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									Iowa Medicaid
  Enterprise



 Welcome To Fall
  Training 2005

                   1
Agenda

      •Medicaid Overview
            •Break!
  •Provider-Specific Training
   •Questions and Answers


                                2
CONTACT INFORMATION


                                  IOWA MEDICAID ENTERPRISE
                                        ADDRESS LIST
                                            Effective 6/30/05

                                          MEDICAID CLAIMS
                                             P. O. Box 150001
                                         Des Moines, Iowa 50315

                                     PROVIDER CORRESPONDENCE
                                            P. O. Box 36450
                                        Des Moines, Iowa 50315

                                  MEDICAL PRIOR AUTHORIZATION




     IME
                                           P.O. Box 36478
                                       Des Moines, Iowa 50315

                                 PHARMACY PRIOR AUTHORIZATION
                                      800-574-2515 - Fax Only

                                          MEMBER SERVICES
                                             P. O. Box 36510
                                         Des Moines, Iowa 50315

                               ESTATE RECOVERY AND MILLER TRUST




  Addresses
                                          P. O. Box 36445
                                      Des Moines, Iowa 50315

                                        THIRD PARTY LIABILITY
                                             P. O. Box 36475
                                         Des Moines, Iowa 50315

                                            LIEN RECOVERY
                                             P. O. Box 36446
                                         Des Moines, Iowa 50315

                                  DRUG REBATE (including Supplemental)
                                              P.O. Box 36448
                                          Des Moines, Iowa 50315
                  (This will be changing 6/30/05. Please use this address until that time.)

                                      ALL OTHER REFUND CHECKS
                                            P.O. Box 36476
                                        Des Moines, Iowa 50315




                                                                                              3
CONTACT INFORMATION
    CONTINUED
                                                  IOWA MEDICAID ENTERPRISE
                                                    CONTACT INFORMATION
                                                                Effective 6/30/05
                             Mailing Address for Claims:                   Visit the IME Website to access
                              Iowa Medicaid Enterprise                           even more information:
                                   P. O. Box 150001                               www.ime.state.ia.us
                               Des Moines, Iowa 50315                             (Effective 5/10/05)
                         ELVS                                                       PROVIDER SERVICES
                         (Eligibility Verification System)                          7:30 AM – 4:30 PM




       IME
                         24 Hours a Day/7 Days a Week                               800-338-7909
                         800-338-7752                                               515-725-1004 (Local)
                         515-323-9639 (Local)                                       515-725-1155 (Fax)

                         PHARMACY Prior Authorization                               EDI SUPPORT SERVICES
                         Provider PA Hotline                                        10:00 AM - 4:00 PM
                         8:00AM – 6:00PM (after-hours on-call available)            800-967-7902
                         877-776-1567
                         515-725-1106 (Local)                                       PROVIDER AUDITS AND
                         Prior Authorization Requests                               RATE SETTING
                         800-574-2515 (Fax Only)                                    8:00 AM – 5:00 PM
                                                                                    866-863-8610
                         PHARMACY POS HELP DESK                                     515-725-1108 (Local)
                         8:00AM – 6:00PM (after-hours on-call available)            State MAC Help Line




     Phone
                         877-463-7671                                               800-591-1183
                         515-725-1107 (Local)
                                                                                    SURS
                         MEDICAL SERVICES                                           8:00 AM – 5:00PM
                         Medical Support                                            877-446-3787
                         8:00 AM – 4:30 PM                                          515-725-1346 (Local)
                         800-383-1173
                         515-725-1008 (Local)                                       REVENUE COLLECTION
                                                                                    Estate Recovery
                         MEDICAL PRIOR                                              7:30 AM – 5:30 PM
                         AUTHORIZATION (PA)                                         877-463-7887
                         8:00 am – 4:30 PM                                          515-725-1005 (Local)
                         888-424-2070                                               Third Party Liability (TPL)
                         515-725-1009 (Local)                                       8:30 AM – 5:00 PM




    Numbers              515-725-1356 (Fax)

