Providers


MY CURRENT PROVIDER IS NOT IN MY MCO'S NETWORK, CAN I CONTINUE TO SEE MY PROVIDER?

Each Managed Care Organization has a list of providers in their network and are adding more providers each day. You will want to make sure that your provider is within your MCO's network once you are enrolled in the managed care program. If your provider is out of your MCO's provider network, they may still continue to see you however, they may also choose not to see you.

Before receiving services from your providers, please show them your MCO card to let them know your chosen MCO and ask them which MCO networks they are signed with. If your provider is not in your MCO's provider network, this is a "Good Cause" reason to change your MCO. If you do not wish to change your MCO, you may choose another provider within your MCO's provider network. 
 
For more information about "Good Cause," please visit the "Good Cause" webpage.
 

WHAT IF I CHOOSE AN MCO AND MY PROVIDER CHOOSES A DIFFERENT MCO? WILL MY VISIT STILL BE COVERED OR WILL I HAVE TO PAY OUT-OF-POCKET?

The member will never be forced to pay out-of-pocket for an Iowa Medicaid provider. The provider may accept the out-of-network rate from the MCO, or choose not to see the patient.
 

Each Managed Care Organization has a list of providers in their network and are adding more providers each day. You will want to make sure that your provider is within your MCO's network once you are enrolled in the managed care program. If your provider is out of your MCO's provider network, they may still continue to see you however, they may also choose not to see you.

Before receiving services from your providers, please show them your MCO card to let them know your MCO and ask them which MCO networks they are signed with. If your provider is not in your MCO's provider network, this is a "Good Cause" reason to change your MCO. For more information about "Good Cause," please visit the "Good Cause" webpage.

If you do not wish to change your MCO, you may choose another provider within your MCO's provider network.

Note: A provider who knowingly treats a Medicaid member cannot bill the member for the rate difference of services rendered. If a Medicaid provider refuses to accept the out-of-network rate, they cannot bill the patient directly. Members may be charged for services that are not covered by Iowa Medicaid, or are not medically necessary. However, per the Iowa Administrative Code 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."
 

A LOT OF PATIENTS ARE SENT TO MAYO CLINIC IN ROCHESTER FOR SERVICES THAT ARE NOT OFFERED IN OUR STATE. is my mco CONTRACTED WITH THESE FACILITIES?

While each MCO has signed a number of the out-of-state providers that are currently enrolled in Medicaid today, others have indicated that they will only serve members in the future through single case agreements, such as the Mayo Clinic in Rochester.

WHAT IS THE PROCESS FOR PROVIDERS WHO REFER MEMBERS TO MAYO CLINIC IN ROCHESTER AND OUT-OF-STATE PROVIDERS?

Providers making such referrals will need to work with a given member's MCO, with considerations including, but not limited to: the medical need for the referral, the unavailability of in-state and/or in-network providers able to provide the medically necessary care, etc.

IF A MEMBER GOES TO URGENT CARE OR AN EMERGENCY ROOM, FOR SOMETHING THAT IS NOT DETERMINED TO BE 'URGENT CARE,' WILL THE MEMBER BE CHARGED?

Urgent care or a “walk-in clinics” have no limit as to what constitutes an urgent condition for rendering services.  Regardless of the status as urgent or non-urgent there is no penalty or financial responsibility to the member for seeking care for a sudden or persistent medical condition in this setting.

For emergency room visits the hospital will make the determination if a member’s care is urgent or non-urgent. If it is determined to be non-urgent, the member may have a copayment, depending on their MCO. The member will be notified if their care is non-urgent prior to services being rendered.

IF A MEMBER OF IA HEALTH LINK SEES A PROVIDER WHO IS A REGISTERED FFS PROVIDER WITH IME, BUT NOT SIGNED WITH ANY MCO AND NOT WILLING TO WORK WITH THE MCOS, WILL THE STATE PAY?

No, the state will not pay. The provider may accept the out-of-network rate from the member’s MCO, or choose not to see the member. A provider who knowingly treats a Medicaid member cannot bill the member for the rate difference of services rendered. If a Medicaid provider refuses to accept the out-of-network rate, they cannot bill the patient directly. 
 

CAN PATIENTS BE BILLED FROM PROVIDERS WHO ARE NOT PARTICIPATING WITH THE MCOS OR MEDICAID? 

Yes. The provider must notify the member that they will pay out of pocket prior to services, or the provider may choose not to see the patient.
 

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Iowa Medicaid Member Services (Monday to Friday from 8 a.m. to 5 p.m.)
1-800-338-8366 (Toll Free) 
515-256-4606 (Des Moines Area)
515-725-1351 (Fax)
 
For telephone accessibility assistance if you are deaf, hard-of-hearing, deaf-blind, or have difficulty speaking, call Relay Iowa TTY at 1-800-735-2942.
 
Llame al 1-800-735-2942, a Relay Iowa TTY (teléfono de texto para personas con problemas de audición, del habla y ceguera) si necesita asistencia telefónicamente.