MCO Information and Q & As (updated 6/22/16)
List of topics covered in this document:
- Provider Manuals
- Incident Reporting
- Level of Care
- Prior Authorizations
- Billing and Claims Procedure
- Case Management
- Ownership and Control
- Policy Updates and Public Announcements from the MCOs
- Miscellaneous Information
Links to MCO Websites:
Determination of eligibility for Medicaid shall be the exclusive right of DHS. Such determinations are not subject to review or appeal by the MCOs.
There may be instances where determination of eligibility may have occurred
Typically yes, however the start date is always the first of the month in which the application was completed (not including a retro period) and if, for example the application was completed on 4/28, the member will be FFS for all of April AND May as they couldn’t make a selection for May on 4/28. Am I making sense?
Batch Eligibility Verification:
- The provider will need to register for a 270 batch eligibility transaction in EDISS Connect. After setup is complete for the 270 eligibility in the system, providers can use the same batch upload feature used for claims submission to transmit the files.
- A wide range of education regarding Total Onboarding (TOB) along with electronic billing is also available on the EDI Support Services3 website.
Eligibility Verification via Telephone Line:
- 515-323-9639 (locally in Des Moines)
- 1-800-338-7752 (toll-free)
- Call volume is generally highest at the beginning of each month.
Which Medicaid Member Remain in FFS
There are some Iowa Medicaid members who are not included in the transition to managed care. These members will continue to use their Iowa Medicaid member eligibility cards. They will not be issued new ID cards. This includes members in the following groups or programs:
- Health Insurance Premium Payment program (HIPP)
- Medicare Savings Program (MSP) only.
- Qualified Medicare Beneficiary plan (QMB)
- Specified Low-Income Medicare Beneficiary (SLMB)
- Medically Needy program, also known as the spenddown program
- Presumptively eligible members (subject to change once ongoing eligibility is determined)
- Newly eligible members who are in their Fee-for-Service period before their MCO coverage begins
When providers verify eligibility through the Eligibility Verification System (ELVS), it will indicate their eligibility type, including whether the member has coverage through an MCO or if they are covered through FFS.
DHS and IME Guidance to HCBS Critical Incident Reporting
Beginning April 1, 2016, incident reports for Medicaid members enrolled in HCBS and Habilitation will be reported to the member’s MCO. The reports for members not enrolled in an MCO will continue to be sent to the IME through the Iowa Medicaid Portal Access (IMPA) system process.
The Iowa Medicaid Critical Incident Report, 470-4698, is found on the DHS web page. It will initially be used by all three of the MCOs and will continue to be used by the IME for major incidence submission. The form should be submitted to the member’s MCO or IME for members not enrolled in an MCO as shown below:
Provider Call Center: 1-800-454-3730
Fax: 844-341-7647 Attn.: AmeriHealth Caritas Iowa Inc., Urgent, Quality Department
Provider Telephone Services: 1-844-411-0579
Non-Provider Telephone Services:1-855-332-2440
TTY: 1-844-214-2471 24 hours a day, 7 days a week
Submit completed form by fax to 1-855-371-7638 or email to firstname.lastname@example.org
Provider Services Call Center:1-888-650-3462
Habilitation and Integrated Health Home providers: email (preferred) to email@example.com or (FAX) 515-725-3536
HCBS Waiver Providers: submit via the IMPA system.
The incident reporting standards apply only to providers who have personal contact with members. A listing of those services can also be found in the Iowa Administrative Code 441 Chapter 77. The standards define “major” and “minor” incidents, prescribe the content of the incident report form, and set procedures for reporting of major and minor incidents.
When a major incident or a staff member becomes aware of a major incident, the staff member involved will notify the staff member’s supervisor, the member’s case manager and the member’s legal guardian by the end of the next calendar day after the incident.
Providers must keep records of all minor incidents, but do not have to report minor incidents to the IME. When a minor incident occurs or a staff member becomes aware of a minor incident, the staff member involved shall submit the completed incident report to the staff member’s supervisor within 72 hours of the incident.
Q & A
Q: All the MCOs seem to have a different reporting standard for critical incidents. What is the policy for each?