                         MEMBER SERVICES
                         8:00 AM – 5:00 PM
                         800-338-8366
                         515-725-1003 (Local)
                      All Hotlines are listed in Central Time
                                                                                    866-810-1206
                                                                                    515-725-1006 (Local)
                                                                                    Lien Recovery
                                                                                    8:30 AM – 5:00 PM
                                                                                    888-543-6742
                                                                                    515-725-1007 (Local)




                                                                                                            4
          ELVS

                                                           ELVS
                                            (Eligibility Verification System)

                               What ELVS can do for you? –

 Eligibility 24 hours a day,     Eligibility verification 24 hours a day, seven days a week. By simply
                                 entering your seven-digit provider number and the member state ID you
                                 can:

                                  Verify member eligibility for today’s date or past date of service.

          7 days a week!          Verify if the member has insurance.
                                  Verify member enrollment with an HMO, MediPass, and the Iowa Plan.
                                    The HMO name or Medipass provider name and telephone number will
                                    be included.
                                  Verify Spend Down amount remaining
                                  Verify Lock-in information

Verify:                           Member eligibility can be verified by date of birth – ddmmyyyy and
                                    social security number or the State ID number.

                                 Provider Payment – By entering your seven-digit provider number you can:




   •Spend Down
                                  Access your last payment amount and date.


                                                   800-338-7752
                                                515-323-9639 (Local)

   •Lock-In
   •Insurance
   •Managed Health Care
   information                                                                                              5
 IME Website

                                  WWW.IME.STATE.IA.US

•Enroll Providers       •Download the         •Contact information
•Download forms         Provider Manuals      •Electronic Claim
•Check eligibility      •Fee schedules        Submission
•Claim status           •Research emergency   information
•Sign up for provider   diagnosis codes       •Get information
training                •Use the Provider     regarding rates,
                        registry              assessments, new
•Get training                                 programs, etc.
materials               •Frequently Asked
                        Questions             •Access policy
•Access informational                         information
releases

                                                                     6
How Can I Make the IME
     Work for Me?


 Use the IME’s internet based Web Portal
                 Access

Sign up for Electronic Funds Transfer (EFT)
        of your Medicaid Payments
                  AND
                                        7
How Can I Make the IME
     Work for Me?


   Use the correct Address when sending
           documents to the IME
      Medicaid Claims
      IME                    Claims Only
      PO Box 150001          No checks please
      Des Moines, IA 50315

      Correspondence
      IME                    Provider inquiries
      PO Box 36450           Credit/Adjustments
      Des Moines, IA 50315   Provider Enrollment
                                                   8
WEB PORTAL


 The IME Web Portal allows you to check
    eligibility and claims status online!
 To enroll, contact IME EDISS to obtain a
         Login ID and Password.
                800-967-7902
                 10AM-4PM
        Email: edi@noridian.com
                                            9
Web Portal
Continued

                       OR…
Go to the EDISS website to get the
registration forms. The easiest way
  to access the website is to go to
 www.ime.state.ia.us and click on
“Electronic Data Interchange” in the
            “Tools” box.
                                       10
ELECTRONIC CLAIMS
   SUBMISSION


                   EDISS
   (ELECTRONIC DATA INTERCHANGE SUPPORT SERVICES)

               800-967-7902
        EMAIL: EDI@NORIDIAN.COM
        www.noridianmedicare.com



   PC ACE PRO32 SOFTWARE
                (It’s Free!)                        11
  ELECTRONIC CLAIMS
     SUBMISSION


• All providers need to complete the appropriate EDI paperwork
in order to submit electronic claims to the IME EDISS.

•The claims registration forms (837P, 837I, or 837D) along with
the EDI Enrollment form must be completed.

• If using PC-ACE Pro32, complete the PC-ACE Pro32 Software
Sublicense Agreement as well.

