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Electronic Billing Required
Iowa Medicaid and the Managed Care Organizations (MCOs) require all Medicaid-enrolled providers to submit claims electronically. This mandatory electronic billing requirement applies to both Fee-for-Service (FFS) and Managed Care claims.
New Durable Medical Equipment (DME) and the NU Modifier
The Iowa Department of Health and Human Services (HHS) requires the use of the NU Modifier when billing for new medical equipment and supplies to align with the Centers for Medicare and Medicaid Services (CMS) guidelines. This modifier is used for new DME items that are purchased. When using the NU modifier, you are indicating you have furnished the member with a new (never used) piece of equipment.
For all codes requiring the NU modifier, please refer to https://med.noridianmedicare.com/web/j
Billing Updates
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The following guidance applies only to Avastin® (bevacizumab) and does not apply to biosimilars of Avastin®.
Below is a list of the current available code options for Avastin® ophthalmological use.
| HCPCS | Definition | NDCs | Billing Units per Eye | Appropriate Setting | |
|---|---|---|---|---|---|
| C9257 | Injection, bevacizumab, 0.25 mg | 50242006001 50242006101 | 5 units = 1.25 mg per eye | Hospital Outpatient | |
| J7999 | Compounded drug, not otherwise classified | 50242006001 50242006101 | 1 unit = 1.25 mg per eye | Office and Outpatient | |
Office and outpatient providers must use HCPCS (Healthcare Common Procedure Coding System) code J7999 when billing Avastin for ophthalmological use. J7999 is also an unspecified code (i.e., “dump code”). The rate of $76 per unit will be applied when the claim is manually priced. In addition, J7999 is not separately payable in an Outpatient setting. Hospital outpatient claims should be submitted using HCPCS code C9257.
When billing Avastin for ophthalmological use, Iowa Medicaid will only accept HCPCS code J3590 on crossover claims when the primary carrier requires the use of that code. Iowa Medicaid will not pay for Avastin claims submitted with J3590 when Iowa Medicaid is the primary payor.
If using an individual dose of Avastin® (bevacizumab) prepared by an FDA-registered 503B outsourcing facility, submit the NDC of the active medication (Avastin®). Outsourcing facilities may, but are not required to, assign NDCs to their finished compounded human drug products, but these NDCs are not eligible for rebate under the Medicaid Drug Rebate Program.
Appending the JW or JZ modifier is required on drug and biological claims:
- JW: drug amount discarded/not administered to any patient
- JZ: zero drug amount discarded/not administered to any patient
Prior Authorization may be required, the provider should contact the appropriate payor for requirements.
This information updates previous guidance in IL No. 2585-MC-FFSdated May 30, 2024
Iowa Medicaid members enrolled with a Managed Care Organization (MCO) have access to an expanded array of mental health and substance use disorder services. These services are often referred to as “B3” services because they are authorized as a 1915(b)(3) waiver exemption by the Centers for Medicare and Medicaid Services (CMS). Individuals not enrolled with an MCO do not have coverage for B3 mental health and substance use disorder services. Iowa Health and Wellness Not Medically Exempt and Hawk-I members are not eligible for any B3 services.
This information is being updated. More to come soon.
The Centers for Medicare and Medicaid Services (CMS) previously published Discarded Drugs and Biologicals – JW Modifier and JZ Modifier Policy (cms.gov) to provide background information and instructions on the discarded drug policy.
The definitions for both modifiers are as follows:
- JW: Drug amount discarded/not administered to any patient – required on all claims when using a single-dose container for a drug or biological and not administering the entire single-dose container.
- JZ: Zero drug amount discarded/not administered to any patient – required on all single dose vials or packages.
Providers and suppliers are required to report the JW modifier on all claims that bill for drugs and biologicals with unused and discarded amounts from single-dose containers or single-use packages.
JW and JZ modifiers are not required for vaccines described under section 1861(s)(10) of the Act that are furnished from single-dose containers.
