1

Iowa Medicaid Enterprise

Welcome To Fall Training 2005

2

Agenda

•Medicaid Overview

•Break!

•Provider-Specific Training

•Questions and Answers

3

CONTACT INFORMATION

IME

Addresses

I O W A M E D I C A I D E N T E R P R I S E A D D R E S S L I S T

E ff e c t i v e 6 / 3 0 / 0 5

M E D I C A I D C L A I M S P . O . B o x 1 5 0 0 0 1

D e s M o i n e s , I o w a 5 0 3 1 5

P R O V I D E R C O R R E S P O N D E N C E P . O . B o x 3 6 4 5 0

D e s M o i n e s , I o w a 5 0 3 1 5

M E D I C A L P R I O R A U T H O R I Z A T I O N P . O . B o x 3 6 4 7 8

D e s M o i n e s , I o w a 5 0 3 1 5

P H A R M A C Y P R I O R A U T H O R I Z A T I O N 8 0 0 - 5 7 4 - 2 5 1 5 - F a x O n l y

M E M B E R S E R V I C E S

P . O . B o x 3 6 5 1 0 D e s M o i n e s , I o w a 5 0 3 1 5

E S T A T E R E C O V E R Y A N D M I L L E R T R U S T

P . O . B o x 3 6 4 4 5 D e s M o i n e s , I o w a 5 0 3 1 5

T H I R D P A R T Y L I A B I L I T Y

P . O . B o x 3 6 4 7 5 D e s M o i n e s , I o w a 5 0 3 1 5

L I E N R E C O V E R Y

P . O . B o x 3 6 4 4 6 D e s M o i n e s , I o w a 5 0 3 1 5

D R U G R E B A T E ( i n c l u d i n g S u p p l e m e n t a l )

P . O . B o x 3 6 4 4 8 D e s M o i n e s , I o w a 5 0 3 1 5

( T h i s w i l l b e c h a n g i n g 6 / 3 0 / 0 5 . P l e a s e u s e t h i s a d d r e s s u n t i l t h a t t i m e . )

A L L O T H E R R E F U N D C H E C K S P . O . B o x 3 6 4 7 6

D e s M o i n e s , I o w a 5 0 3 1 5

4

CONTACT INFORMATIONCONTINUED

I O W A M E D I C A I D E N T E R P R I S E C O N T A C T I N F O R M A T I O N

E ff e c t i v e 6 / 3 0 / 0 5

M a i l i n g A d d r e s s f o r C l a i m s : I o w a M e d i c a i d E n t e r p r i s e

P . O . B o x 1 5 0 0 0 1 D e s M o i n e s , I o w a 5 0 3 1 5

V i s i t t h e I M E W e b s i t e t o a c c e s s e v e n m o r e i n f o r m a t i o n :

w w w . i m e . s t a t e . i a . u s ( E ff e c t i v e 5 / 1 0 / 0 5 )

E L V S ( E l i g i b i l i t y V e r i fi c a t i o n S y s t e m ) 2 4 H o u r s a D a y / 7 D a y s a W e e k 8 0 0 - 3 3 8 - 7 7 5 2 5 1 5 - 3 2 3 - 9 6 3 9 ( L o c a l )

P H A R M A C Y P r i o r A u t h o r i z a t i o n P r o v i d e r P A H o t l i n e 8 : 0 0 A M – 6 : 0 0 P M ( a f t e r - h o u r s o n - c a l l a v a i l a b l e ) 8 7 7 - 7 7 6 - 1 5 6 7 5 1 5 - 7 2 5 - 1 1 0 6 ( L o c a l ) P r i o r A u t h o r i z a t i o n R e q u e s t s 8 0 0 - 5 7 4 - 2 5 1 5 ( F a x O n l y )

P H A R M A C Y P O S H E L P D E S K 8 : 0 0 A M – 6 : 0 0 P M ( a f t e r - h o u r s o n - c a l l a v a i l a b l e ) 8 7 7 - 4 6 3 - 7 6 7 1 5 1 5 - 7 2 5 - 1 1 0 7 ( L o c a l )

