Claims and Billing

Coronavirus (COVID-19)

Guidance on covered services and claims billing related to coronavirus and COVID-19.


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

Prior Authorization

Prior Authorization from the Iowa Medicaid Enterprise (IME) is required for certain services and supplies.  It is necessary to fill out and submit the Outpatient Services (470-5595) and Supplemental Form (470-5619) to obtain these  services and/or supplies. Read more about prior authorization.

International Classification of Diseases, 10th Edition (ICD-10)

As announced in Informational Letter 1440, the Iowa Medicaid Enterprise (IME) will not accept claims with ICD-9 codes for services delivered on or after October 1, 2015, and inpatient discharges occurring October 1, 2015 or after. The registration for Iowa Medicaid Enterprise (IME) ICD-10 Volunteer Testing is now open. To register for testing, please contact the IME Provider Services Unit at 1-800-338-7909, or locally in Des Moines at 515-256-4609 or by email at

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.

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 Billing

Effective August 1, 2019, the Iowa Medicaid Enterprise (IME) 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 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 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.

  • ICD-10 Code
    Please go here to view the ICD-10 codes that are considered to be emergent for dates of services on or after January 1, 2022.
  • ICD-9 Code
    Please go here to view the ICD-9 codes that are considered to be emergent for dates of services prior to October 1, 2015.

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 HIPAA compliant as they give more detailed information than 835's. This document is to help providers translate what the HIPAA 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 45 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).