This information updates previous guidance in Informational Letter 2475
Medicaid Claims & Billing Processes
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Ambulatory Payment Classifications Additional Procedure Codes
APCs or Ambulatory Payment Classifications are the United States government's method of paying for facility outpatient services. A part of the Federal Balanced Budget Act of 1997 made the Centers for Medicare and Medicaid Services (CMS) create a new Medicare "Outpatient Prospective Payment System" (OPPS) for hospital outpatient services -analogous to the Medicare prospective payment system for hospital inpatients known as Diagnosis-related group or DRGs. This OPPS was implemented on August 1, 2000. APCs are an outpatient prospective payment system applicable only to hospitals. Physicians are reimbursed via other methodologies for payment in the United States, such as Current Procedural Terminology or CPTs.
Important Information
The claims forms provided on this website are for reference purposes only. In order to process claims, Iowa Medicaid must have original versions of the forms. Please do not submit claims on the forms found on this website. Original versions of the CMS-1500, UB-04 and Dental Claim forms can be found at office supply stores. Originals of the Targeted Medical Care claim forms can be requested from Iowa Medicaid by contacting Provider Services at 1-800-338-7909 or locally at 515-256-4609.
Health Insurance Claim Form Instructions and Sample Forms
Iowa Medicaid uses a variety of claim forms to reimburse providers for services they render. The form used is determined by the category of service and aligns with industry standard practices supporting healthcare payment. Claims must be completed according to instructions published on this page. Submitted claims are then processed by Iowa Medicaid according to program policies. Claims are a legal document bearing providers attestation of services provided. Accuracy is important in this process to ensure only those services actually provided are ultimately claimed and paid.
- UB04 Health Insurance Claim Form
- ADA 2012 Health Insurance Claim Form
- ADA 2012 Claim Form Instructions
- ADA 2012 Sample Claim Form
- Targeted Medical Care 470-2486 Claim Form Instructions
- 470-2486: Targeted Medical Care Health Insurance Claim Form (coming soon)
- Institutional Crossover Claim Form Instructions
- Professional Crossover Claim Form Instructions
- UB04 Claim Form Instructions
- UB04 Sample Claim Form
- CMS-1500 Claim Form Instructions
- CMS-1500 Information and Sample Claim Form (02/12)
The purpose of the Disallowance project is to notify providers of potential third party liability (TPL) for claims submitted and paid by Iowa Medicaid. In general, Disallowance projects are released to providers five (5) times each year with a listing of claims paid by Iowa Medicaid where TPL may exist. The providers have 45 days to work the Disallowance project by contacting the TPL vendor and then responding to Iowa Medicaid with the result. Acceptable responses include:
- Repayment of all or a portion of the Medicaid payment,
- Recoupment of future payments or
- Refuting evidence indicating that the claim is not covered by the primary carrier.
The Disallowance project is a program that used to comply with the Federal Deficit Reduction Act (DRA) and the State of Iowa Health Care Information Sharing legislation. The Disallowance Link provides easy access to the provider's listing of claims for research and response.
Effective August 1, 2019, Iowa Medicaid and the Managed Care Organizations (MCOs) implemented a mandatory electronic billing requirement for all Medicaid enrolled providers for both Fee-for-Service (FFS) and Managed Care (MC) claims. This requirement was implemented for Medicaid enrolled dental providers effective February 1, 2020.
This requirement excludes Individual Consumer Directed Attendant Care (CDAC) providers.
Electronic Data Interchange is Iowa Medicaid's clearinghouse for electronic healthcare transactions. In these transactions, providers and Iowa Medicaid exchange information though defined, electronic conventions that support established processes such as eligibility look-up, claim submission and payment information. Iowa Medicaid's portal for these transactions is EDI support services (EDISS). At EDISS, providers identify themselves and enroll for transactions they intend to utilize.
- Please go here to view the active ICD-10 codes that are considered to be emergent for dates of services on or after January 1, 2025.
- Please go here to view the ICD-10 codes that are no longer considered to be emergent.
Explanation of Benefits (EOB) Crosswalk
- Iowa Medicaid allows providers to crosswalk from the Health Insurance Portability and Accountability Act (HIPAA) compliant and "generalized" EOB on an electronic 835 transaction.
Two forms of the EOB are available on:
- The Iowa Department of Health and Human Services' (HHS) website for its Iowa Medicaid Portal Access (IMPA)
- The 835 website, offered by our electronic vendor
The EOB codes used by Iowa Medicaid differ and are considered non-HIPAA compliant as they give more detailed information than the 835 website. This document is to help providers translate what the HIPAA compliant 835 EOB codes mean to what Iowa Medicaid posts on the EOBs offered through Iowa Medicaid Portal Access.
