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Iowa Medicaid Enterprise

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Presentation on theme: "Iowa Medicaid Enterprise"— Presentation transcript:

1 Iowa Medicaid Enterprise
Welcome To Fall Training 2005

2 Provider-Specific Training
Agenda Medicaid Overview Break! Provider-Specific Training Questions and Answers



5 Eligibility 24 hours a day,
ELVS Eligibility 24 hours a day, 7 days a week! Verify: Spend Down Lock-In Insurance Managed Health Care information

6 IME Website WWW.IME.STATE.IA.US Enroll Providers Download forms
Check eligibility Claim status Sign up for provider training Get training materials Access informational releases Download the Provider Manuals Fee schedules Research emergency diagnosis codes Use the Provider registry Frequently Asked Questions Contact information Electronic Claim Submission information Get information regarding rates, assessments, new programs, etc. Access policy information

7 How Can I Make the IME Work for Me?
Use the IME’s internet based Web Portal Access Sign up for Electronic Funds Transfer (EFT) of your Medicaid Payments AND

8 How Can I Make the IME Work for Me?
Use the correct Address when sending documents to the IME Medicaid Claims IME PO Box Des Moines, IA 50315 Correspondence PO Box 36450 Claims Only No checks please Provider inquiries Credit/Adjustments Provider Enrollment

9 To enroll, contact IME EDISS to obtain a
WEB PORTAL The IME Web Portal allows you to check eligibility and claims status online! To enroll, contact IME EDISS to obtain a Login ID and Password. 10AM-4PM

10 OR… Web Portal Continued
Go to the EDISS website to get the registration forms. The easiest way to access the website is to go to and click on “Electronic Data Interchange” in the “Tools” box.


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.

13 Claims Submission Issues
Claims must include a valid Medicaid Provider number in the correct box on the claim form No black and white claim copies Use the original “Drop-out” red and white CMS-1500 and UB-92 claim forms. Do not use high-lighters on any document Highlighted documents will be blacked out by the scanner Do not use red ink Red ink will not show up on a scanned document New credit and adjustment form Do not use created to look like an original Medicaid claim form. Dental Forms – ’99, 2000, and 2002 form

14 Tips for Faster Claim Processing
Do not use red ink or highlighter on any document sent to the IME For Medicare crossovers circle the claim on the Medicare EOMB. Do not rebill services that are currently in process. A provider signature is required on all non-electronic claims. If the signature field contains block letters or a computer-generated signature, it is not considered valid unless it has been initialed. Claims that are resubmitted after a year has passed since the date of service must be on paper and have the original filing date beside the signature. Don’t send resubmitted claims to Provider Services.

15 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

16 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.


18 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.

19 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 36450 Des Moines, IA 50315     


21 Third-Party Liability
If commercial insurance denies, the denial must be noted in the other coverage field on the claim form (#11d on the CMS 1500 check yes and no; occurrence code 24 on the UB-92). If commercial insurance pays, the amount of payment, including any contractual write-off must be noted on the claim form (#29 on the CMS 1500 and #54 on the UB-92). If commercial insurance pays part of a claim and denies another, the claims must be split-billed. The charges that insurance pays on should be on one claim form, and the denied charges on another. If a “lump sum” payment is made, it must be pro-rated across all charges billed to Medicaid.

22 Third-Party Liability Continued
If commercial insurance pays equal to or more than the normal Medicaid payment, Medicaid will pay $0. If the insurance payment is less than the Medicaid allowable, Medicaid will pay the balance up to the Medicaid allowable charge. If a member’s primary insurance pays to the member or the member’s family, the provider must be able to collect that payment from the member before Medicaid can be billed. If the member does not turn over payment, they will be liable for the claim.

23 Medical and Dental Prior Authorization
Mail your requests to: Iowa Medicaid Enterprise Medical Prior Authorizations PO Box 36478 Des Moines, IA Questions?      (Local)      (Fax)

24 Guidelines for Medicare Crossovers
Medicaid pays only coinsurance/deductibles on Medicare crossover claims. If submitting a claim that has not “crossed-over” or if there is commercial insurance information that needs to be noted, submit only the Medicare EOB on paper. Note the member’s Medicaid ID, your billing provider number, and if commercial insurance paid, write “TPL paid $____”. If commercial insurance denied, write “TPL denied”. Submit only the Medicare EOB for a patient with Spendown.

