Medicaid Claims and Billing

340B

Guidance on Iowa Medicaid 340B Program Policy and Billing. 

Search for Ordering and Referring Providers

Iowa Medicaid has an online searchable directory of currently enrolled Providers that may order or prescribe durable medical equipment (DME), independent lab services or consultations. Please consult the attached online directory before services or supplies are provided. The online directory is searchable by entering a National Provider Identification (NPI) number and Date of Service.

For more information, please read Informational Letter 1416 on the Informational Letters webpage.

If you wish to enroll as an Ordering/Referring provider, please go to the the Provider Enrollment webpage.

Prior Authorization

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.

Electronic Billing

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 Support Services (EDISS)

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.

Emergency Diagnosis Codes

  • Active ICD-10 Codes
    • 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, 2024.
  • Termed ICD-10 Codes
    • 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.

Rebatable Drug List for J-Code Billing

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.

Disallowance Project

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.

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.

Multiple Source National Drug Codes, Not Top 20

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.

Claim Forms and Instructions

Important Information Regarding Claims Forms 

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.

Electronic Billing Tips and FAQ

Effective August 1, 2019, Iowa Medicaid and the Managed Care Organizations (MCOs) started a mandatory electronic billing requirement for all Medicaid enrolled providers for both Fee-for-Service (FFS) and Managed Care claims. This requirement was implemented for Medicaid enrolled dental providers effective February 1, 2020.

This requirement excludes Individual Consumer Directed Attendant Care (CDAC) providers.

Details of this requirement were announced in Informational Letter 2003-MC-FFS and Informational Letter 2022-MC-FFS-D. You can find them on the Informational Letters webpage. 

FFS Claims

What is the electronic billing requirement? 

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.

How do I submit claims electronically? 

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.
How do I submit supporting documents to Iowa Medicaid?

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. 

How do I get access to IMPA? 

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.

  1. 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. 
  2. Once an IMPA account has been created, providers must request access to upload documents to IMPA.
What can I submit in IMPA? 

Supporting documents for FFS claims.

What documents are not to be submitted in IMPA? 
  • Paper claims
  • Provider inquiries
  • Adjustment forms
  • Recoupment forms
How do I submit a document in IMPA? 
  1. 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.
  2. 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.
  3. “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:
      1. Format should be member ID number with date of service.
      2. EXAMPLE: If the member ID number is 1234567A and the date of service was August 1, 2019, the ACN would be 1234567A08012019
      3. 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.

How do you know which documents are attached to which claims? What is an ACN?

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.

Where do I put the ACN on my claim? 
  • 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.

When should I submit a provider inquiry?

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.

How do I submit electronic adjustment requests?

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.
How do I submit electronic recoupment requests? 

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.
Have more questions not covered here? 

Please contact Iowa Medicaid Provider Services Unit at 1-800-338-7909, or email at IMEProviderServices@dhs.state.ia.us.

MCO Claims

Find more information about submitting electronic claims to the MCOs:

Iowa Total Care

Molina Healthcare of Iowa

Wellpoint