The National Drug Code (NDC) is a unique product identifier used in the United States for drugs intended for human use. The Drug Listing Act of 1972[1] requires registered drug establishments to provide the Food and Drug Administration (FDA) with a current list of all drugs manufactured, prepared, propagated, compounded or processed by it for commercial distribution. Drug products are identified and reported using the NDC. The National Drug Code is a unique 10-digit, 3-segment numeric identifier assigned to each medication listed under Section 510 of the US Federal Food, Drug, and Cosmetic Act. The segments identifies the labeler or vendor, product (within the scope of the labeler) and trade package (of this product).
For more information, please read Informational Letter 1416 on the Informational Letters webpage.
Prior Authorization from Iowa Medicaid is required for certain services and supplies. For more information, please see the Prior Authorization webpage.
National Correct Coding Initiative
The Centers for Medicare & Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI) to promote uniform, accurate coding methodologies and to combat improper and abusive coding. The policies are based on conventions defined by the American Medical Association, national societies and analysis of standard practices. The National Correct Coding Initiative (NCCI) Coding Policy Manual is updated annually, with individual edits quarterly. The NCCI Coding Policy Manual should be utilized as a general reference tool that explains the rationale for NCCI edits. In cases where claims processed by Iowa Medicaid (IM) show a "correct coding edit" post on a provider's remittance advice statement, supplemental edit details are available on the Correct Coding Edit Verification Portal by entering the Transaction Control Number (TCN) and billing NPI of the claim.
To comply with the Centers for Medicare & Medicaid Services (CMS) requirements pursuant to the Federal Deficit Reduction Act (DRA) of 2005, Iowa Medicaid implemented a change involving the reporting of all drugs administered in an office/clinic or other outpatient setting. Effective December 17th 2007, providers are required to report a National Drug Code (NDC) when billing with a "J" code. The NDC must be on the rebatable list to be payable by Iowa Medicaid per the Omnibus Budget Reconciliation Act of 1990 (OBRA'90). The lists are updated on a quarterly basis and providers will need to review the lists each quarter to ensure that the NDC is still considered rebatable.
The lists can be found on Iowa Medicaid Informational Letters webpage.
Fee-for-Service Claims: Frequently Asked Questions
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Effective August 1, 2019, Iowa Medicaid providers are required to process claims electronically through the IME and MCOs. Please see below for additional information regarding how to bill electronically. The mandatory electronic billing requirement also applies to recoupments and adjustments for FFS. Paper forms 470-0040 and 470-4987 are not accepted as of August 1, 2019.
Providers billing for FFS claims use the Iowa Medicaid Portal Access (IMPA) system for submitting supporting documents only.
Iowa Medicaid offers the following options for providers to consider for electronic billing:
- ABILITY PC-ACE Pro: This software is available to all providers through Iowa Medicaid for billing FFS claims. Contact the Iowa Medicaid at the number below for additional information. There is no cost for FFS member claims billed through ABILITY PC-ACE Pro.
- MCO portals: Each MCO has an online portal for claim submission management. Contact the MCOs at the numbers listed below for additional information.
- Electronic Data Interchange (EDI) Clearinghouse Options: EDI Clearing House options are available that can be used to bill both FFS and MCO claims.
Providers billing for FFS claims use the IMPA system for submitting supporting documents.
Providers only need to submit supporting documents when such documents are necessary to process a claim. If supporting documents are necessary, providers must upload the documents to IMPA within seven business days of submitting the medical claim.
Once documents are uploaded from IMPA they remain on file. There is no need to upload documents if the claim is denying for something other than documentation.
IMPA access will be needed for anyone billing claims to Iowa Medicaid. If there are multiple billers wishing to upload documents independently, each biller must have their own IMPA account.
- Information about creating an IMPA account and requesting access to upload documents can be found in Informational Letter 2003-MC-FFS on our Informational Letters webpage.
- Once an IMPA account has been created, providers must request access to upload documents to IMPA.
Supporting documents for FFS claims.