M E D I C A L S E R V I C E S M e d i c a l S u p p o r t 8 : 0 0 A M – 4 : 3 0 P M 8 0 0 - 3 8 3 - 1 1 7 3 5 1 5 - 7 2 5 - 1 0 0 8 ( L o c a l )

M E D I C A L P R I O R A U T H O R I Z A T I O N ( P A ) 8 : 0 0 a m – 4 : 3 0 P M 8 8 8 - 4 2 4 - 2 0 7 0 5 1 5 - 7 2 5 - 1 0 0 9 ( L o c a l ) 5 1 5 - 7 2 5 - 1 3 5 6 ( F a x )

M E M B E R S E R V I C E S 8 : 0 0 A M – 5 : 0 0 P M 8 0 0 - 3 3 8 - 8 3 6 6 5 1 5 - 7 2 5 - 1 0 0 3 ( L o c a l )

A l l H o t l i n e s a r e l i s t e d i n C e n t r a l T i m e

P R O V I D E R S E R V I C E S 7 : 3 0 A M – 4 : 3 0 P M 8 0 0 - 3 3 8 - 7 9 0 9 5 1 5 - 7 2 5 - 1 0 0 4 ( L o c a l ) 5 1 5 - 7 2 5 - 1 1 5 5 ( F a x )

E D I S U P P O R T S E R V I C E S

1 0 : 0 0 A M - 4 : 0 0 P M 8 0 0 - 9 6 7 - 7 9 0 2

P R O V I D E R A U D I T S A N D R A T E S E T T I N G 8 : 0 0 A M – 5 : 0 0 P M 8 6 6 - 8 6 3 - 8 6 1 0 5 1 5 - 7 2 5 - 1 1 0 8 ( L o c a l ) S t a t e M A C H e l p L i n e 8 0 0 - 5 9 1 - 1 1 8 3

S U R S 8 : 0 0 A M – 5 : 0 0 P M 8 7 7 - 4 4 6 - 3 7 8 7 5 1 5 - 7 2 5 - 1 3 4 6 ( L o c a l )

R E V E N U E C O L L E C T I O N E s t a t e R e c o v e r y 7 : 3 0 A M – 5 : 3 0 P M 8 7 7 - 4 6 3 - 7 8 8 7 5 1 5 - 7 2 5 - 1 0 0 5 ( L o c a l ) T h i r d P a r t y L i a b i l i t y ( T P L )

8 : 3 0 A M – 5 : 0 0 P M 8 6 6 - 8 1 0 - 1 2 0 6 5 1 5 - 7 2 5 - 1 0 0 6 ( L o c a l ) L i e n R e c o v e r y 8 : 3 0 A M – 5 : 0 0 P M 8 8 8 - 5 4 3 - 6 7 4 2 5 1 5 - 7 2 5 - 1 0 0 7 ( L o c a l )

IME

Phone

Numbers

5

ELVS

E L V S ( E l i g i b i l i t y V e r i fi c a t i o n S y s t e m )

W h a t E L V S c a n d o f o r y o u ? –

E l i g i b i l i t y v e r i fi c a t i o n 2 4 h o u r s a d a y , s e v e n d a y s a w e e k . B y s i m p l y e n t e r i n g y o u r s e v e n - d i g i t p r o v i d e r n u m b e r a n d t h e m e m b e r s t a t e I D y o u c a n : V e r i f y m e m b e r e l i g i b i l i t y f o r t o d a y ’ s d a t e o r p a s t d a t e o f s e r v i c e . V e r i f y i f t h e m e m b e r h a s i n s u r a n c e . V e r i f y m e m b e r e n r o l l m e n t w i t h a n H M O , M e d i P a s s , a n d t h e I o w a P l a n .

T h e H M O n a m e o r M e d i p a s s p r o v i d e r n a m e a n d t e l e p h o n e n u m b e r w i l l b e i n c l u d e d .

V e r i f y S p e n d D o w n a m o u n t r e m a i n i n g V e r i f y L o c k - i n i n f o r m a t i o n M e m b e r e l i g i b i l i t y c a n b e v e r i fi e d b y d a t e o f b i r t h – d d m m y y y y a n d

s o c i a l s e c u r i t y n u m b e r o r t h e S t a t e I D n u m b e r .

