1. Iowa Medicaid Enterprise
Welcome to
FALL TRAINING
2006

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

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. 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. 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. 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. 3% Fee Increase FY ‘06 3% Increase Effective July 1, 2005
All processing of claims has occurred
Adjustment Reason 40
Questions

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

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

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:

12. CONTACT INFORMATION
IME
Addresses

13. CONTACT INFORMATION CONTINUED
IME
Phone
Numbers

14. Eligibility 24 hours a day, 7 days a week!
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. 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)
for your Medicaid Payments

16. IME Website

17. ELECTRONIC CLAIMS SUBMISSION
EDISS
(ELECTRONIC DATA INTERCHANGE SUPPORT SERVICES)
PC ACE PRO32 SOFTWARE
(It’s Free!)

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. 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. 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. 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. 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. 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. 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
    

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

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

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

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. 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. Iowa 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.

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 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

34. Iowa Plan for Behavioral Health
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

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 member’s Medicaid Eligibility Card.

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. 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.

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. Mail or fax the request to: Department of Human Services
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. 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. 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. Break Time!!

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 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.

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. 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)

48. Email 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 = 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: