Provider Enrollment

Provider Enrollment Process

The Iowa Medicaid Enterprise (IME) has developed a visual aid to help prospective providers better understand the process for enrolling with IME. This only describes the IME enrollment process. Once a provider is enrolled with the IME, they must go through the Managed Care Organization (MCO) credentialing process. Download and print the Provider Enrollment Process Flow Chart.

Provider Application Fees

The Iowa Medicaid Enterprise will require an application fee for newly enrolling and re-enrolling institutional providers effective August 1, 2016. Code of Federal Regulations section 455.460 requires institutional providers to pay the application fee with initial applications for new enrollment, applications for a new practice location and any re-enrollment. For more information, please refer to the Frequently Asked Questions or contact Provider Enrollment at 1-800-338-7909 (option 2) or in Des Moines 515-256-4609 (option 2) or by email at IMEProviderEnrollment@dhs.state.ia.us.

Enrolling as an Iowa Medicaid provider:

Providers wanting to enroll as an Iowa Medicaid provider must submit an enrollment application to the Iowa Medicaid Enterprise (IME) Provider Enrollment Unit. No payment will be made to a provider for services prior to the effective date of the department's approval of an application. The enrollment application is used to screen and verify that provider has met federal regulations and state requirements prior to enrollment.

How to Enroll as an Iowa Medicaid Provider:

Document on How to Enroll as an Iowa Medicaid Provider
Sample Documents for Home- and Community-Based Services (HCBS) and Habilitation Providers

Required Documents for Enrolling as an Iowa Medicaid Provider:

If your Tax ID is already active and enrolled with the Iowa Medicaid Enterprise (IME) and you need to add a sub-part or an individual, please complete "Section B" of the Iowa Medicaid Universal Provider Enrollment Application (Form # 470-0254) shown above.

How to Enroll as an Ordering/Referring Provider:

Before Iowa Medicaid can reimburse for services or medical supplies resulting from a practitioner's order, prescription, or referral, the Affordable Care Act requires that the practitioner be enrolled in Medicaid. To address this new requirement and to encourage non-enrolled practitioners to enroll in the IME, a simplified application for practitioners who only order, prescribe, and refer Iowa Medicaid members for services or supplies is available. The Ordering/Referring Provider Application, 470-5111, is available at the link below along with the other necessary documents to complete enrollment.

Providers already enrolled as Iowa Medicaid providers do not need to do anything new.

Practitioners not otherwise enrolled as Iowa Medicaid providers may enroll as ordering/referring providers.

Questions in completing this application may be directed to Iowa Medicaid Enterprise Provider Enrollment Unit at (800) 338-7909 (option 2) or (515) 256-4609 (option 2).

Enrolling as an Iowa Medicaid provider in the Waiver program:

The following page provides information for both Individual Consumer Directed Attendant Care (CDAC) providers and Agency / Business waiver providers.

Enrolling as an Iowa Medicaid provider in the Chronic Condition Health Home program:

A Health Home enables providers to offer additional services for members with specific chronic conditions. Providers must meet standards outlined by the state and seek patient centered medical home (PCMH) recognition within 12 months of enrolling in the program. To facilitate a team-based, community focused approach, providers participating as a Health Home must connect to the Iowa Health Information Network (IHIN).

Enrolling as an Iowa Medicaid Provider in the Integrated Health Home Program:

An Integrated Health Home (IHH) is a team of professionals, including family and peer support services, working together to provide whole-person, patient-centered, coordinated care for adults with a serious mental illness (SMI) and children with a serious emotional disturbance (SED). This includes individuals currently receiving Targeted Case Management (TCM) and Case Management through Medicaid- funded Habilitation. Care coordination is provided for all aspects of the individual's life and for transitions of care the individual may experience. The IHH is required to assist individuals with their paper work and guide them through the application process for benefits for which they qualify. The IHH is required to coordinate all services for an individual, including medical, behavioral, and community services regardless of the funding sources for those services.

Program Integrity Provisions of the Affordable Care Act (ACA) for Provider Enrollment and Screening:

To improve the program integrity of the Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP) programs, the Patient Protection and Affordable Care Act (ACA) requires these programs to screen and enroll all providers associated with the program. For the IME, the new requirements are more extensive than the previous screening procedures and include enrolling providers who were not previously required to enroll in Medicaid. The changes will allow Medicaid programs to more effectively monitor and restrict those individuals or entities who purposely defraud and abuse the Medicaid system.

Provider Quality Management Self-Assessment:

The Home and Community-Based Services (HCBS) Provider Quality Management Self-Assessment will be required of all providers enrolled for the services identified, regardless of whether those services are currently being provided. All sections of the self-assessment must be completed as requested (Sections A, B, C, D, E, and F) and submitted as a single document by the deadline indicated each year.

Excluded Individuals and Entities:

A searchable, online database for all individuals and entities excluded from participation with Iowa Medicaid. This is a national list maintained by the US Department of Health and Human Services, Office of the Inspector General and is regularly updated.

Rights and Responsibilities

Program Integrity Provisions of the Affordable Care Act (ACA) for Provider Enrollment and Screening

To improve the program integrity of the Medicare, Medicaid, and the Childrens Health Insurance Program (CHIP) programs, the Patient Protection and Affordable Care Act (ACA) requires these programs to screen all enrolling and re-enrolling providers associated with the program according to the federally identified categorical risk level of a provider type. For the Iowa Medicaid Enterprise (IME), the new requirements are more extensive than the former screening requirements and include enrolling providers who were not previously required to enroll in Medicaid. The changes will allow Medicaid programs to more effectively monitor and restrict those individuals or entities who purposely defraud and abuse the Medicaid system.

Screening Levels and New Screening Requirements:

The federally identified categorical risk level of a provider type (limited, moderate, high) is based on national statistics of the provider types risk of fraud, waste or abuse. The following outlines each risk level and the corresponding new screening requirements for provider types in each risk category:

Limited Risk

Limited risk providers will be subject to verification that the provider meets applicable federal regulations or state requirements for their specific provider type, state licensure verification and database checks both before and after enrollment in order to ensure that applicable enrollment criteria are met.
Screening Requirements:

Provider license check List of Excluded Individuals/Entities(LEIE)
Check at enrollment and monthly
System for Award Management (SAM)
Information on providers who have been debarred, suspended, excluded or disqualified
Check at enrollment and monthly Social Security Administration (SSA) Death Master File
Nation-wide check National Plan and Provider Enumeration Systems (NPPES)
To check National Provider Identifiers Medicare Exclusion Database (MED) Medicaid and Childrens Health Insurance Program State Information Sharing System (MCSIS)
List of Terminated providers in all states Provider Enrollment Chain and Ownership System (PECOS)
Providers enrolled in Medicare

Moderate Risk

Moderate risk providers will be subject to pre- and post- enrollment site visits wherein the IME will verify that the information submitted by the provider is accurate and will determine compliance with federal and state enrollment requirements. The IME is not required to conduct site visits on those providers who have already been screened as a moderate risk provider type by Medicare or another States Medicaid or CHIP program within the previous twelve months.

Screening Requirements:

All screening requirements associated with the Limited risk category
Conduct Pre- and Post- enrollment site visits

High Risk

High-risk providers include newly enrolling home health agencies and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers or enrolling a new practice location. In addition to those screening procedures that are conducted under the limited and moderate risk categories, these providers will be subject to criminal background checks and fingerprinting.