Covered Services, Rates and Payments

The Centers for Medicare and Medicaid Services (CMS) publishes a quarterly code update, which include Healthcare Common Procedure Coding System (HCPCS©), Current Procedural Terminology (CPT©), and Current Dental Terminology (CDT©) code updates. 

CMS also issues an annual international classification of diseases, tenth revision, clinical modification, and procedure coding system (ICD-10-CM, ICD-10-PCS) code updates.

Please see the most recent update below for Iowa Medicaid Fee-For-Service coverage and billing information.

2024 Bulletins

• 2024 Q1 Bulletin
• 2024 Q2 Bulletin
• 2024 Q3 Bulletin

Iowa Legislature mandated that Iowa Medicaid no longer provides coverage or payment for elective, non-medically necessary C-section deliveries. This change was effective July 1, 2013, and aligns with initiatives being undertaken by the Iowa HealthCare Collaborative, as well as by various individual hospitals and hospital systems. This diagnosis code list is split into three parts. The first is diagnosis codes that will always be payable (i.e., Group 1), the second is diagnosis codes that will require documentation to determine medical necessity and payment (i.e., Group 2), and the third list is diagnosis codes that will not be payable (i.e., Group 3). A table with these different diagnosis groups is on the following page.

Elective C-Sections Group 1

Elective C-Sections Group 2

Elective C-Sections Group 3

The payment methodology for a physician-administered drugs (e.g., J codes) that are listed as “by-report” is based on the Average Wholesale Price (AWP) for the National Drug Code (NDC) billed less 12%. The source of the AWP is Medi-Span. Then, based on legislative requirements there is a further 5% reduction then a 1% increase.

The payment methodology for Durable Medical Equipment (DME) and Medical Supply codes that are listed as “by-report” payment is based on Manufacturer’s Suggested Retail Price (MSRP) less 15%. If MSRP is not available, payment is based on invoice, cost plus 10%.

The payment methodology for Enteral Nutrition codes that are listed as “by-report” is based on AWP less 10%. If AWP is not available, payment is based on Manufacturer’s Suggested Retail Price (MSRP) less 15%. If MSRP is not available, payment is based on invoice, cost plus 10%.

The payment methodology for other procedure codes that are listed as “by-report” is based on comparison of procedure codes of similar description and complexity.  If there is no procedure code of similar description and complexity, then Provider Cost Audit (PCA) is contacted to assist with developing a fee.

Maternity care includes antepartum care, delivery services, and postpartum care. The document referenced below contains billing guidance for obstetrical (OB) codes and maternity care services. In addition, the guidance indicates what services are and are not separately reimbursable to other maternity services.

Maternity Billing Guidelines

The status indicator of the codes is determined by the Centers for Medicare and Medicaid Services (CMS) and can be changed on a quarterly basis. Providers should check the CMS website on a quarterly basis for any updates or status changes for these codes. 

A code that is listed as a status “C” code by CMS will not be paid under the Outpatient Prospective Payment System (OPPS). The member should be admitted, and the claim billed appropriately to reflect the inpatient status. Please note that any claims submitted to Iowa Medicaid with a status “C” (inpatient only code) on an outpatient claim will be denied for Medically Unlikely CCI Edit. This claim denial edit cannot be altered by Iowa Medicaid.

Skilled nursing services with Iowa Medicaid are covered in hospital based-facilities and hospital swing-beds that provide round-the-clock care. Skilled nursing services include necessary therapy, medications, wound care, stoma care, ventilator, tracheostomy care or tube feedings.  The list of hospital based skilled nursing facilities and swing bed facilities in the state of Iowa are available here.

Iowa Skilled Special Populations Nursing Facilities

Hospital Based Swing Bed Facilities in Iowa

Medicaid recognizes Medicare's National Level II Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) codes. However, not all HCPCS and CPT are covered. The specific CPT codes that are covered for chiropractors under Iowa Medicaid are listed below. It is noted that Iowa Medicaid does not cover any HCPCS codes for chiropractors.

It is the provider's responsibility to select the procedure code that best describes the item of services that was dispensed. A claim submitted without a procedure code and a corresponding diagnosis code will be denied.