P r o v i d e r P a y m e n t – B y e n t e r i n g y o u r s e v e n - d i g i t p r o v i d e r n u m b e r y o u c a n : A c c e s s y o u r l a s t p a y m e n t a m o u n t a n d d a t e .

8 0 0 - 3 3 8 - 7 7 5 2 5 1 5 - 3 2 3 - 9 6 3 9 ( L o c a l )

Eligibility 24 hours a day,

7 days a week!

Verify:

•Spend Down

•Lock-In

•Insurance

•Managed Health Care information

6

IME Website

•Enroll Providers

•Download forms

•Check eligibility

•Claim status

•Sign up for provider training

•Get training materials

•Access informational releases

•Download the Provider Manuals

•Fee schedules

•Research emergency diagnosis codes

•Use the Provider registry

•Frequently Asked Questions

•Contact information

•Electronic Claim Submission information

•Get information regarding rates, assessments, new programs, etc.

•Access policy information

WWW.IME.STATE.IA.US

7

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) of your Medicaid Payments

AND

8

How Can I Make the IME Work for Me?

Use the correct Address when sending documents to the IME

Medicaid Claims

IME

PO Box 150001

Des Moines, IA 50315

Correspondence

IME

PO Box 36450

Des Moines, IA 50315

Claims Only

No checks please

Provider inquiries

Credit/Adjustments

Provider Enrollment

9

WEB PORTAL

The IME Web Portal allows you to check eligibility and claims status online!

To enroll, contact IME EDISS to obtain a

Login ID and Password.

800-967-7902

10AM-4PM

Email: edi@noridian.com

10

Web Portal Continued

Go to the EDISS website to get the registration forms. The easiest way

to access the website is to go to www.ime.state.ia.us and click on

“Electronic Data Interchange” in the “Tools” box.

OR…

11

ELECTRONIC CLAIMS SUBMISSION

EDISS(ELECTRONIC DATA INTERCHANGE SUPPORT SERVICES)

800-967-7902EMAIL: EDI@NORIDIAN.COMwww.noridianmedicare.com

PC ACE PRO32 SOFTWARE

(It’s Free!)

12

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.

13

Claims Submission Issues

• Claims must include a valid Medicaid Provider number in the correct box on the claim form

• No black and white claim copies• Use the original “Drop-out” red and white CMS-1500 and UB-92

claim forms.• Do not use high-lighters on any document

– Highlighted documents will be blacked out by the scanner• Do not use red ink

– Red ink will not show up on a scanned document• New credit and adjustment form• Do not use created to look like an original Medicaid claim form.• Dental Forms – ’99, 2000, and 2002 form

14

Tips for Faster Claim Processing

• Do not use red ink or highlighter on any document sent to the IME• For Medicare crossovers circle the claim on the Medicare EOMB. • Do not rebill services that are currently in process. • A provider signature is required on all non-electronic claims. If the signature field contains block letters or a computer-generated signature, it is not considered valid unless it has been initialed.• Claims that are resubmitted after a year has passed since the date of service must be on paper and have the original filing date beside the signature. • Don’t send resubmitted claims to Provider Services.

15

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?

•www.ime.state.ia.us (click on “Providers”, then “Forms”)

•Provider Manual

16

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.

IOWA MEDICAID PROGRAM

CREDIT/ADJUSTMENT REQUEST (If the claim is DENIED, DO NOT USE THIS FORM. Resubmit the corrected claim.)

(DO NOT USE RED INK.) SECTION A: Check the appropriate box and follow the steps that are outlined

X CLAIM ADJUSTMENT

a) Attach a completed claim copy, with corrections made directly on the claim, OR b) Attach a copy of the remittance advice, with corrections made directly on the remittance, AND c) Complete Sections B and C.