A: What may be a little frustrating for providers is the lack of clarity on the issue of reporting standards for the MCOs. Some require limited reporting while others want updates on every single action that takes place. From all three, the bottom line is still that unless it’s an HCBS wavier, critical incident reporting goes to IME, not the MCOs. LAI contacted all three MCOs and received the following answers:
Amerigroup: Amerigroup’s critical incident reporting requirements are the same for HCBS waiver providers as in the past. The requirements are listed on page 67 of our provider manual. Amerigroup has an email box dedicated to incident reporting. IAincidents@amergroup.com
If providers are serving Amerigroup members that are not on a waiver, they are not required to submit critical incidents to Amerigroup.
AmeriHealth: Is currently reviewing the procedure and will report back to LAI upon finalization of the policy.
UHC: Critical incident reporting requirements are the same for HCBS waiver providers as in the past. The procedure for submitting incident reports for the HCBS waiver are listed in following link.
If providers are serving UHC members that are not on a waiver, they are not required to submit critical incidents to UHC
Additionally, LAI is keeping our MCO Information and Q & A up to date with the latest information for our providers. We are working on it making it more user friendly for our members and would love feedback on additional topics to include or cover in more depth. Feel free to email Matt Blake with suggestions.
The initial LOC to determine waiver eligibility, these will need to be sent to the IME.
The annual CSR will be initiated by the MCOs and will need to be returned to the MCOs, annually.
Continued Stay Reviews (CSRs) for medical approval are the responsibility of the member’s MCO, unless the member is FFS. FFS CSRs are completed by the IME Medical Services Unit. The purpose of a CSR is to determine if the resident continues to need the facility care. Level of care reassessments are to be completed at least annually and when the member’s functional or medical status has changed in a way that may affect level of care eligibility.
Any changes to the LOC determined at the time of the CSR for MCO enrolled members will be forwarded by the MCO to the IME Medical Services Unit for review.
Prior Authorization Process for Long-Term Care Stays
Prior Authorizations are required for LTC stays for residents residing in a NF for Amerigroup and AmeriHealth. UnitedHealthcare has dropped the requirement of prior authorization for LTC and it will not be necessary to fill out a prior authorization form for next month.
Below are the specific requirements that each MCO has sent out regarding the prior authorizations:
Amerigroup: The following message was sent by Amerigroup regarding Prior Authorizations for NF:
Custodial NF auto load should occur late this week or early next week. There is not a formal notification process to the NF, however, we can run a report to capture the authorizations in Facets by the provider and send them the file.
We will need authorizations for all members, but hopefully, the auto load will decrease the work load drastically.
New admits: If the member is transitioning from an inpatient stay, the UM Nurse will submit the authorization. If the member is coming in from the community, the CBCM should be the one submitting the request. Of course, there will always be extenuating circumstances.
Existing members: Hoping the auto load will take care of most. The request should come through the CBCM.
From the message, it seems that auto load program will help with prior authorization process. LAI recommends contacting Amerigroup and asking for the report that captures the authorizations to see if there are any issues.
AmeriHealth: Stated there was no change in the policy regarding prior authorizations. LAI recommends follow the procedure outlined in the AH provider manual. Additionally, LAI suggests getting prior authorizations filled out soon in preparation for the July 1 deadline.
UHC: Prior Authorizations for Custodial care in NF is not necessary. From the UHC provider manual “Long Term Care (custodial) members residing in nursing facilities will NOT require prior authorization of the custodial stay. Facilities do not need to submit any prior authorization information when claims are submitted.”
For New or Renewal of Services:
- Effective April 1, 2016, the MCOs will be responsible for PA requests and authorizations.
- Providers should seek PA under the MCOs' policies to ensure timely and appropriate reimbursement.
- During the first 30 days of the transition to managed care, from April 1-30, 2016, no prior authorizations will be required, except for pharmacy drug claims.
- Pharmacy Drug Claim PAs
- Beginning April 1, 2016, all prescribers, whether in-network or out-of-network, must follow the MCOs' pharmacy drug PA requirements included in the health plans Provider Manuals.
- Drug claims requiring a PA will not be processed by the MCOs if there is not an approved PA in place.
- Providers should continue to follow the IME pharmacy drug PA policies and processes for the Fee-for-Service (FFS) members.
- Other PAs for Services and Providers
- Beginning May 1, 2016, all Medicaid providers whether in-network or out of network must follow the MCOs' PA requirements included in the health plans' Provider Manuals.