Covered procedures for chiropractic manipulative treatment are: 

98940: Spinal, one or two regions

98941: Spinal, three or four regions

98942: Spinal, five regions

98943: Regions other than spine

Chiropractic Services Primary

Chiropractic Diagnosis Category I

Chiropractic Diagnosis Category II 

Chiropractic Diagnosis Category III 

Generally, Medicaid limits chiropractic manipulative treatment to one code per day per patient. You are not required to bill excluded services. Please see the Chiropractic Provider Manual for additional information. 

The utilization guideline for diagnostic combinations between categories is 28 manipulations per 12-month period. Any treatments beyond the utilization guidelines listed must be submitted with documentation to support the medical necessity. If documentation is not submitted, the claim will be denied for lack of information. The claim may be resubmitted with documentation for reconsideration. 

This section outlines a complete listing of all the technical and instructional manuals used by recognized provider types as specified by Iowa Medicaid. Each of the provider manual is specific to a service offered by Iowa Medicaid and is designed to guide providers with clear and concise outlines of what services are covered or not covered under that service.

The manuals also provide instructions on how to read and complete the various forms required by Iowa Medicaid for each offered service. These manuals serve as very important tools for providers in helping them ensure a more seamless administrative process involving Iowa Medicaid guidelines, billings and documentations.

The Iowa Medicaid fee schedule is a list of the payment amounts, by provider type, associated with the health care procedures and services covered by Iowa Medicaid Providers are contractually obligated to submit their usual and customary charges but accept the Iowa Medicaid fee schedule reimbursement as payment in full. Provider charges are routinely reviewed by policy staff to determine the cost for service and the fee schedule can be increased or decreased based upon comparable charges throughout the community.

Diagnosis-Related Group (DRG) Weights:
Acute Care Hospital inpatient claims are reimbursed using prospective payment system diagnosis-related groups (DRG). Hospital base rates and capital cost rates are developed using a blend of hospital-specific and statewide average costs taken from hospital cost reports. In addition, there are weights assigned to more than 500 diagnosis-related groups, which represent the relative resource consumption, as measured by the relative charges by hospitals for cases associated with each DRG. Iowa Medicaid uses the Medicare DRG system with Medicaid-specific weights calculated for each DRG to determine the payment for all hospitals. There are also provisions within the DRG payment methodology for additional payments for treating patients with a long length stay (day outlier) or a large amount of economic resources (cost outlier). Payments are reduced or limited for certain treatment cases with a short-length stay (short-stay day outlier) or where a patient transfer has occurred.

MS-DRG Version 38.1

MS-DRG Version 36.0

MS-DRG Version 33.0 

MS-DRG Version 29.0

This link will bring you a listing of current and archived nursing facility rates which are further broken down into quarterly sections. These rates are determined by a cost report, which is based on a case mix of current residents in the facility. New cost reports are due annually from nursing facilities to determine the per diem (daily rate) that is assigned by Provider Cost Audit and Rate Setting. The listing of the current rates is a tool that Hospice providers can use to determine the Per Diem that is due per patient per day based on the location of the facility.

Long-Term Care (LTC) Compilation Reports:
The annual LTC compilation reports of costs and other statistical data are prepared using data from the cost reports for nursing facilities, and intermediate care facilities for the intellectually disabled.  These reports are used to establish statewide reimbursement limits, and to evaluate changes in cost that can be used to assist the legislature and the department in determining fiscal impacts to proposed changes and in developing budgets.

Nursing Facility (NF) Compilation Report

Intermediate Care Facility for Individuals with Intellectual Disability (ICF/ID) Compilation Report

Iowa Medicaid implemented the ambulatory payment classification (APC) methodology for outpatient services in acute care hospitals on October 1, 2008. The outpatient hospital payments are based on Medicare's Outpatient Prospective Payment System (OPPS) APC's and relative weights and are updated annually effective January 1st using the most current calendar update as published by Centers for Medicare & Medicaid Services (CMS). To assist hospitals with claims processing, a Medicaid- specific listing of Outpatient Coding Editor (OCE) edits were posted on the Iowa Medicaid website at the above link.

Site of care (SOC) for specialty drug administration refers to the physical location where the specialty drug is administered. Medically necessary services should be rendered in the least intensive setting appropriate for delivery of the services and supplies. The goal of the Iowa Medicaid Specialty Drug Administration - Alternative SOC program is to provide alternative SOC options for members on select chronic, provider-administered drugs (i.e., improve access and accessibility).