                                                            12
   Claims Submission
        Issues

• Claims must include a valid Medicaid Provider number in the
  correct box on the claim form
• No black and white claim copies
• Use the original “Drop-out” red and white CMS-1500 and UB-92
  claim forms.
• Do not use high-lighters on any document
   – Highlighted documents will be blacked out by the scanner
• Do not use red ink
   – Red ink will not show up on a scanned document
• New credit and adjustment form
• Do not use created to look like an original Medicaid claim form.
• Dental Forms – ’99, 2000, and 2002 form
                                                                     13
  Tips for Faster
 Claim Processing


• Do not use red ink or highlighter on any document sent to the IME
• For Medicare crossovers circle the claim on the Medicare EOMB.
• Do not rebill services that are currently in process.
• A provider signature is required on all non-electronic claims. If the
signature field contains block letters or a computer-generated signature,
it is not considered valid unless it has been initialed.
• Claims that are resubmitted after a year has passed since the date of
service must be on paper and have the original filing date beside the
signature.
• Don’t send resubmitted claims to Provider Services.

                                                                   14
 Credit/Adjustment
      Request


When to request a Credit or an Adjustment?
•Request a Credit if you want the IME to take back an entire
payment on a claim.
•Request an Adjustment when there is a correction to be
made on a claim (date of service, number of units, primary
payment, late insurance payments, etc).

                Where do I find the form?
 •www.ime.state.ia.us (click on “Providers”, then “Forms”)
                     •Provider Manual
                                                               15
Credit/Adjustment Request
        Continued

 The Credit/Adjustment Request Form has three sections that
 must be completed.
 • In Section A, choose “Credit” or “Adjustment”.
 •In Section B, note the 17-digit TCN number found on the
 remittance advice.
 • In Section C, sign and date the request.
 •Do not submit a Credit/Adjustment Request if the claim is
 denied.
 •Requests must be submitted one year or sooner after the
 date of original payment.
                                                       16
                                       IOWA MEDICAID PROGRAM
                               CREDIT/ADJUSTMENT REQUEST
                 (If the claim is DENIED, DO NOT USE THIS FORM. Resubmit the corrected claim.)
                                            (DO NOT USE RED INK.)

SECTION A: Check the appropriate box and follow the steps that are outlined

       X   CLAIM ADJUSTMENT

             a) Attach a completed claim copy, with corrections made directly on the claim, OR
             b) Attach a copy of the remittance advice, with corrections made directly on the remittance, AND
             c) Complete Sections B and C.

       CLAIM CREDIT (NOTE: This will result in Medicaid retracting the claim payment.)
             d) Attach a remittance copy.
             e) Complete Sections B and C

SECTION B: This section MUST be filled out completely in order to process:

1.     17-DIGIT TCN: 0-00000-00-000-0000-00
2.     7 DIGIT PAY-TO-PROVIDER NUMBER: 1234567

3.     PROVIDER NAME: Jeremy Morgan

                     CITY: Des Moines                         STATE: IA              ZIP: 50315
4.     8-DIGIT MEMBER STATE ID NUMBER: 1234567A
5.     REASON FOR ADJUSTMENT OR CREDIT: ___A short explanation or description of what you are asking
for.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________


SECTION C: Signature and Date REQUIRED
Signature
DATE: 10/03/05


                                     RETURN ALL REQUESTS TO:
                                    IOWA MEDICAID ENTERPRISE
                                           PO BOX 36450
                                       DES MOINES, IA 50315
  Provider Inquiry

     How can I get an answer in writing?
               Use the Provider Inquiry Form
           www.ime.state.ia.us or the Provider Manual

Submit a Provider Inquiry when you have a question regarding a claim
and need to receive the answer in writing. Attach the Provider Inquiry
Form to a claim and any documentation required.

Fill the form out completely- include the 17-digit TCN number found on
the remittance advice, describe the situation, and note your provider
number, address, and phone number. Also, be sure to sign and date the
                                                                    18
form.
   Provider Inquiry
      Continued

When to use:
   –To initiate an investigation into a claim denial
When not to use:
   –To add documentation to a claim
   –To update/change/correct a paid claim


•Mail Provider Inquiries to:     IME
                             PO Box 36450
                          Des Moines, IA 50315         19
                                              PROVIDER INQUIRY
             Attach supporting documentation. Check applicable boxes:  Claim copy            Remittance copy
                                                        Other pertinent information for possible claim reprocessing.