- All claims submitted without a PA will be subject to retrospective review by the MCOs to determine if services were medically necessary
- The medically necessary definition remains the same as it is today per state and federal requirements. Just like today, if a claim is determined not to be medically necessary, payment may be recovered
Impact on Long Term Services and Supports:
Typically, long term care services do not require PA. Instead, these services are established based on level of care (LOC) determinations and, for those on Home and Community Based Services (HCBS) waivers, service plan determinations.
- LOC and service plans will be reviewed and updated on the regular renewal schedule.
- After March 31, all Individual Consumer Directed Attendant Care (CDAC) providers enrolled with Iowa Medicaid will be considered enrolled and contracted with the participating MCOs. They will be paid at 100 percent of the established rate floor. Claims must be submitted directly to the appropriate MCO, adhering to the MCO's claims submission and timeliness guidelines. Services will continue to require approval through the member's case management agency and/or the MCO's community case manager.
- Services may only be modified through an updated assessment. Assessments may only be updated if the member's needs have changed or at annual review.
Q & A
Q: Do you need to submit preauthorization numbers on claims for billing?
A: No, submitting claims without the prior authorization number will not hold up claims. As long as the authorization is in the system, then it will pay without a problem.
DHS and IME Guidance
The IME enrolls providers under several types of practice; they may enroll as individuals, corporation/profit organizations, not for profit, or groups. Providers should always be aware of the type of practice under which they have enrolled with the IME as this directly dictates how claim forms should be completed.
MCO Billing and Claims Information
- Submitting claims electronically.
- Submitting claims by mail.
- Long term services and supports (LTSS) and consumer-directed attendant care (CDAC) claims.
- IA Health Link Frequently Asked Questions (PDF 231.87 KB) - 5.31.2016
- 2016 Comparison of the State of Iowa Medicaid Enterprise Basic Benefits Based on Eligibility - 4.8.2016
- Home - and Community-Based Services Settings Reference Guide (PDF 118.39 KB) - 3.1.2016
- Informational Brochure (PDF 427.15 KB) - 12.20.2015
- Quick Reference Guide (verify eligibility, where to submit claims) (PDF 323.11 KB) - 4.27.2016
- Value-Added Member Benefits (PDF 521.96 KB) - 4.21.2016
- Why File Claims Electronically (PDF 75.18 KB) - 5.10.2016
IME Paper Claim Form Completion:
The IME accepts the following claim forms and each form is specific for the service provided:
- UB04 for institutional services.
- CMS 1500 (02/12) for professional services.
- ADA 2012 (replaces all other versions of the ADA) for dental services.
- Claim for Targeted Medical Care, 470-2486, for billing Home-and Community-Based (HCBS) waiver services.
Claim form instructions must be followed exactly as written. The IME has detailed claim form instructions for all providers on the Claim Forms and Instructions1 webpage.
- Claims must be billed with these three identifiers:
- National Provider Identifier (NPI).
- Taxonomy code (different than the tax ID number).
- Zip code (5 digits or 9 digits, no dash is required.) This refers to both the service location and billing location zip.
- The above three items must exactly match the information on the provider application submitted to the IME.
In order to process claims, the IME must have original versions of the claim forms. Original versions of the CMS-1500, UB-04 and ADA 2012 dental claim forms are found at office supply stores. Original Targeted Medical Care claim form for Fee-for-Service (FFS) members may be requested from the IME by contacting the IME Provider Services Unit at the number shown below.
Claim Forms by MCO:
Below is a chart that outlines the claim forms required by each MCO broken down by service type and payment timeframes. Please contact the member’s MCO for the Waiver claim form.
Caritas Iowa, Inc.
UnitedHealthcare Plan of the River Valley, Inc.
Standard CMS 1500
Standard CMS 1500
Standard CMS 1500
Iowa Claim for
Targeted Medical Care 470-2486 or the universal CMS 1500
AmeriHealth Claim for Targeted Medical Care or the universal
Iowa Claim for
Targeted Medical Care 470-2486 or the universal CMS 1500
Timeframe for payment
Every business day
3 times per week
Every business day
*UB-04 may also be known as the CMS-1450
Processing Crossover Claims
Effective for dates of service on or after April 1, 2016, all Medicare crossover claims for MCO enrolled members will become the responsibility of the member’s MCO. This includes both claims from Medicare Advantage Plans and traditional Medicare.
