2Agenda Medicaid Overview General Billing Guidelines Break! NPI and The Iowa NPI Verification ToolProvider-Specific TrainingQuestions and Answers
3Iowa MedicaidIowa 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.
4Iowa MedicaidIn Fiscal Year 2006, the average monthly Medicaid enrollment was 297,000 membersGrowth of approximately 4 percent is projected for Fiscal Year 2007The average Iowa cost per member is $2,200 a year. But costs vary widely
5Iowa MedicaidMore than half of Medicaid members are children, but they account for only 17% of the expenditures10% are elderly, but they account for 25% of expenditures16% are disabled, but they account for half of the expenditures
6IME FactsPer month:Average over 29,000 phone calls to Provider ServicesAverage 1,445 written inquiriesRespond to an average of 664 sProcess over 900 new provider enrollments, 1670 changesAverage 1.5 million claims processed85% electronic338,610 Medicaid members as of 7/31/0636,000 Iowa Medicaid providers
73% Fee Increase FY ‘06 3% Increase Effective July 1, 2005 All processing of claims has occurredAdjustment Reason 40Questions
83% Fee Increase FY ‘07The 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.
9Top 10 Denial Reasons Exact duplicate claim Member not eligible Missing or Invalid MediPass referral numberThird-party insurance should have been billed primaryMedicare should have been billed primaryMissing or Invalid member ID numberProcedure/Treating Provider conflictMedicare paid amount is zeroFragmented billing of medical servicesProcedure/Provider Type conflict
10Payment Cycles On August 7, 2006, the IME began weekly payment cycles Electronic Funds Transfer (EFT)Electronic Claims Submission
11Contact InformationWhat 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 atus at:
17ELECTRONIC CLAIMS SUBMISSION EDISS(ELECTRONIC DATA INTERCHANGE SUPPORT SERVICES)PC ACE PRO32 SOFTWARE(It’s Free!)
18ELECTRONIC 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.
19Claims Submission Issues Do not use red ink or any light-colored inkAny light print will not show up on a scanned documentDo not use high-lighters on any documentHighlighted documents will be blacked out by the scannerPosition data in the center of each boxUse 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 boxesDiagnosis codes and procedure codes can not include descriptionsOn the 1500, do not use the diagnosis code in Column EOn a UB, do not give the name of the attending physicianOn a UB, do not put your rate in Column 44The dental form can not be used as a Prior Authorization form
20Claim Submission Issues (cont) Indicate both the dollars and cents for the sub-charges and total chargesThe total charge box must be completedIf the claim has multiple pages, total only the last pageDo not staple or tape documents to the inside of envelopesInquiry forms should not be used to submit claimsClear direction on Medicare EOBMSIQ forms must be updated at the IME prior to claim submission
21Credit/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
22Credit/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.
24Provider Inquiry How can I get an answer in writing? Use the Provider Inquiry Formor the Provider ManualSubmit 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.
25Provider Inquiry Continued When to use:To initiate an investigation into a claim denialWhen not to use:To add documentation to a claimTo update/change/correct a paid claimMail Provider Inquiries to: IMEPO Box 36450Des Moines, IA 50315
27Third-Party Liability MedicareOther InsuranceUpdating to the IMEUsing the SIQ form
28Guidelines for Medicare Crossovers Coinsurance and deductibles onlyInformation needed on the EOMB copyTPL payment
29Iowa Medicaid Enterprise Medical Prior Authorizations Mail your requests to:Iowa Medicaid EnterpriseMedical Prior AuthorizationsPO Box 36478Des Moines, IAQuestions? (Local) (Fax)
30Timely Filing Guidelines Initial FilingMust be filed within 12 months of the first date of serviceThe date of submission must be shown beside the signature on paper claimsMedicare crossovers must be filed within 24 months of the first date of serviceExceptionsExceptions to the 12 month filing limit are considered in only two cases:Retroactive EligibilityThird-party related delays
31Timely Filing Guidelines Continued ResubmissionsIf 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 AdjustmentsRequests 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.
32Iowa Administrative Code 441 79.9(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 patient’s file.
33Iowa Medicaid Eligibility Cards Green Card: Traditional fee-for-service Medicaid members. Also Medically Needy Members who have met their spenddownPink Card: Managed Health Care members (MediPASS and HMO)Blue Card: Lock-in recipientsViolet Card: Qualified Medicare Beneficiaries (QMB), as well as Alien-Status individuals with limited benefitsIowaCare Card: Members are covered if seen at the University of IowaHospitals and Clinics, Broadlawns Medical Center, and the State’s four Mental Health Institutions at Cherokee, Clarinda, Independence, and Mt. PleasantNotice of Decision: Presumptively eligible women. Coverage is for:Women who have or may have breast or cervical cancer. Applies to all Medicaid covered servicesPregnant women. Applies to ambulatory prenatal care only
34Iowa Plan for Behavioral Health For information about the Iowa Plan, members may callProviders may call the ELVS line for Iowa Plan eligibility at orFor information regarding the Iowa Plan, providers should call Magellan at
35Managed Health CareComprised 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 member’s Medicaid Eligibility Card.
36The 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 facilityCare in an intermediate care facility for the mentally retardedCare in an institution for mental disease
37The Medically Needy Program SpenddownIf a member’s 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 ClaimsIf 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.
38Lock-In ProgramTo refer members with potential issues in utilizing Medicaid services, contact Iowa Medicaid Medical Services at or and press the option for medical inquiries.
39Mail or fax the request to: Department of Human Services Exception To PolicyProviders 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 ServicesAppeals Section 1305 E Walnut Street, 5th Floor Des Moines, IA FAX (515)OR….
40Exception To PolicyComplete 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 ProcessingHoover State Office Building1305 E. WalnutDes Moines, IA 50315
41Education and Outreach The Education and Outreach Staff is a pro-active teamthat provides training for providers. We can help you with the following:Pro-active Educational Issues On-site Training Sessions for Providers PC ACE Pro32 softwareFall Training!
43National 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 23rd, All entities covered by HIPAA will have to obtain a NPI number by May 23rd, 2007.Why do I need an NPI?- Due to federal regulations, starting May 23rd, 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.
44National Provider Identifier (NPI) (continued) How do I get an NPI?-To register for your National Provider Identifier (NPI) number click on:https://nppes.cms.hhs.gov/NPPES/Welcome.doThe NPPES site will instruct you on how to register and obtain an NPI.
45National Provider Identifier (NPI) (continued) IME will gather all providers’ NPI number(s) between October and the end of December 2006This process is web-based through the Iowa NPI Verification ToolThis tool is operational and ready to be accessed effective October 9, 2006It is an easy-to-use web portal developed to gather your NPI number(s)
48Email Confirmation You will receive the following email: 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 = xxxxxxxxxxxThe 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