CLAIM CREDIT (NOTE: This will result in Medicaid retracting the claim payment.)

d) Attach a remittance copy. e) Complete Sections B and C

SECTION B: This section MUST be filled out completely in order to process: 1. 17-DIGIT TCN: 0-00000-00-000-0000-00

2. 7 DIGIT PAY-TO-PROVIDER NUMBER: 1234567

3. PROVIDER NAME: Jeremy Morgan

CITY: Des Moines STATE: IA ZIP: 50315

4. 8-DIGIT MEMBER STATE ID NUMBER: 1234567A

5. REASON FOR ADJUSTMENT OR CREDIT: ___A short explanation or description of what you are asking

for.

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

SECTION C: Signature and Date REQUIRED Signature

DATE: 10/03/05

RETURN ALL REQUESTS TO:

IOWA MEDICAID ENTERPRISE PO BOX 36450

DES MOINES, IA 50315

18

Provider Inquiry

How can I get an answer in writing?Use the Provider Inquiry Form

www.ime.state.ia.us 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.

 

19

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

    

  

 

Fall 2005 Iowa Medicaid Enterprise 1

PROVIDER INQUIRY Attach supporting documentation. Check applicable boxes: Claim copy Remittance copy

Other pertinent information for possible claim reprocessing.

1. 17-DIGIT TCN

2. NATURE OF INQUIRY

I N Q U I R Y

A

1. 17–DIGIT TCN

2. NATURE OF INQUIRY

I N Q U I R Y

B

Provider Signature/Date: MAIL TO: IME Provider

Services P. O. BOX 36450 DES MOINES IA 50315

IME Signature/Date:

7-digit Medicaid Provider ID#

Telephone

Provider Please Complete:

Name Street City, St Zip

(FOR IME USE ONLY)

PR Inquiry Log #

Received Date Stamp:

470-3744 (Rev. 07/05)

21

Third-Party Liability

• If commercial insurance denies, the denial must be noted in the other coverage field on the claim form (#11d on the CMS 1500 check yes and no; occurrence code 24 on the UB-92).•If commercial insurance pays, the amount of payment, including any contractual write-off must be noted on the claim form (#29 on the CMS 1500 and #54 on the UB-92). •If commercial insurance pays part of a claim and denies another, the claims must be split-billed. The charges that insurance pays on should be on one claim form, and the denied charges on another. If a “lump sum” payment is made, it must be pro-rated across all charges billed to Medicaid.

22

Third-Party Liability Continued

• If commercial insurance pays equal to or more than the normal Medicaid payment, Medicaid will pay $0. If the insurance payment is less than the Medicaid allowable, Medicaid will pay the balance up to the Medicaid allowable charge.

• If a member’s primary insurance pays to the member or the member’s family, the provider must be able to collect that payment from the member before Medicaid can be billed. If the member does not turn over payment, they will be liable for the claim.

23

Medical and Dental Prior Authorization

M e d i c a l a n d D e n t a l P r i o r A u t h o r i z a t i o n E ff e c t i v e 6 / 3 0 / 0 5 , M e d i c a l a n d D e n t a l P r i o r A u t h o r i z a t i o n r e q u e s t s s h o u l d b e m a i l e d t o : I o w a M e d i c a i d E n t e r p r i s e M e d i c a l P r i o r A u t h o r i z a t i o n s P O B o x 3 6 4 7 8 D e s M o i n e s , I A 5 0 3 1 5 W h e n s u b m i t t i n g a d d i t i o n a l d o c u m e n t a t i o n w i t h a P r i o r A u t h o r i z a t i o n r e q u e s t , b e s u r e t o i n d i c a t e y o u r p r o v i d e r n a m e a n d t h e m e m b e r ’ s n a m e a n d s t a t e I D o n t h e d o c u m e n t a t i o n . T o e n s u r e t h e r e t u r n o f D e n t a l X - r a y s a n d S t u d y M o d e l s , b e s u r e t o s h o w t h e p r o v i d e r n a m e a n d a d d r e s s a s w e l l a s t h e m e m b e r ’ s n a m e a n d a d d r e s s o n t h e s e d i a g n o s t i c t o o l s . Q u e s t i o n s c a n b e d i r e c t e d t o t h e P r i o r A u t h o r i z a t i o n U n i t a t :

