Iowa Medicaid Enterprise
The Iowa Medicaid Enterprise (IME) is an endeavor that unites State Staff and "Best of Breed" contractors into a performance-based model for the administration of the Iowa Medicaid program. Medicaid is a state-federal funded program that is administered by the Department of Human Services of the State of Iowa.
How the Enterprise Works
The Iowa Medicaid Enterprise is a collection of specific units, each having an area of expertise, and all working together to accomplish the goals of the Medicaid program. Housed in a single building, the IME has staff who participate in the following activities:
State DHS Policy Staff
These state employees provide overall guidance to the operations of the IME through the development of policies about coverage and payment for all services from dental to nursing facility to hospital care.
Enroll health care professionals as participating providers. Offer assistance for billing services through routine training seminars and telephone assistance. The Provider Services pages include more information about providers, including finding a provider and how to enroll in the Medicaid program.
Staff and operate a statewide telephone call center to assist Medicaid members in accessing services or explaining how services can be provided. The call center staff will assist members in enrolling in managed care, when applicable. The Member Services pages include more information about eligibility and how to apply for Medicaid coverage.
Long Term Care
Long term care services are available for Medicaid members to help them maintain a good quality of life in settings such as their home or, if needed, in a facility. Services are intended to help people reach the highest degree of independence possible.
Provider Audit & Rate Setting
This group helps policy staff to develop payment rates that are consistent and appropriate for services being provided to members. This includes rates for physicians and hospitals among others, using various methodologies.
The Core group is that which performs a myriad of functions for the IME that includes processing and payment of claims, mail handling and reporting. This unit also provides and updates the automated eligibility reporting system known as ELVS.
This unit consists of medical professionals and affiliated staff that provide medical opinions on specific areas such as coverage and benefits as well as assisting with opinions on exceptions to policy and appeals. The prior authorization page includes more information about specific requirements for prior authorization.
Pharmacy Medical Services
This unit oversees the operation of the Preferred Drug List (PDL) and Prior Authorization (PA) for prescription drugs. The development and updating of the PDL allows the Medicaid program to optimize the funds spent for prescription drugs. The Pharmacy Medical group performs drug Prior Authorization with medical professionals who evaluate each request for the use of a number of drugs.
Program Integrity in Iowa Medicaid
This unit will routinely inspect claims submitted to the IME to assure that Medicaid is paying appropriately for covered services.
This is the pharmacy point of sale system. It is a real-time system for pharmacies to submit prescription drug claims for Iowa Medicaid members and receive a timely determination regarding payment. Visit the POS page for more information about Pharmacy POS.
The Revenue Collections Unit provides for capture of payments that are to be made to the Medicaid program through other third-party insurance, estate recovery, and liens.
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