Rights and Responsibilities

Peer-to-Peer Conversation
Decisions on requests for services are based on standards of care and medical necessity. Providers who receive an adverse decision related to a medical necessity determination may request a Peer-to-Peer Conversation to discuss the decision with the physician or other professional reviewer who made the decision. The request may be made by calling 800-383-1173 or locally 515-256-4623. Requestors must provide the name of the member, member ID, and services that were denied. IME Medical Services will arrange for a conference call between the requesting provider and the peer reviewer who denied or modified the request for services.

Appeals Process:
This page directs anyone engaged in services with the Iowa Department of Human Services (DHS), whether it is a member or provider, on how to appeal any decision made by DHS. All appeals must be made within 90 days of the DHS decision or a hearing will not be granted. An English and Spanish version of the form is available on the link above. Contact information is also provided if you have any further questions.

Exception to Policy:
An exception to policy is a request for an item or service not otherwise covered by the Iowa Department of Human Services (DHS). Exceptions to policy may be granted to the DHS rules, but they cannot be granted to rules that are based on federal policy or state law. Exceptions will not be granted for program eligibility requirements, such as income guidelines or resource limits. An exception to policy is a last resort request and should only be used when all other options have been exhausted.

Excluded Individual and Entities:
This site is run by the Office of Inspector General (OIG) to protect the integrity of Department of Health & Human Services (HHS) programs and the health and welfare of program beneficiaries. We ask that you use this site to determine if a member of your staff is listed on the Excluded Individuals List. Per Informational Letter 974, if the HHS-OIG excludes individuals and entities , they are not allowed to participate as providers in Medicare, Medicaid, the State Children's Health Insurance Program (CHIP), and all Federal health care programs (as defined in section 1128B(f) of the Social Security Act (the Act). When the HHS-OIG has excluded a provider, Federal health care programs (including Medicaid and CHIP programs) are generally prohibited from paying for any items or services furnished, ordered, or prescribed by excluded individuals or entities. This prohibition applies even when the Medicaid payment itself is made to another provider, practitioner or supplier that is not excluded.

HIPAA:
The Health Insurance Portability and Accountability Act (HIPAA) was passed by Congress in 1996. As part of the Act, Congress called for regulations promoting administrative simplification of healthcare transactions as well as regulations ensuring the privacy and security of patient information. These regulations apply to what are called "covered entities" (e.g. healthcare providers, health plans, and healthcare clearinghouses) that transmit any health information in electronic form in connection with a transaction covered under HIPAA. The Iowa Department of Human Services (DHS) is considered a covered entity under HIPAA as a health plan and became HIPAA compliant as of April 21, 2005. Please use this area to review the Privacy Policy and procedures implemented by DHS governing the release of protected health information (PHI).

Provider Critical Incident Reporting:
The provider incident reporting standards found in the Iowa Administrative Code 441, Chapter 77 impacts providers who have personal contact with Medicaid members under the Home-and-Community-Based Services (HCBS) habilitation and waiver services. The Centers for Medicare and Medicaid Services (CMS) have approved amendments to Iowas waivers that require a process for incident reporting. The incident reporting standards apply only to providers who have personal contact with members. The standards set in the Iowa Administrative Code (IAC) define "major" and "minor" incidents, prescribe the content of the incident report form, and set procedures for reporting of major and minor incidents. Providers must keep records of all minor incidents, but do not have to report minor incidents. Only when a defined major incident has occurred should this be reported. The above link will allow providers to electronically report the incident along the guidelines that have been set by the IAC.

Provider Rules:
This section outlines a complete listing of all the technical and instructional manuals used by recognized provider types as specified by the Iowa Medicaid Enterprise (IME). Each of the provider manual is specific to a service offered by the IME and is designed to guide an IME Provider with clear and concise outlines of what services are covered or not covered under that service. Additionally, the manuals also provide instructions on how to read and complete the various forms required by the IME for each offered service. These manuals serve as a very important tool for providers in helping them ensure a more seamless administrative process involving IME guidelines, billings, and documentations.