      1. 17-DIGIT TCN

      2. NATURE OF INQUIRY

 I
 N
 Q
 U
 I
 R
 Y

 A



      1. 17–DIGIT TCN
      2. NATURE OF INQUIRY

 I
 N
 Q
 U
 I
 R
 Y

 B



 Provider Signature/Date:                   MAIL TO: IME Provider             IME Signature/Date:
                                            Services
                                            P. O. BOX 36450
                                            DES MOINES IA 50315
                                                                                         (FOR IME USE ONLY)
 Provider      7-digit Medicaid Provider
 Please        ID#                                                            PR Inquiry Log #
 Complete:
               Telephone                                                      Received Date Stamp:
 Name
 Street
 City, St
 Zip


470-3744 (Rev. 07/05)


Fall 2005                       Iowa Medicaid Enterprise                                    1
     Third-Party
      Liability

• If commercial insurance denies, the denial must be noted in the other
coverage field on the claim form (#11d on the CMS 1500 check yes and
no; occurrence code 24 on the UB-92).
•If commercial insurance pays, the amount of payment, including any
contractual write-off must be noted on the claim form (#29 on the CMS
1500 and #54 on the UB-92).
•If commercial insurance pays part of a claim and denies another, the
claims must be split-billed. The charges that insurance pays on should be
on one claim form, and the denied charges on another. If a “lump sum”
payment is made, it must be pro-rated across all charges billed to
Medicaid.
                                                                  21
   Third-Party
Liability Continued



• If commercial insurance pays equal to or more than the normal Medicaid
payment, Medicaid will pay $0. If the insurance payment is less than the
Medicaid allowable, Medicaid will pay the balance up to the Medicaid
allowable charge.

• If a member’s primary insurance pays to the member or the member’s
family, the provider must be able to collect that payment from the member
before Medicaid can be billed. If the member does not turn over payment,
they will be liable for the claim.

                                                                  22
Medical and Dental
Prior Authorization


   Mail your requests to:          Medical and Dental Prior Authorization


 Iowa Medicaid Enterprise      Effective 6/30/05, Medical and Dental Prior Authorization requests should
                               be mailed to:

                               Iowa Medicaid Enterprise
                               Medical Prior Authorizations


Medical Prior Authorizations   PO Box 36478
                               Des Moines, IA 50315

                               When submitting additional documentation with a Prior Authorization



       PO Box 36478
                               request, be sure to indicate your provider name and the member’s name and
                               state ID on the documentation. To ensure the return of Dental X-rays and
                               Study Models, be sure to show the provider name and address as well as the
                               member’s name and address on these diagnostic tools.




   Des Moines, IA 50315        Questions can be directed to the Prior Authorization Unit at:

                                  
                                  
                                    888-424-2070
                                    515-725-1009 (Local)
                                  515-725-1356 (Fax)

                               HIPAA X12 278 Transactions:

                               The Iowa Medicaid Enterprise has the capability to accept Prior
                               Authorizations electronically using the HIPAA 278 transaction. In order to


        Questions?             submit Prior Authorizations electronically, providers must have the
                               capability to send the standard transaction format.




      888-424-2070
                               Providers must register with the IME EDISS in order to submit electronic
                               transactions. To register, go to:
                               http://www.noridianmedicare.com/provider/edi/user_docs_iowa_medicaid.html


                               To learn more about submitting Prior Authorization Requests electronically,




    515-725-1009 (Local)
                               please contact EDISS at:

                               800-967-7902 between 10AM – 4PM CT




     515-725-1356 (Fax)
                                                                                                             23
  Guidelines for
Medicare Crossovers

•Medicaid pays only coinsurance/deductibles on Medicare
crossover claims.
•If submitting a claim that has not “crossed-over” or if there
is commercial insurance information that needs to be noted,
submit only the Medicare EOB on paper. Note the member’s
Medicaid ID, your billing provider number, and if commercial
insurance paid, write “TPL paid $____”. If commercial
insurance denied, write “TPL denied”.
•Submit only the Medicare EOB for a patient with Spendown.

