Claims and Billing

Prior Authorization Codes:
Prior Authorization from the Iowa Medicaid Enterprise (IME) is required for certain services and supplies.  It is necessary to fill out and submit the Prior Authorization Form # 470-0829 to the IME to obtain these services and/or supplies. Attached below are the lists of codes that require the submission of the Prior Authorization Form.

Atypical Code Conversion Project:
In accordance with direction from the Centers of Medicare and Medicaid Services (CMS), the Iowa Medicaid Enterprise (IME) has completed a project converting all service codes that begin with a "W" to standardized codes. These "W" codes were previously used to bill waiver, habilitation, case management, and targeted case management services to the IME. This conversion affects the Individualized Services Information System (ISIS), Notices of Decision (NOD), and claims billed to the IME. This transition is effective for dates of service on or after July 1, 2013. Billing for dates of service prior to July 1, 2013, will still require the “W” code.

Claim Forms and Instructions:
The Iowa Medicaid Enterprise (IME) 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 the IME 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.

Clear Coverage High Technology Radiology Prior Authorization:
The Iowa Medicaid Enterprise (IME) utilizes an online prior authorization (PA) system, McKesson's Clear CoverageTM, for certain elective outpatient high technology radiologic tests. Turnaround time for most prior authorizations is 3 to 5 business days. Requests that meet medical criteria in Clear Coverage are approved automatically in the system. The PA must be obtained by the ordering provider. The ordering provider must give the PA number to the radiology provider for inclusion on the claim. Prior authorization will not be required for procedures that occur during inpatient hospital or emergency room visits. For more detailed information about the Clear Coverage High Technology Radiology Prior Authorization, please review Informational Letter No. 876.

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 Enterprise (IME) shows a "correct coding edit" post on a provider's remittance advice statement, supplemental edit details are available on the Correct Coding Edit Verification Portlet by entering the Transaction Control Number (TCN) and billing NPI of the claim.

Electronic Data Interchange Support Services (EDISS):
Electronic Data Interchange is the Iowa Medicaid Enterprises' (IME) clearinghouse for electronic healthcare transactions. In these transactions, providers and the IME exchange information though defined, electronic conventions that support established processes such as eligibility look-up, claim submission and payment information. IME'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 Code:
Effective September 1, 2011, the Iowa Medicaid Enterprise (IME) updated their copayment requirements for members going to the emergency room for non-emergent issues (IL 1025). The above link is a listing of all diagnoses codes that are considered emergent by the IME. If you are in doubt as to whether a service is considered emergent or non-emergent please review the above listing. This list is updated frequently by the IME Medical Services staff.

Explanation of Benefits (EOB) Crosswalk:
The Iowa Medicaid Enterprise (IME) 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 Human Services' (DHS) website for its Iowa Medicaid Portal Access (IMPA)

  1. The 835 website (offered by our Electronic Vendor)

The EOB codes used by the IME differ and are considered non HIPPA compliant as they give more detailed information than 835's. This document is to help providers translate what the HIPPA compliant 835 EOB codes mean to what IME posts on the EOBs offered through the 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, the Iowa Medicaid Enterprise (IME) 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 the IME 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.

Disallowance Project:
The purpose of the Disallowance project is to notify providers of potential third party liability (TPL) for claims submitted and paid by the Iowa Medicaid Enterprise (IME). In general, Disallowance projects are released to providers five (5) times each year with a listing of claims paid by the IME where TPL may exist. The providers have 60 days to work the Disallowance project by contacting the TPL vendor and then responding to the IME 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 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).