The MCOs will not have the automated crossover process up and running until the end of June 2016. The MCOs will need to complete approximately three months of testing before Medicare crossover claims are approved to be sent automatically from Medicare to the MCOs for processing.
During this three-month testing period, the IME will continue to receive claims from Medicare; however, the IME will issue a denial for any COB crossovers for MCO-enrolled members. It will be the provider’s responsibility to submit the crossover claim to the appropriate MCO for reimbursement. Once testing is completed by the MCO, crossover claims will be sent automatically by Medicare to the MCO.
During this three-month testing period all three MCOs will accept crossover claims in both standard electronic and paper formats, using the standard claim submission process outlined in their provider manuals.
When a member has traditional Medicare, the claim should automatically "crossover" to the IME for payment of the remaining co-insurance and/or deductible.
In a situation where the claim does not automatically "crossover" all providers enrolled with Iowa Medicaid are required to use the IME Medicare Crossover Invoice Forms; Institutional 470-4707 and Professional 470-4708, located on the DHS Claim Forms and Instructions webpage. Each submission should include a copy of the Explanation of Medicare Benefits (EOMB) as an attachment. The forms are to be used only after Medicare has paid and established a coinsurance and/or deductible. These forms are not for submission of a claim where Medicare has denied the charge(s). Providers should not submit claims to both Medicare and the IME.
Providers are also encouraged to submit Part B crossovers electronically to the IME when claims do not crossover automatically through coordination of benefits (COB). Please refer to Informational Letter 1465 for submission instructions.
In a situation where Medicare has denied charges, either the CMS-1500 or UB04 claim form, should be submitted with the denied EOMB attached.
If a provider submits a "straight" Medicaid claim (billed on a UB04 or CMS-1500) and later finds out the member is Medicare eligible, the Medicaid claim should be credited back before submitting the claim to Medicare
Q & A
Q: Which rate do we use to submit to the MCOs? The 7/1/15 rate? The most recent adjusted rate?
A: This has been quite the headache for providers as we move into the first managed care billing cycle. LAI is still seeking a clear answer, as we have received differing responses from both the MCOs and IME. Per some reports, the MCOs may honor the quarterly rate adjustments that are distributed by IME. As LAI has reported in the past, quarterly rate adjustments will still take place for the limited FFS Medicaid beneficiaries you receive. The continued rate adjustments is why a provider must still submit a claims report IME.
From some LAI members who have successfully submitted claims, some have been reimbursed at the April 2016 rate. Their discussions with the MCOs indicate that the MCOs are willing to pay the adjusted rates. They told LAI providers to submit the quarterly adjustments to them, and they will honor the rates. However, official conversations
LAI has had with IME has yielded a different response. LAI conversations with IME and DHS officials indicated an uncertainty to an unwillingness to submit adjusted quarterly rates to the MCOs. This uncertainty prompted LAI's legislative initiative to protect CMI adjusted rates in the HHS budget bill.
LAI recommends that members talk with their provider relations/account executive with each MCO and discuss how the MCO plans on handling the quarterly adjustments. While LAI works with IME and DHS to get a finalized policy on adjusted rates, members should see what steps must be taken in order for the MCO to honor your particular rates.
Q: What is the new process for billing IME under FFS?
A: LTC providers are not authorized to bill on UB-04 forms. IME requests submission of FFS claims on the Crossover Health Insurance Claim Forms (Institutional) on their website. Even though this is not a cross over situation, IME states this is the claim LTC providers should use.
Q: When submitting claims to the MCOs, which rates do we use? Do we use the base rate or the full reimbursement rate?
A: When submitting claims to the MCOs, LAI members should submit for the reimbursement rates which include the base rate, the add on, and the pass through.
Q: After April 1, what is the process for billing for newly eligible Medicaid members? Who do I bill and when do I find out which MCO to bill for a newly eligible Medicaid member?
A: When an individual is found to be newly eligible by DHS, LAI member should bill IME for FFS. The newly enrolled MCO eligible members will have a tentative assignment generated and Choice Packet mailed out within a few days of being determined eligible. Mailings occur daily and are not limited to the calendar month. The effective date with a particular MCO will occur on the first of the month following the eligibility determination; i.e. members will have 10-45 days to make the initial selection depending on the specific date eligibility was approved. Any dates prior to that, including retroactive periods, will be covered by Iowa Medicaid FFS (IME). Members will always have a 90-day open enrollment period to make their selection.