                                                            24
   Guidelines for
 Medicare Crossovers
     Continued


•Only services approved by Medicare can be submitted as
crossovers. Non-covered Medicare services should be submitted
on a Medicaid claim form with the statement “Not a Medicare
Benefit” written on the claim form. This applies only for payable
Medicaid services.

•Do NOT use red ink or highlighter on the Medicare EOB.

•Send EOMBs to the regular claims address.
                                                            25
      Timely Filing
       Guidelines

                            Initial Filing
Original claim submissions must be filed within 12 months of the first
     date of service. The date of submission must be shown beside the
     signature on paper claims. Medicare crossovers must be filed
     within 24 months of the first date of service.


                              Exceptions
Exceptions to the 12 month filing limit are considered in only two cases:
•   Retroactive Eligibility
•   Third-party related delays

                                                                  26
   Timely Filing
Guidelines Continued


                        Resubmissions
 If a claim is filed timely but denied, an additional 12 month
     follow up period is allowed. These claims must be
     submitted on paper with the original filing date noted.


                      Claim Adjustments
 Requests for claim adjustments must be made within 12
   months of the payment date. Claim credits or partial
   refunds are not subject to a time limit.



                                                                 27
Iowa Administrative Code 441



 9.10(8) Medicaid billing. Only the following information shall be
      released to bona fide providers of medical services in the
      event that the provider is unable to obtain it from the
      subject and is unable to complete the Medicaid claim form
      without it:
 a) Patient identification number.
 b) Health coverage code as reflected on the subject’s medical
      card.
 c) The subject’s date of birth.
 d) The subject’s eligibility status for the month that the
      service was billed.
                                                             28
 Iowa Administrative Code 441
         Continued




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.

The member must be informed of the date and procedure that
will not be covered by Medicaid.
This information must be noted in the patient’s file.


                                                            29
   Iowa Medicaid
   Eligibility Cards

Green Card:        Traditional fee-for-service Medicaid members. Also Medically Needy
                   Members who have met their spenddown.
Pink Card:         Managed Health Care members (MediPASS and HMO).
Blue Card:         Lock-in recipients.
Violet Card:       Qualified Medicare Beneficiaries (QMB), as well as Alien-Status
                   individuals with limited benefits.
IowaCare Card:     Members are covered if seen at the University of Iowa
                   Hospitals and Clinics, Broadlawns Medical Center, and the State’s four
                   Mental Health Institutions at Cherokee, Clarinda, Independence, and Mt.
                   Pleasant.
Notice of Decision: Presumptively eligible women. Coverage is for:
                   •women who have or may have breast or cervical cancer. Applies to all
                   Medicaid covered services.
                   •Pregnant women. Applies to ambulatory prenatal care only.
                                                                                   30
     Medical Resource
          Codes

                                            Medical Resource Codes

 If the member has medical resources, a code appears opposite the member’s name in the “Other
Insurance” column on the medical eligibility card. This is a four digit code. The third digit
indicates the type of health insurance coverage. The fourth digit identifies the source of
coverage which the person may have.



          Type of Health Insurance                          Source of Coverage
        (Third Digit)Code Information                 (Fourth Digit)Code Information
                                                                                                 W Physician/Drug/Other
A   Hospital                                    0    None
B   Physician                                   A    Medicare Part A
                                                                                                 X Other (including ambulance, home health,
C   Dental                                      B    Accident                                      hospice, laboratory and x-ray, medical
D   Drugs                                       G    Absent parent, not court-ordered              equipment, nursing facility, both skilled and
E   Hospital/Physician                          H    Absent parent                                 intermediate, specific disease (both heart or
F   Hospital/Physician/Dental                   I    Major medical                                 cancer), or any other type)
G   Hospital/Physician/Dental/Drug              J    Absent parent major medical, not court-
                                                     ordered
H   Hospital/Dental                             K    Absent parent major medical, court-
                                                     ordered**                                   Y   Physician/Dental/Other
I   Hospital/Drug                               L    Indemnity                                   Z   Hospital/Physician/Dental/Drug/Vision/Other
J   Hospital/Physician/Drug                     1    Medicare Part B
K   Physician /Drug                             2    Medicare Parts A and B                      1   Hospital/Physician/Drug/Vision/Other
L   Physician/Dentist                           3    CHAMPVA
M   Hospital/Physician/Dental/Drug/Vision       4    CHAMPUS
                                                                                                 2   Hospital/Physician/Vision/Other
N   Hospital/Physician/Drug/Vision              5    Veterans Administration
0   Hospital/Physician/Vision                   6    Other
P   Hospital/Physician/Other                    7    CHAMPUS absent parent, not court-
                                                     ordered
Q   Hospital/Physician/Dental/Other             8    CHAMPUS absent parent, court ordered