List of specialty drugs open for alternative site of care

The Point of Sale (POS) website provides information regarding claim submission for providers. The website contains the Iowa HHS Point of Sale Agreement as well as the most recent payer sheet. Current informational letters notify providers regarding recent changes to the claim submission process. The website also provides information regarding quantity limits for medications, reimbursement for specialty drug products, and the preferred listing of diabetic supplies.

Iowa Medicaid Preferred Drug List (PDL) Website

Iowa Medicaid Pharmacy Provider Portal

Iowa Medicaid and the State of Iowa implemented the Preferred Drug List (PDL) on January 15th, 2005, as cost saving measure for the Medicaid Budget. The PDL lists all pharmaceuticals allowed by Iowa Medicaid and is a reference point for all pharmaceutical coverage. This site will assist Pharmacists and other providers to determine if a drug is covered with or without prior authorization. This will also provide information on the quantity and frequency of dispensation for any given drug that members may receive.

The Iowa Medicaid Smoking Cessation Program is comprised of two components: "Quitline Iowa" and pharmacy services. Quitline Iowa provides counseling services for tobacco users who want to quit. A toll-free helpline is available at 1-800-784-8669. Pharmacy services include various nicotine replacement products such as the patch, gum or other products. Medicaid members need to work with their physicians to receive a diagnosis and prior authorization for access to the products.

The FPP is for men and women between the ages of 12-54. The FPP helps with the cost of family planning related services. This program is a state-funded DHS program which replaced the Iowa Family Planning Network (IFPN) program. IFPN members were transitioned to the FPP July 1, 2017. The list of covered services is arranged by diagnosis and procedure codes. The codes as of March 1, 2024, are available below:

FPP Diagnosis Codes

FPP Procedure Codes

View the fee schedule for reimbursement rates associated with Provider Type 22 (Family Planning).

*Please note: Not all of the procedure codes listed here are in the Provider Type 22 fee schedule. Some of the codes have special programming in the background to be associated with the FPP.

House File 2668 requires Iowa Medicaid to provide coverage of Biomarker testing for Medicaid and Hawki members. Coverage of biomarker testing includes for purposes of diagnosing, treating, appropriately managing, or monitoring a disease or condition in a covered person when the biomarker testing has demonstrated clinical utility. 

“Clinical utility" means sufficient medical and scientific evidence indicating that the use of a biomarker test will provide meaningful information that affects treatment decisions and guides improvement of net health outcomes, including an improved quality of life or longer survival.

Sources used for determining clinical utility may include but are not limited to any of the following: 

a. Labeled indications for a test approved or cleared by the United States food and drug administration or indicated tests for a drug approved by the United States food and drug administration, such as compiled in the FDA approved list of companion tests.

b. Centers for Medicare and Medicaid services of the United States department of health and human services national coverage determinations or Medicare administrative contractor local coverage determinations. 

c. Nationally recognized clinical practice guidelines and consensus statements, such as the National Comprehensive Cancer Network (NCCN). 

d. American Cancer Society list of biomarkers

Iowa Medicaid has biomarker codes that are open and have medical necessity criteria in place through the Clinical Advisory Committee (CAC) criteria. The criteria can be located in the HHS website under CAC Criteria Material Library and Laboratory Testing. 

Additional biomarker tests that are not currently open may be requested for a member through the exception to policy process (See process below).  

Iowa Medicaid will evaluate utilization and consider if additional biomarker codes should be added to the Independent Lab fee schedule.

Exception to Policy Process-Fee for Service:

Fee for Service members only should follow the process as outlines below. See below for process for each Managed Care Unit.

Providers may complete and the Exception to Policy form. 

Once the form is completely filled out, click the submit button at the bottom of the form. Your request will be sent directly to the Appeals Section.

If you have additional documentation that will help support your request, please mail, fax or email the information to the Appeals Section so it can be used when making a decision on your request.

If the request is medical in nature, please provide documentation to prove that the item or service is medically necessary. You will need to include the costs or proposed savings of the request.

Mail, fax or email the additional documentation to:

Department of Human Services

Appeals Section

1305 E Walnut Street, 5th Floor

Des Moines, IA 50319

FAX: 515-564-4118

Email:  exceptions@hhs.iowa.gov

Additional Option to Request Exception to Policy:

If a provider chooses not to use the Petition for Exception to Policy form to request an exception to policy, the provider may write a letter with the following:

List the name, address, and Medicaid number (state ID number) of the person who needs the exception.