However, the start date is always the first of the month in which the application was completed (not including a retro period) and if, for example, the application was completed on 4/28, the member will be FFS for all of April AND May as they couldn't make a selection for May on 4/28. So, if the selection comes near the end of the month, you may bill FFS for two months. To check on eligibility, a provider can use the ELVS, check via the MCO eligibility websites, or review a Medicaid members MCO card when it arrives.
LAI is working with DHS to help work on a system for giving providers updates on Medicaid recipients for when an MCO is officially assigned or a recipient switches between MCOs.
Q: There has been some problems with Client Participation not being added to the reimbursement for some of the Medicaid recipients in my facility. Who should I contact in order to fix the issue? Will the CP continue to be transmitted to the MCOs?
A: Several providers have noticed that CP was not being taken out on some of the reimbursements. If this is occurring, the MCOs recommend contacting the respective account manager for the MCO and tell them of the error. The issue is with billing procedure and can be resolved internally.
AmeriHealth also responded back with the following suggestion:
"Number one, not all of the client participation amounts had been entered into JIVA by Amerihealth LTSS staff, therefore some didn't pull over. Those are now caught up. To avoid this issue in the future, however, the providers can use D3 value code on the UB04 with the CP amount in the value code box which will flag the claim to manually process correctly. The providers will no longer get that CP amount mailing from DHS, it will now all be housed in IMPA. Any providers who didn't have CP taken out will need to send in a corrected claim with the D3 value code. Hope that helps."
DHS states the CP amount is communicated to the MCOs and is calculated by DHS. If a provider is still have trouble with the CP amount, please let LAI know and we will provide contact at DHS to elevate the issue further.
Q: Can you submit multiple services on form?
A: For Amerigroup: Can submit multiple services on a claims form.
Q: Will providers need to submit QAAF fees quarterly? And, will providers still receive the additional revenue?
A: Informational Letter (IL) 1636-MC was published on March 14, 2016, which addressed the Quality Assurance Assessment Fee. Beginning with dates of service April 1, 2016, providers will be required to remit the money for the assessment directly to the IME by check. Here is a link to the IL: https://dhs.iowa.gov/sites/default/files/1636-MC_Update_MonthlyProviderAssessment.pdf.
Q & A
Q: When a case manager comes to a facility for the first time, should they provide some form of identification?
A: Case managers should take reasonable steps to identify themselves to LAI members. If calling by phone, they should follow the same HIPAA disclosure procedure as all other individuals. If they are visiting the campus for the first time, taking reasonable steps for them to identify themselves as the proper case manager for a particular MCO is a recommendation. Reasonable steps could include calling the MCO representative for your facility, having them sign a release form, or other procedure you feel secures your HIPAA information.
Q: Do providers still submit CARs?
A: As of February 1, 2016, nursing facilities are required to use the PathTracker system to enter all resident admissions, transfers, discharges and changes in level of care or funding. The PathTracker data is transmitted to DHS on a daily basis and then used to generate an electronic Case Activity Report for the Income Maintenance (IM) Worker. Currently, the data transmission only includes the admission, transfer, and discharge information so facilities will need to continue to send in a paper CAR to the Centralized Facility Eligibility Unit (CFEU) for any changes in level of care or funding until updates to the system are made.
Ownership and Control Disclosures
Federal regulations at 42 CFR 455.104 require the IME to collect OCD information for all Medicaid providers, regardless of risk level. This includes:
- The name and address of any person (individual or corporation) with an ownership or control interest in the disclosing entity. The address for corporate entities must include as applicable primary business address, every business location, and P.O. Box address.
- Date of birth and Social Security Number (in the case of an individual).
- Other tax identification number (in the case of a corporation) with an ownership or control interest in the disclosing entity or in any subcontractor in which the disclosing entity has a five percent or more interest.
“Disclosing entities” normally are corporations or partnerships where there are owners, board of directors, officers, partners, or managing employees who run the company. Disclosures on these individuals are captured as these parties are considered “behind the scenes” and direct how the organization will operate. They are responsible for decisions made in policies and procedures for how services will be provided and for billing.