25 Guidelines for Medicare Crossovers Continued
Only services approved by Medicare can be submitted as crossovers. Non-covered Medicare services should be submitted on a Medicaid claim form with the statement “Not a Medicare Benefit” written on the claim form. This applies only for payable Medicaid services. Do NOT use red ink or highlighter on the Medicare EOB. Send EOMBs to the regular claims address.

26 Timely Filing Guidelines
Initial Filing Original claim submissions 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

27 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.

28 Iowa Administrative Code 441
9.10(8) Medicaid billing. Only the following information shall be released to bona fide providers of medical services in the event that the provider is unable to obtain it from the subject and is unable to complete the Medicaid claim form without it: Patient identification number. Health coverage code as reflected on the subject’s medical card. The subject’s date of birth. The subject’s eligibility status for the month that the service was billed.

29 Iowa Administrative Code 441 Continued
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.

30 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 State’s 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.

31 Medical Resource Codes

32 Submission of Medical Records
Examples of Claims Medical Records Required Surgery that could be considered cosmetic Operative report NICU Care beyond specific time frames Daily progress reports CPT/HCPCS dump codes Detailed explanation of service, invoice, etc. Sterilization Consent Form Use of ’22’ modifier Home health claims Plan of care

33 Submission of Medical Records
Reminders for submission of medical records: When attaching medical records to claims, the records must accompany each claim submission. If more than one claim is billed, the records must be copied and submitted with each claim. Medical records are considered a part of the submitted claim and are imaged and maintained on file for future reference. If a claim is denied due to the lack of medical records, the claim can be resubmitted with the records attached.

34 Iowa Plan for Behavioral Health
The Iowa Plan for Behavioral Health is a statewide Medicaid managed care plan for mental health and substance abuse treatment services. Medicaid members enrolled with the Iowa Plan must access mental health and substance abuse treatment services through providers which are contracted with Merit Behavioral Care of Iowa to provide Iowa Plan Medicaid Services. When a Medicaid member is not enrolled with the Iowa Plan, the Medicaid fee-for-service program covers mental health and substance abuse treatment services in accordance with regular Medicaid program policies and procedures.

35 Iowa Plan for Behavioral Health Continued
For information about the Iowa Plan, members may call This number is printed on their eligibility cards. Providers may call the ELVS line for Iowa Plan eligibility at or For information regarding the Iowa Plan, providers should call Merit Behavioral Care of Iowa at

36 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 member’s Medicaid Eligibility Card.

37 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

38 The Medically Needy Program
Spenddown If 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 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.

39 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.

40 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. How to request an Exception to Policy? Mail or fax the request to: Department of Human Services Appeals Section    1305 E Walnut Street, 5th Floor     Des Moines, IA     Phone (515)     FAX (515) OR….

41 Exception To Policy Email the request to:
OR complete the Exception to Policy form online at . You will receive a letter signed by the Director if the request is approved. Once the Exception to Policy is approved, how to submit a claim for payment? Submit an original claim form with a copy of the approval letter to: IME Exception Processing Hoover State Office Building 1305 E. Walnut Des Moines, IA 50315

42 Fraud & Abuse The Iowa Medicaid Program monitors submitted billings on a pre-payment basis to ensure that payment is made for reasonable, necessary, and appropriate services. The objectives of Medicaid claim reviews are to: verify that claims paid were for services that were actually provided that were appropriate for members’ needs to identify and correct billing problems to eliminate overuse or abuse to obtain payment recovery that result from incorrect billings.

43 Fraud & Abuse Continued
To report instances of possible fraud or abuse, contact one of the following telephone numbers: Medicaid Fraud Control Unit Medicaid Surveillance & Utilization Review or

44 Outreach and Education
Education and Outreach Contacts  Jeremy Morgan, Supervisor: Phone  Leann Howland, Coordinator: Phone  Maile Johnson, Coordinator: Phone  Kathy Eshelman, Coordinator: Phone Good morning/afternoon. Thank you for joining me today to discuss an important program that affects our entire state: Medicaid. From healthcare providers and Medicaid program members to legislators and taxpayers, stakeholders in Iowa’s Medicaid Program understand that its success is critical to promoting and maintaining our citizens’ health and well-being. We also know that our success is dependent upon our ability to work together. With this in mind, we at the Department of Human Services are currently taking steps to make Medicaid in Iowa better than ever—for everyone involved. With your help, the end result will be a highly integrated health delivery model on par with those offered by the most reputable and professional managed care organizations. This new model is called the Iowa Medicaid Enterprise or IME.

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

46 Break Time!!

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