R   Hospital/Physician/Dental/Drug/Other        9    Medicaid trust
S   Hospital/Dental/Other                       ** Pay and Chase for claims for recipients
                                                whose insurance is carried by an Absent
                                                Parent as the result of a court order. Pay and
T   Hospital/Drug/Other                         Chase for court ordered Absent Parent
U
V
    Hospital/Physician/Drug/Other
    Vision
                                                Insurance covers all diagnosis codes.
                                                                                                                                                   31
W   Physician/Drug/Other
  Submission of
 Medical Records

      Examples of Claims           Medical Records Required
Surgery that could be considered   Operative report
cosmetic
NICU Care beyond specific time     Daily progress reports
frames
CPT/HCPCS dump codes               Detailed explanation of service,
                                   invoice, etc.
Sterilization                      Consent Form
Use of ’22’ modifier               Operative report
Home health claims                 Plan of care

                                                                      32
      Submission of
     Medical Records

         Reminders for submission of medical records:
•When attaching medical records to claims, the records must accompany
each claim submission.

•If more than one claim is billed, the records must be copied and
submitted with each claim.

•Medical records are considered a part of the submitted claim and are
imaged and maintained on file for future reference.

•If a claim is denied due to the lack of medical records, the claim can be
resubmitted with the records attached.                                33
     Iowa Plan for
   Behavioral Health


• The Iowa Plan for Behavioral Health is a statewide Medicaid managed
care plan for mental health and substance abuse treatment services.
• Medicaid members enrolled with the Iowa Plan must access mental
health and substance abuse treatment services through providers which
are contracted with Merit Behavioral Care of Iowa to provide Iowa Plan
Medicaid Services.
• When a Medicaid member is not enrolled with the Iowa Plan, the
Medicaid fee-for-service program covers mental health and substance
abuse treatment services in accordance with regular Medicaid program
policies and procedures.

                                                               34
     Iowa Plan for
   Behavioral Health
      Continued

• For information about the Iowa Plan, members may
call 800-317-3738. This number is printed on their
eligibility cards.
• Providers may call the ELVS line for Iowa Plan
eligibility at 800-338-7752 or 515-323-3693.
• For information regarding the Iowa Plan, providers
should call Merit Behavioral Care of Iowa at 800-638-
8820.
                                                35
Managed Health Care



• Comprised of MediPASS and any HMO contracted with
DHS.
• Primary Care Providers can be one of the five provider
types that provide primary care services.
• Managed Care is mandatory in many counties in the State
of Iowa.
• Providers of care must obtain a referral from the provider
listed on the member’s Medicaid Eligibility Card.
                                                        36
     The Medically
     Needy Program

This program provides medical coverage to people who incur
high medical expenses but have too much income or
resources to qualify for regular Medicaid.