The IME is required to collect this information regardless of the entity’s for-profit or nonprofit status. This OCD information will be collected only by the IME, not by the state’s contracted MCOs. The IME will conduct regular checks of this information against several exclusionary databases to assure that an excluded individual is not participating with a Medicaid provider. In the event that the IME finds any excluded individuals, the IME will provide the MCO with the provider’s name and NPI number. The MCO will then be expected to suspend payment to the provider until the matter is resolved.
Each of the MCOs has selected a transportation vendor. Providers will contract with each broker to provide NEMT. TMS/A2C will continue to schedule NEMT trips for March 2016. Below are the steps that members, providers, MCOs, brokers and their sub-contractors need to know as the IME transitions from a single NEMT broker to an MCO system.
Amerigroup – See Provider Manual
June 3- Home health claims billing process
To ensure timely and accurate processing for home health claims, AmeriHealth Caritas Iowa would like to remind providers to follow this process:
- Bill home health visits on a UB04.
- Be sure to include the revenue code and authorized CPT/HCPCS codes on each claim.
- Don’t forget to include the authorization number in field 63 or appropriate EDI loop.
- For Medicare primary members, if services are not covered, please be sure to include one of the following condition codes in field 18.
- XA Condition stable.
- XB Not homebound .
- XC Maintenance care.
- XD No skilled service.
- Use the member’s AmeriHealth Caritas Iowa member ID or Medicaid ID when billing for services.
EDI claim submissions are recommended. If you have any questions, please contact Provider Services at 1-844-411-0579 or your Provider Network Account Executive for more details.
Listed below are changes to the UHC manual. Please note some billing change related to codes for nursing facilities. (GET DATE)
Medicaid ID Numbers
All three Managed Care Organizations (MCOs) include the member's Medicaid ID number on the member's MCO ID card. The Amerigroup of Iowa, Inc. member ID card refers to the number as "Medicaid number." The AmeriHealth Caritas of Iowa, Inc. member ID card refers to the number as "State ID." UnitedHealthcare Plan of the River Valley, Inc. uses the Medicaid ID as the MCO ID number and is referred to on the card as "Member ID."
Minimum Data Set (MDS) 3.0 Section "Q" Referral Process
DHS released informational letter 1660. The letter provides updated instructions on the process for Section "Q" referrals to the local contact agencies (LCAs). The process will be as follows:
After completion of the MDS 3.0, the NF discharge planner should call the IME Medical Services Unit at 1-800-383-1173 or locally in Des Moines at 256-4623 between 8:00 am and 4:30 pm Monday through Friday and ask to speak to a reviewer about a Section "Q" referral.
The IME reviewer will gather the necessary information from the facility. The IME reviewer will then determine if the member is assigned to an MCO. If the member is enrolled in an MCO, the member's contact information will be forwarded to the MCO's care coordination team. The MCO care coordination team will respond to the individual's request for information and provide additional outreach to further assess the member's needs related to transition into the community.
If the member is with Medicaid Fee-for-Service (FFS) and is not enrolled with an MCO or is not Medicaid eligible, the member's contact information will be forwarded to a Money Follows the Person (MFP) transition specialist who will perform additional outreach to further assess the member's needs related to transition to the community.
Within the Preadmission Screening and Resident Review (PASRR) there is a similar process to follow whenever an individual has 1) been approved by PASRR for a short-term period of approval NF care, with a goal of placement in a lower level of care, or 2) self-disclosed through a process other than via the MDS 3.0 Section "Q", that they wish to seek transition to a lower level of care. In these cases, the NF will be expected to make appropriate referrals following the guidance offered within the PASRR Summary of Findings and PASRR training.
If you have any questions regarding the MDS 3.0 Section "Q" referral process, please contact Sally Oudekerk, Program Manager, firstname.lastname@example.org.
If you have any questions regarding the PASRR program or process, please contact Lila Starr, PASRR Program Manager, email@example.com, or Ascend Management Innovations, firstname.lastname@example.org.
Q & A
Q: DHS stated in informational letter 1647 that limited risk providers will get information related to the renewal process in April. Where is our information?
A: DHS has stated that an informational letter will be released this month outlining the renewal process. Reports show the providers will be able to use the Iowa Medicaid Portal Access to enroll. LAI will keep you informed of the letter as it is published.