• Describe what the person needs.
• Explain why it is needed. If it is medical in nature, include the medical necessity of the item or service.
• Provide documentation indicating what other testing has been completed that indicates need for biomarker testing.

Mail, fax or email the request and additional documentation to:

Department of Human Services

Appeals Section

1305 E Walnut Street, 5th Floor

Des Moines, IA 50319

FAX: 515-564-4118

Email:  exceptions@hhs.iowa.gov

What Information Should be Included with the Exception to Policy Request?

Providers should include the following information with the exception to policy request to assist in making clinical utility determination:

• Medical Records
• Literature to Support Request

What if the Provider or Member Disagrees with the Outcome of the Exception to Policy?

If the provider or the member disagree with an exception to policy recommendation, you can ask to have your request reconsidered. You may write a letter or complete the Petition for Exception to Policy form.

Once the form is completely filled out, click the submit button at the bottom of the form. Your request will be sent directly to the Appeals Section.

If you have additional documentation that will help support your request, please mail, fax or e-mail the information to the Appeals Section so it can be used when making a decision on your request.

If the request is medical in nature, please provide documentation to prove that the item or service is medically necessary. You will need to include the costs or proposed savings of the request.

Mail, fax or email the additional documentation to:

Department of Human Services

Appeals Section
1305 E Walnut Street, 5th Floor
Des Moines, IA 50319
FAX: 515-564-4118

Email: exceptions@hhs.iowa.gov

There are no appeal rights on an exception to policy request. 

Exception to Policy Process-Managed Care Organizations:

Molina Healthcare: 

Exception to policy information can be found on the Molina Healthcare website

Wellpoint:

Providers must submit a prior authorization request for a service or medication and indicate on the request that an exception to policy is desired. Through the utilization review process, the Medical Director determines if it is appropriate to submit a request for exception to policy to the director of the Iowa Health and Human Services. 

A request for the exception to policy is submitted to the director by the department director with Wellpoint. Once it has gone through director review, HHS communicates the decision to the director at Wellpoint, then Wellpoint notifies the member and provider of the director's decision. 

If the ETP is approved, the authorization is updated to the terms specified in the EPT, not to exceed one calendar year. 

Decisions made by HHS regarding ETPs are final and not appealable

Iowa Total Care:

The associated Iowa Total Care department receives a State Exception to Policy (ETP) request. 

For LTSS, ETP requests are submitted by the Case Manager via the member’s person-centered service plan.  This request is reviewed, during a Medical Rounds meeting, by a Medical Director and LTSS Senior Directors, with input from the case manager and/or their manager.

For all other ETP requests, providers should submit an Exception to the Policy request using the same process as a prior authorization request.

Prior Authorization request submission process:

• For medical and behavioral health authorizations the preferred method for submitting prior authorizations is through our secure provider portal. The provider must be contracted with Iowa Total Care and a registered user on the secure provider portal. If the provider is not a registered user and needs assistance or training on submitting prior authorizations, the provider should contact their assigned provider relations representative. 

• Pharmacy Prior Authorizations – The preferred method of requesting a pharmacy prior authorization is through covermymeds website. 

• Other methods for submitting prior authorization requests are as follows: 

• By fax with the appropriate prior authorization form below.
• Outpatient Prior Authorization Form Physical Health - Fax #: 1-833-257-8327
• Behavioral Health - Fax #: 1-844-908-1170
• Inpatient Prior Authorization Form Physical Health - Fax #: 1-833-257-8327
• Pharmacy Point of Sale Authorization Form Fax #: 1-833-404-2392
• Medical Pharmacy Buy & Bill Drug Requests - Fax #: 1-833-711-0485
• EVOLENT Fax #: 1-800-784-6864 

Faxes are not monitored after hours and will be responded to the next business day.

• Call 1-833-404-1061 (TTY: 711) for Medical (including authorizations that must be submitted to EVOLENT) and behavioral health prior authorization requests or call 1-866-399-0928 for pharmacy prior authorization requests.
• Normal business hours are Monday - Friday, 8 a.m. to 5 p.m. CT. Voicemails left after hours will be responded to on the next business day.
• Prior authorization must be obtained prior to the delivery of certain elective and scheduled services.
• Any prior authorization request that is faxed or sent via the secure provider portal after normal business hours (Monday - Friday, 8 a.m. to 5 p.m., excluding holidays) will be processed the next business day