Iowa Admin. Code r. 441-80.2 - Submission of claims
Providers of medical and remedial care participating in the program shall submit claims for services rendered to the Iowa Medicaid enterprise on at least a monthly basis. All nursing facilities and providers of home- and community-based services shall submit claims for services after the end of the calendar month in which the services are provided. Following audit of the claim, Iowa Medicaid will make payment to the provider of care.
(1) Electronic submission. Providers are
required to submit claims electronically whenever possible.
a. When filing electronic claims, pharmacies
shall use the format prescribed by the National Council for Prescription Drug
Programs.
b. Claims submitted
electronically shall be filed on the American National Standards Institute
(ANSI) Accredited Standards Committee (ASC) X12N 837 transaction, Health Care
Claim.
(1) Providers listed as filing claims
on Form CMS-1500 or on the Claim for Targeted Medical Care shall file claims on
the professional version of the 837 Health Care Claim.
(2) Providers listed as filing claims on Form
CMS-1450 or UB04 shall file the institutional version of the 837 Health Care
Claim.
(3) Dentists shall file the
dental version of the 837 Health Care Claim.
(4) Pharmacists providing drugs and
injections shall use the format prescribed by the National Council for
Prescription Drug Programs.
c. If a claim submitted electronically
requires attachments or supporting clinical documentation and a national
electronic attachment has not been adopted, the provider shall:
(1) Use the Iowa Medicaid portal access
(IMPA) system to submit supporting documents when billing Medicaid fee for
service claims; and
(2) Reference
the attachment control number submitted on the ASC X12N 837 electronic
transaction.
(2) Claim forms. Claims for payment for
services provided recipients shall be submitted on Form CMS-1500, Health
Insurance Claim Form, except as noted below.
a. The following providers shall submit
claims on Form UB-04, CMS-1450:
(1) Home
health agencies providing services other than home- and community-based
services.
(2) Hospitals providing
inpatient care or outpatient services, including inpatient psychiatric
hospitals.
(3) Psychiatric medical
institutions for children.
(4)
Rehabilitation agencies.
(5)
Hospice providers.
(6)
Medicare-certified nursing facilities.
(7) Nursing facilities for the mentally
ill.
(8) Special population nursing
facilities as defined in 441-Chapter 81.
(9) Out-of-state nursing
facilities.
(10) Health insurance
premium payment (HIPP) providers.
b. All other nursing facilities and
intermediate care facilities for persons with an intellectual disability shall
file claims using an electronic version of Form UB-04 CMS-1450.
c. Pharmacies shall submit claims on the
Universal Pharmacy Claim Form when filing paper claims.
d. Dentists shall submit claims on the dental
claim form approved by the American Dental Association.
e. Providers of home- and community-based
waiver services, including home health agencies, shall submit claims on Form
470-2486. In the event of the death of the member, the case manager or service
worker shall sign and date the claim form if the services were
delivered.
f. Case management
providers billing services provided pursuant to 441-Chapter 90 to
fee-for-service members shall submit claims using a HIPAA-compliant electronic
claim.
g. For fee-for-service
members, providers billing claims for Medicare beneficiaries that do not cross
over electronically to Iowa Medicaid must submit the following electronically,
in accordance with the All Providers, IV. Billing Iowa Medicaid manual, located
at dhs.iowa.gov/sites/default/files/All-IV.pdf:
(1) Form UB-04.
(2) Form CMS-1500. The Explanation of
Medicare Benefits (EOMB) is only required when requested by Iowa
Medicaid.
h. For managed
care members, providers billing claims for Medicare beneficiaries that do not
cross over electronically must submit the following electronically:
(1) Form UB-04 and the Explanation of
Medicare Benefits (EOMB); and
(2)
Form CMS-1500 and the Explanation of Medicare Benefits (EOMB).
i. Health insurance premium payment
(HIPP) providers shall submit Form 470-5475 along with an explanation of
benefits (EOB).
(3)
Providers shall purchase their supplies of forms CMS-1450 and CMS-1500 for use
in billing.
Notes
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