Medicaid Reimbursement Best Practices

Receive a free prescription pad holder with your first order from SecureRxPad.com! These are very nice script pad holders, made of Napa simulated black leather, with an expanded spine to hold a 100 sheet prescription pad. The holder has a clear pocket with calendar card insert and is suitable for both vertical and horizontal pads.

Get your Free Pad Holder at www.securerxpad.com

REIMBURSEMENT FOR SERVICES
As a condition of participation in the Medicaid program, you must agree to accept the payment made by the Medicaid program as payment in full and make no additional charges to the member or others.

No Medicaid payment can be made directly to a member or to anyone other than the provider of service. A Medicaid claim may be submitted when a patient becomes eligible after service is provided and has already paid for the service. To do this, refund the payment to the patient before submitting the Medicaid claim.

Provider reimbursement may be changed each July 1, following the direction of the Legislature. Provider reimbursement changes are announced in an informational release to all providers. If you have any questions about reimbursement rates, you may call the IME Provider Services Unit.

1. Claims
Obtain CMS-1500, UB-04, pharmacy, and dental claim forms from any wholesale vendor. Order the Claim for Targeted Medical Care from the IME Provider Services Unit. (See Form Orders for instructions on ordering forms.) The Iowa Medicaid Enterprise supports the electronic submission of claims. Through electronic submission, you are able to submit claims more accurately. You also receive your Medicaid payments more quickly than if you submitted paper claims.

If you are not currently submitting claims electronically but would like to do so, IME offers a free software program called PC-ACE Pro32. To use PC-ACE Pro32, you need an IBM-compatible personal computer running Windows-95 or newer, as well as a local modem and analog phone line access. For information about electronic claims, please call 1-800-967-7902.

For information specific to your office, contact the EDISS coordinator at 1-800-967-7902. Or visit the IME web site at www.ime.state.ia.us. Follow the links for electronic data interchange. You will find the required EDI forms as well as the PC-ACE Pro32 software for downloading. The EDI staff can assist you in installing PC-ACE Pro32 if you need help.

a. Procedure Coding
The Health Care Financing Administration Common Procedure Coding System (HCPCS) includes specially designed codes and modifiers for reporting medical services and procedures that are copyrighted by the American Medical Association.

Iowa Medicaid has adopted a coding scheme based on the Current Procedure Terminology, Fourth Edition, copyright 1985, by the American Medical Association (CPT-4). The CPT-4 is a listing of descriptive terms and numeric identifying codes and modifiers for reporting medical services and procedures.

HCPCS codes are divided into three levels. Level 1 is the current CPT-4 codes. Levels 2 and 3 are specially designed five-position codes consisting of a letter followed by four numbers. Level 2 (regional codes) begin with letters from A-V. Level 3 (local codes) begin with letters from W-Z.

b. Claim Submission
Submit claims any time during the month. Payment will be made for covered services when the IME receives the initial claim within one year from the date of service.

Claims submitted beyond the one-year limit may be paid when they are delayed due to delays in receiving third-party payments or retroactive certification for eligibility. State on the claim form the reason the claim is late, or attach it.

When you resubmit claims to correct a problem on the claim form, clearly mark them as a resubmission of a previous claim.

2. Third-Party Liability
The Medicaid Program is the payer of last resort for services covered by the program. Federal and state rules require that providers make a reasonable effort to pursue third-party resources.

Call ELVS or access the web portal to determine if other third-party resources In addition, question the member to determine if any other resources are available for payment. If you note a discrepancy between the member's statement and the verification system, please notify the IME Revenue Collection Unit, either:

- Verbally at 1-866-810-1206 or 515-725-1006 (local); or
- In writing to Iowa Medicaid Enterprise, Revenue Collections Unit, PO Box
36450, Des Moines, Iowa 50315; or
- By electronic mail to REVCOL@dhs.state.ia.us.

If a third-party resource is identified, you must pursue payment from the other source. If you do not accept assignment from an available third-party resource, it is your responsibility to collect the other insurance payment from the patient before billing Medicaid.

"Pay and chase" means that you bill Medicaid even though the member has health insurance and Medicaid bills the insurance company. Medicaid requires "pay and chase" for certain situations, including when services are provided to:

- Pregnant women. The Medicaid system is programmed to recognize pregnant women when the diagnosis is entered on the claim.
- Children whose medical is provided from an absent parent, as identified by statements of the parent concerning who provides the insurance.
- Children under the age of 21 for preventative pediatric services, which include all drugs; home health services with procedure codes S9122, S9123, S9124; and the following V codes

V01.0-9
V02.0-V02.9
V03.0-V02.9
V07.0-V07.9
V20.0-C20.2
V70.0
V72.0-V72.3
V73.0-V75.9
V77.0
V77.7
V78.2-V78.3
V79.2-V79.3

List on the claim form any payments made by the other insurance, whether made to you or to the patient. If the other source denies payment, indicate this on the Medicaid claim form. (See Chapter III for claim form instructions.)

- If the insurance makes a payment, you may submit a claim to Medicaid for consideration, unless you received payment in full.
- On the claim, show the amount that was paid by the insurance. You are not required to show the contractual write-off as payment from a third- party payer. Indicate only the actual payment you received from the third-party payer.
- Medicaid will make payment only according to the Medicaid allowance. The third-party payment plus any Medicaid payment cannot exceed the Medicaid allowance.
- If the third-party payment equals or exceeds the Medicaid allowance, Medicaid will pay the claim at $0.00. Medicaid now considers the claim paid and you cannot bill the Medicaid member.

a. Eligibility Under Both Medicare and Medicaid
Medicare is a federally administered program of health insurance for people who are over age or are permanently disabled. The program is financed in the same manner as Social Security.