8 8 8 - 4 2 4 - 2 0 7 0 5 1 5 - 7 2 5 - 1 0 0 9 ( L o c a l ) 5 1 5 - 7 2 5 - 1 3 5 6 ( F a x )

H I P A A X 1 2 2 7 8 T r a n s a c t i o n s : T h e I o w a M e d i c a i d E n t e r p r i s e h a s t h e c a p a b i l i t y t o a c c e p t P r i o r A u t h o r i z a t i o n s e l e c t r o n i c a l l y u s i n g t h e H I P A A 2 7 8 t r a n s a c t i o n . I n o r d e r t o s u b m i t P r i o r A u t h o r i z a t i o n s e l e c t r o n i c a l l y , p r o v i d e r s m u s t h a v e t h e c a p a b i l i t y t o s e n d t h e s t a n d a r d t r a n s a c t i o n f o r m a t . P r o v i d e r s m u s t r e g i s t e r w i t h t h e I M E E D I S S i n o r d e r t o s u b m i t e l e c t r o n i c t r a n s a c t i o n s . T o r e g i s t e r , g o t o : h t t p : / / w w w . n o r i d i a n m e d i c a r e . c o m / p r o v i d e r / e d i / u s e r _ d o c s _ i o w a _ m e d i c a i d . h t m l

T o l e a r n m o r e a b o u t s u b m i t t i n g P r i o r A u t h o r i z a t i o n R e q u e s t s e l e c t r o n i c a l l y , p l e a s e c o n t a c t E D I S S a t : 8 0 0 - 9 6 7 - 7 9 0 2 b e t w e e n 1 0 A M – 4 P M C T

Mail your requests to:Iowa Medicaid Enterprise

Medical Prior AuthorizationsPO Box 36478

Des Moines, IA 50315

Questions? 888-424-2070

     515-725-1009 (Local)     515-725-1356 (Fax)

24

Guidelines for Medicare

Crossovers

 •Medicaid pays only coinsurance/deductibles on Medicare crossover claims.

•If submitting a claim that has not “crossed-over” or if there is commercial insurance information that needs to be noted, submit only the Medicare EOB on paper. Note the member’s Medicaid ID, your billing provider number, and if commercial insurance paid, write “TPL paid $____”. If commercial insurance denied, write “TPL denied”.

•Submit only the Medicare EOB for a patient with Spendown.

25

Guidelines for Medicare Crossovers

Continued

•Only services approved by Medicare can be submitted as crossovers. Non-covered Medicare services should be submitted on a Medicaid claim form with the statement “Not a Medicare Benefit” written on the claim form. This applies only for payable Medicaid services.

•Do NOT use red ink or highlighter on the Medicare EOB.

•Send EOMBs to the regular claims address.

26

Timely Filing Guidelines

Initial FilingOriginal claim submissions 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.

ExceptionsExceptions to the 12 month filing limit are considered in only two cases:• Retroactive Eligibility• Third-party related delays

27

Timely Filing Guidelines Continued

ResubmissionsIf 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 AdjustmentsRequests 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.

28

Iowa Administrative Code 441

9.10(8) Medicaid billing. Only the following information shall be released to bona fide providers of medical services in the event that the provider is unable to obtain it from the subject and is unable to complete the Medicaid claim form without it:

a) Patient identification number.

b) Health coverage code as reflected on the subject’s medical card.

c) The subject’s date of birth.

d) The subject’s eligibility status for the month that the service was billed.

29

Iowa Administrative Code 441Continued

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.

30

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.

31

Medical Resource Codes

Medical Resource Codes

If the member has medical resources, a code appears opposite the member’s name in the “Other Insurance” column on the medical eligibility card. This is a four digit code. The third digit indicates the type of health insurance coverage. The fourth digit identifies the source of coverage which the person may have.

