Iowa Admin. Code r. 441-80.2

Current through Register Vol. 47, No. 11, December 11, 2024

Rule 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.

Iowa Admin. Code r. 441-80.2

ARC 9403B, lAB 3/9/11, effective 5/1/11; ARC 9724B, lAB 9/7/11, effective 9/1/11; ARC 9889B, lAB 11/30/11, effective 1/4/12

Amended by IAB September 30, 2015/Volume XXXVIII, Number 07, effective 12/1/2015

Amended by IAB July 5, 2017/Volume XL, Number 01, effective 7/1/2017

Amended by IAB August 30, 2017/Volume XL, Number 5, effective 10/4/2017

Amended by IAB December 6, 2017/Volume XL, Number 12, effective 1/10/2018

Amended by IAB November 6, 2019/Volume XLII, Number 10, effective 12/11/2019

Amended by IAB November 4, 2020/Volume XLIII, Number 10, effective 1/1/2021

Amended by IAB February 8, 2023/Volume XLV, Number 16, effective 4/1/2023