- Paper claims
- Provider inquiries
- Adjustment forms
- Recoupment forms
- As of August 1, 2019, providers who have been granted access to upload documents will see an “Upload File” option under the “File” menu on the top left corner within IMPA.
- After clicking “Upload File”, providers choose “Electronic Billing Attachments” under the second menu; Do not use “Documents to IME” under the “Upload File” menu to attach documents to an electronic FFS claim. Do not use form number 470-5403 Medicaid Member Documentation Upload Cover Sheet with documents for electronic billing.
- “Electronic Billing Attachments” section:
- In the “Document Types” drop down menu, choose “Claim Attachment”
- Enter a 16-digit Attachment Control Number (ACN) with the following format:
- Format should be member ID number with date of service.
- EXAMPLE: If the member ID number is 1234567A and the date of service was August 1, 2019, the ACN would be 1234567A08012019
- Some providers have been reporting errors showing "Duplicate file name (ACN) for this document type" on IMPA when trying to upload documents. After the provider puts in regular ACN (1234567AMMDDYYYY), the "duplicate" documentation would need to have an underscore and the number 2 at the end (1234567AMMDDYYYY_2). If there is already a 2 being used, then 3 can be used (and so on...).
Screen shots of the step-by-step process once you have reached the “Electronic Billing Attachments” section can be found in the Iowa Program Updates slide deck.
When uploading documentation to IMPA, providers must enter a 16-digit Attachment Control Number (ACN) and their 10-digit National Provider Identifier (NPI) number.
Enter a 16-digit ACN with the following format:
- EXAMPLE: If the member ID number is 1234567A and the date of service was August 1, 2019, the ACN would be 1234567A08012019
The ACN must also be on the electronic claim so that the claim form and supporting documentation can be matched by the IME when reviewing additional documentation.
- If using ABILITY PC-ACE Pro software:
- The ACN box is located on the Institutional claim on the Extended General tab. Enter the ACN number in the box marked “Attachment Control Number‟.
- If using the Professional claim use the EXT Pat/Gen (2) tab. Enter the ACN number in the box marked “Attachment Control Number‟.
- If using the 837I or 837P
- The ACN field is loop 2300 segment PWK05-06.
If you are not able to locate the field, please contact your software vendor for assistance with where you may note the ACN on the claim form.
Provider Inquiry Form 470-3744 may not be submitted for the purpose of attaching documentation.
Supporting documents needed by the IME to process a claim must be uploaded to IMPA. Provider inquiries will still be accepted on paper as of August 1, 2019, but only for appropriate requests:
- Requesting Medical Services/policy review of Healthcare Common Procedure Coding System (HCPCS)
- Requesting Medical Services/policy review of fee schedule for HCPCS code
- Disputing denial of a previously reviewed claim
- May not be submitted for the purpose of attaching documentation
- No claim in system with documentation
- Letter to provider (inquiry will not be processed)
For adjustments and provider inquiries with Amerigroup, the mandatory electronic requirement applies. Overpayment notifications will be accepted on the designated paper forms at the Amerigroup website noted below.
An adjustment is a request for Medicaid to make a change to a previously paid claim.
- On the 837I/837P enter the REF01 value “F8” in the 2300 REF segment with the Payer Claim Internal Control Number, which is the 17-digit Medicaid TCN number of the claim that needs adjusted.
- The frequency code of “7” must be entered in the 2300 Loop CLM Segment.
- It is important to include all charges that need to be processed, not just the line that needs to be corrected; if previously paid lines are not submitted on the adjustment request, they will be recouped from the original request but not repaid on the adjustment, likely resulting in an unintentional credit balance.
A recoupment is a request for Medicaid to take back the entire original claim payment.
- On the 837I.837P, enter the REF01 value "F8" in the 2300 REF segment with the Payer Claim Internal Control Number, which is the 17-digit Medicaid TCN number of the claim that needs to be recouped.
- The frequency code of "8" must be entered in the 2300 Loop CLM Segment.
Find more information about submitting electronic claims to the MCOs:
Questions & Concerns
If you have additional questions or concerns not covered on this page, please contact Iowa Medicaid Provider Services Unit at 1-800-338-7909, or email at imeproviderservices@hhs.iowa.gov.