Type of Health Insurance (Third Digit)Code Information

Source of Coverage (Fourth Digit)Code Information

A Hospital 0 None B Physician A Medicare Part A C Dental B Accident D Drugs G Absent parent, not court-ordered E Hospital/Physician H Absent parent F Hospital/Physician/Dental I Major medical G Hospital/Physician/Dental/Drug J Absent parent major medical, not court-

ordered H Hospital/Dental K Absent parent major medical, court-

ordered** I Hospital/Drug L Indemnity J Hospital/Physician/Drug 1 Medicare Part B K Physician /Drug 2 Medicare Parts A and B L Physician/Dentist 3 CHAMPVA M Hospital/Physician/Dental/Drug/Vision 4 CHAMPUS N Hospital/Physician/Drug/Vision 5 Veterans Administration 0 Hospital/Physician/Vision 6 Other P Hospital/Physician/Other 7 CHAMPUS absent parent, not court-

ordered Q Hospital/Physician/Dental/Other 8 CHAMPUS absent parent, court ordered

R Hospital/Physician/Dental/Drug/Other 9 Medicaid trust S Hospital/Dental/Other ** Pay and Chase for claims for recipients

whose insurance is carried by an Absent Parent as the result of a court order. Pay and Chase for court ordered Absent Parent Insurance covers all diagnosis codes.

T Hospital/Drug/Other U Hospital/Physician/Drug/Other V Vision W Physician/Drug/Other

W Physician/Drug/Other X Other (including ambulance, home health,

hospice, laboratory and x-ray, medical equipment, nursing facility, both skilled and intermediate, specific disease (both heart or cancer), or any other type)

Y Physician/Dental/Other Z Hospital/Physician/Dental/Drug/Vision/Other

1 Hospital/Physician/Drug/Vision/Other 2 Hospital/Physician/Vision/Other

32

Submission of Medical Records

Surgery that could be considered cosmetic

Operative report

NICU Care beyond specific time frames

Daily progress reports

CPT/HCPCS dump codes Detailed explanation of service, invoice, etc.

Sterilization Consent Form

Use of ’22’ modifier Operative report

Home health claims Plan of care

Examples of Claims Medical Records Required

33

Submission of Medical Records

Reminders for submission of medical records:•When attaching medical records to claims, the records must accompany each claim submission.

•If more than one claim is billed, the records must be copied and submitted with each claim.

•Medical records are considered a part of the submitted claim and are imaged and maintained on file for future reference.

•If a claim is denied due to the lack of medical records, the claim can be resubmitted with the records attached.

34

Iowa Plan for Behavioral Health

• The Iowa Plan for Behavioral Health is a statewide Medicaid managed care plan for mental health and substance abuse treatment services.

• Medicaid members enrolled with the Iowa Plan must access mental health and substance abuse treatment services through providers which are contracted with Merit Behavioral Care of Iowa to provide Iowa Plan Medicaid Services.

• When a Medicaid member is not enrolled with the Iowa Plan, the Medicaid fee-for-service program covers mental health and substance abuse treatment services in accordance with regular Medicaid program policies and procedures.

35

• For information about the Iowa Plan, members may call 800-317-3738. This number is printed on their eligibility cards. • Providers may call the ELVS line for Iowa Plan eligibility at 800-338-7752 or 515-323-3693. • For information regarding the Iowa Plan, providers should call Merit Behavioral Care of Iowa at 800-638-8820.

Iowa Plan for Behavioral Health

Continued

36

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.

37

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

38

The Medically Needy Program

SpenddownIf 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 ClaimsIf 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.

39

Lock-InProgram

To refer members with potential issues in utilizing Medicaid

services, contact Iowa Medicaid Medical

Services at 800-383-1173 or 515-725-1008 and press the option for medical inquiries.

1

h e

L o c k - I n P r o g r a m L o c k - i n p r o g r a m h a s t w o c o m p o n e n t s :

E d u c a t i o n a b o u t u s i n g M e d i c a i d b e n e fi t s M a n a g e m e n t o f c a r e t h r o u g h p r o v i d e r r e s t r i c t i o n s

M e m b e r s a r e s e l e c t e d f o r r e v i e w f r o m t w o s o u r c e s :

C l a i m s w i t h p a t t e r n s o f u t i l i z a t i o n i n d i c a t i n g d u p l i c a t i o n o r m i s u s e

R e f e r r a l s f r o m p r o v i d e r s R e v i e w c r i t e r i a i n c l u d e :

