A Medically Needy member is responsible for payment of services used to meet spenddown.

38 38 Lock-In Program To refer members with potential issues in utilizing Medicaid services, contact Iowa Medicaid Medical Services at or and press the option for medical inquiries.

39 39 Exception To Policy Providers or members may request an Exception to Policy in order to have a member receive a service that is not normally covered by Iowa Medicaid. Mail or fax the request to: Department of Human Services Appeals Section 1305 E Walnut Street, 5th Floor Des Moines, IA FAX (515) OR….

40 40 Exception To Policy Complete the Exception to Policy form online at You will receive a letter signed by the Director if the request is approved. Submit an original claim form with a copy of the approval letter to: Exception Processing Hoover State Office Building 1305 E. Walnut Des Moines, IA 50315

41 41 Education and Outreach The Education and Outreach Staff is a pro-active team that provides training for providers. We can help you with the following: Pro-active Educational Issues On-site Training Sessions for Providers PC ACE Pro32 software Fall Training!

42 42 Break Time!!

43 43 National Provider Identifier (NPI) What is NPI? - The NPI is the standard unique health care identifier for providers. The old health care provider identifiers are being replaced by the new NPI. The new NPI number will be the primary identification for the provider after May 23 rd, All entities covered by HIPAA will have to obtain a NPI number by May 23 rd, Why do I need an NPI? - Due to federal regulations, starting May 23 rd, 2007, providers must start using the NPI system. Under HIPAA, all providers covered must register, obtain, and use the HIPAA identification code when making transactions between covered entities.

44 44 National Provider Identifier (NPI) (continued) How do I get an NPI? - To register for your National Provider Identifier (NPI) number click on: The NPPES site will instruct you on how to register and obtain an NPI.

45 45 National Provider Identifier (NPI) (continued) –IME will gather all providers NPI number(s) between October and the end of December 2006 –This process is web-based through the Iowa NPI Verification Tool –This tool is operational and ready to be accessed effective October 9, 2006 –It is an easy-to-use web portal developed to gather your NPI number(s)

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48 48 Confirmation You will receive the following You have created a new account with the Iowa NPI Verification Tool. To complete the account creation process, please click on the following link and fill out the Registration Confirmation Form. You will be asked to supply a Confirmation Code. Your unique Confirmation Code is shown below. Confirmation Code = xxxxxxxxxxx The most accurate way to enter the Confirmation Code is to cut and paste from this to the form. Once the account has been established, please access the home page using the following link: https://www.imeservices.org

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