Enrolled members are eligible for payment of all services
covered by Medicaid except:
   –Care in a nursing facility
   –Care in an intermediate care facility for the mentally
   retarded
   –Care in an institution for mental disease             37
   The Medically
   Needy Program

                       Spenddown
If a member’s income exceeds a set amount, the individual
will be required to “spenddown” some of their income by
paying for a portion of outstanding medical expenses before
receiving a Medicaid Card.
                   Submitting Claims
If a member has not met spenddown, he/she will not have a
Medicaid card. A Medically Needy member is responsible for
payment of services used to meet spenddown.
                                                      38
Lock-In
Program
                          he




                                             Lock-In Program
To refer members with     Lock-in program has two components:
                                    Education about using Medicaid benefits
                                    Management of care through provider restrictions

   potential issues in    Members are selected for review from two sources:
                                  Claims with patterns of utilization indicating duplication or
                                    misuse


   utilizing Medicaid             Referrals from providers

                          Review criteria include:
                                   Multiple ER visits


services, contact Iowa             Receiving services from more than one physician/provider or
                                      specialty care
                                   Utilizing more than one pharmacy
                                   Obtaining unusual amount of prescription drugs
                                   Receiving unusual amounts of medical services

   Medicaid Medical       Lock-in is more restrictive than the MediPASS program. Members are
                          restricted to:
                                     One PCP and one specialty care provider

  Services at 800-383-               One hospital
                                     One pharmacy

                          MediPASS and MHC members must be disenrolled from MHC prior to


 1173 or 515-725-1008     enrollment in Lock-in.

                          To refer members with potential issues in utilizing Medicaid services,
                          contact Iowa Medicaid Medical Services at 1-800-383-1173 or 515-725-


 and press the option     1008 (local) and press the option for medical inquiries.

                          From January 2005 through June 2005, Iowa Medicaid realized over 2
                          million state dollars through the Lock-in program. Over 5,000 Medicaid


 for medical inquiries.   members received education or provider restrictions as a result of the Lock-
                          in program.


                                                                1




                                                                                                         39
   Exception
   To Policy

Providers or members may request an Exception to Policy in
order to have a member receive a service that is not normally
covered by Iowa Medicaid.
           How to request an Exception to Policy?
                   Mail or fax the request to:
                 Department of Human Services
                       Appeals Section
                 1305 E Walnut Street, 5th Floor
                      Des Moines, IA 50319
                      Phone (515) 242-6302
                        FAX (515) 281-4597             40
                              OR….
   Exception
   To Policy

            Email the request to: exceptions@dhs.state.ia.us.
           OR complete the Exception to Policy form online at
             http://www.dhs.state.ia.us/forms/470-3888.htm .
You will receive a letter signed by the Director if the request is approved.

Once the Exception to Policy is approved, how to submit a claim for
payment? Submit an original claim form with a copy of the approval letter
to:                              IME
                         Exception Processing
                      Hoover State Office Building
                             1305 E. Walnut
                          Des Moines, IA 50315                    41
      Fraud &
       Abuse

The Iowa Medicaid Program monitors submitted billings on a pre-payment basis
to ensure that payment is made for reasonable, necessary, and appropriate
services.

The objectives of Medicaid claim reviews are to:
• verify that claims paid were for services that were actually provided
• that were appropriate for members’ needs
•to identify and correct billing problems
•to eliminate overuse or abuse
•to obtain payment recovery that result from incorrect billings.
                                                                          42
Fraud & Abuse
  Continued

    To report instances of possible fraud or abuse,
    contact one of the following telephone numbers:

    • Medicaid Fraud Control Unit
       800-831-1394

    • Medicaid Surveillance & Utilization
    Review 877-447-8610 or 515-725-1108

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Outreach and
 Education


   Education and Outreach Contacts
    Jeremy Morgan, Supervisor: Phone 515-725-1365
           Email: jmorgan1@dhs.state.ia.us
    Leann Howland, Coordinator: Phone 515-725-1364
            Email: lhowlan@dhs.state.ia.us
    Maile Johnson, Coordinator: Phone 515-725-1363
           Email: kjohnso7@dhs.state.ia.us
   Kathy Eshelman, Coordinator: Phone 515-725-1362
            Email: keshelm@dhs.state.ia.us
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Education and Outreach
      Continued



The Outreach and Education Staff
is a pro-active department that provides training for
providers. They can help you with the following:
• Proactive Educational Issues
• On-site Training Sessions for Providers
• PC ACE Pro32 software
• Fall Training!
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Break Time!!



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