M u l t i p l e E R v i s i t s R e c e i v i n g s e r v i c e s f r o m m o r e t h a n o n e p h y s i c i a n / p r o v i d e r o r

s p e c i a l t y c a r e U t i l i z i n g m o r e t h a n o n e p h a r m a c y O b t a i n i n g u n u s u a l a m o u n t o f p r e s c r i p t i o n d r u g s R e c e i v i n g u n u s u a l a m o u n t s o f m e d i c a l s e r v i c e s

L o c k - i n i s m o r e r e s t r i c t i v e t h a n t h e M e d i P A S S p r o g r a m . M e m b e r s a r e r e s t r i c t e d t o :

O n e P C P a n d o n e s p e c i a l t y c a r e p r o v i d e r O n e h o s p i t a l O n e p h a r m a c y

M e d i P A S S a n d M H C m e m b e r s m u s t b e d i s e n r o l l e d f r o m M H C p r i o r t o e n r o l l m e n t i n L o c k - i n .

T o r e f e r m e m b e r s w i t h p o t e n t i a l i s s u e s i n u t i l i z i n g M e d i c a i d s e r v i c e s , c o n t a c t I o w a M e d i c a i d M e d i c a l S e r v i c e s a t 1 - 8 0 0 - 3 8 3 - 1 1 7 3 o r 5 1 5 - 7 2 5 -1 0 0 8 ( l o c a l ) a n d p r e s s t h e o p t i o n f o r m e d i c a l i n q u i r i e s . F r o m J a n u a r y 2 0 0 5 t h r o u g h J u n e 2 0 0 5 , I o w a M e d i c a i d r e a l i z e d o v e r 2 m i l l i o n s t a t e d o l l a r s t h r o u g h t h e L o c k - i n p r o g r a m . O v e r 5 , 0 0 0 M e d i c a i d m e m b e r s r e c e i v e d e d u c a t i o n o r p r o v i d e r r e s t r i c t i o n s a s a r e s u l t o f t h e L o c k -i n p r o g r a m .

40

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.

How to request an Exception to Policy?Mail or fax the request to:

Department of Human Services

Appeals Section   

1305 E Walnut Street, 5th Floor    Des Moines, IA 50319    Phone (515) 242-6302    FAX (515) 281-4597

OR….

41

Exception To Policy

Email the request to: exceptions@dhs.state.ia.us.

OR complete the Exception to Policy form online at http://www.dhs.state.ia.us/forms/470-3888.htm .

You will receive a letter signed by the Director if the request is approved.

Once the Exception to Policy is approved, how to submit a claim for payment? Submit an original claim form with a copy of the approval letter to: IME

Exception Processing

Hoover State Office Building

1305 E. Walnut

Des Moines, IA 50315

42

Fraud & Abuse

The Iowa Medicaid Program monitors submitted billings on a pre-payment basis to ensure that payment is made for reasonable, necessary, and appropriate services.

The objectives of Medicaid claim reviews are to:• verify that claims paid were for services that were actually provided• that were appropriate for members’ needs•to identify and correct billing problems •to eliminate overuse or abuse •to obtain payment recovery that result from incorrect billings.

43

Fraud & Abuse Continued

To report instances of possible fraud or abuse, contact one of the following telephone numbers:

• Medicaid Fraud Control Unit

800-831-1394

• Medicaid Surveillance & Utilization Review 877-447-8610 or 515-725-1108

44

Education and Outreach Contacts Jeremy Morgan, Supervisor: Phone 515-725-1365

Email: jmorgan1@dhs.state.ia.us

 Leann Howland, Coordinator: Phone 515-725-1364

Email: lhowlan@dhs.state.ia.us

 Maile Johnson, Coordinator: Phone 515-725-1363

Email: kjohnso7@dhs.state.ia.us

 Kathy Eshelman, Coordinator: Phone 515-725-1362

Email: keshelm@dhs.state.ia.us

 

Outreach and Education

45

Education and OutreachContinued

The Outreach and Education Staff

is a pro-active department that provides training for providers. They can help you with the following:• Proactive Educational Issues   • On-site Training Sessions for Providers• PC ACE Pro32 software• Fall Training!

46

Break Time!!