- Medicare Part A (hospital insurance) helps pay the expenses of a patient in a hospital, in a skilled nursing facility, or at home receiving services from a home health agency.
- Medicare Part B (medical insurance) helps pay for physician services, outpatient hospital services, medical services and supplies, home health services, outpatient physical therapy, and other health care services.

When Medicare benefits are available for services also provided under the Medicaid program, the only charges payable by the Medicaid program are the deductibles and coinsurance amounts, beginning with services rendered on or after the first day of the patient's eligibility for Medicaid. (This includes for hospitalization (Part A), practitioner services (Part B), or any other covered services.)

Part B providers must in all instances accept assignment of the claim if Medicaid is to make payment for deductibles or coinsurance. There is no provision in Medicaid for reimbursement of the member for any payments the member may make to a provider of service.

It is not necessary to secure the member's signature on the Medicare claim form, because there is on file in the Department's local office a one-time statement from all Medicare beneficiaries agreeing to a permanent assignment of all Part B claims.

b. Services Provided to Medicare Beneficiaries
To obtain Medicaid reimbursement for services provided to Medicare beneficiaries, observe the following special conditions:

- Always bill the Part A or Part B Medicare intermediary first for any Medicare-covered services. Use the Medicare billing form. Following payment of Medicare-covered services, the Medicare intermediary transfers the claim to the Iowa Medicaid Enterprise for payment of deductibles, coinsurance, and any Medicaid-covered services beyond the scope of Medicare (if there is Medicaid coverage at that time).(There may be a delay in determining Medicaid eligibility, and a resultant delay in Medicaid payment of the Medicare Part B premium.)
- If the member has been denied benefits through Medicare on the basis that the benefits were not medically necessary, the member is not eligible to receive these benefits under the Medicaid program for the same reason.
- Medicaid payment for Medicare deductibles and coinsurance amounts is limited to the maximum allowable charge under the Medicare program for that particular service.
- When parts of the services are covered by Medicare Part A or Part B and others are covered only by Medicaid, submit separate billings to the Medicare intermediary and to the Iowa Medicaid Enterprise. The Medicaid program pays in its usual manner for services that Medicaid covers but Medicare does not. Submit claims for these services separately to the Iowa Medicaid Enterprise on the regular Medicaid billing form.

c. Medicare With Other Insurance
If a patient has Medicare coverage and insurance, bill the other sources before submitting a bill to Medicaid. If you receive a payment, but the other resource has not paid your full charge, the central Medicare contractor will send your claim to the IME.

You may submit the bill to Medicaid for consideration if the payment is not made within 60 days of the Explanation of Medicare Benefits (EOMB). If the payment you received is less than the allowable Medicaid payment, Medicaid will pay the difference, up to the Medicaid allowed amount.

Send a copy of the EOMB for processing. The following information must be written on the EOMB:

- The member's Medicaid identification number.
- Your rendering and billing NPI or Medicaid provider number, tax identification with qualifier, and zip number of the billing provider.
- Any third-party insurance determination (whether the third-party resource has approved or denied payment and the amount of the payment).
For crossover claims from Medicare HMOs, please also include the words "Medicare HMO" written at the top of the EOMB, the type of claim form, and any TPL. Do not use red ink or highlighter.
The total of the insurance payments and the Medicare payment cannot be more than the Medicaid reimbursement rate for that service. If the member receives mental health services that are payable by Medicare, the IME will pay the coinsurance, copayments, and deductibles of Medicare.

3. Copayment
A copayment is a charge that the member must pay to the provider of service when the service is covered under Medicaid.

As a condition of participating in the Medicaid program, you may not deny care or services to a member because of the member's inability to pay a copayment. An assertion that the person is unable to pay establishes inability to pay. However, this does not remove the member's liability for these charges, and it does not preclude you from attempting to collect the copayment.

a. Drugs
The member must pay a copayment for new and refill prescription drugs as follows:
- $1.00 for generic drugs and preferred brand-name drugs.
- $2.00 for non-preferred brand-name drugs for which the cost to the state is $25.01 to $50.00.
- $3.00 for non-preferred brand-name drugs for which the cost to the state is $50.01 or more.

b. Other Services
The member must pay a $1.00 copayment for the total services rendered on a given date for the following types of services:
- Chiropractor services
- Physical therapists
- Podiatrist services
The member must pay a copayment of $2.00 for the total services rendered on a given date for the following types of service:
- Ambulance services
- Audiologist services
- Hearing aid dealer services
- Medical equipment and appliances
- Optician services
- Optometrist services
- Orthopedic shoes
- Prosthetic devices and sickroom supplies
- Psychologist services
- Rehabilitation agency services

The member must make a copayment of $3.00 for the total covered service rendered on a given date for:
- Dental treatment
- Hearing aids
- Services rendered in a physician (MD/DO) office visit Dually eligible Medicare and Medicaid members must make a copayment of $1.00 for Medicare Part B (crossover) claims submitted to Medicaid for services in which Medicaid collects a copayment.

c. Exemptions
Copayment is not applicable to the following services:
- Services provided to members under age 21. The member's age is indicated on the member's Medical Assistance Eligibility Card.
- Family planning services (oral contraceptives, contraceptive devices).
- Services provided to members in nursing facilities, intermediate care facilities for the mentally retarded, or psychiatric institutions.
EXCEPTIONS: Copayment is required for:
- Residents in a noncertified facility or noncertified bed,
- Nursing facility residents who have transferred resources, or
- Medically Needy members who reside in a nursing facility.
Medicaid cannot make payment for nursing care for these residents; therefore they are not exempt from copayments.
Any service provided to pregnant women. Members have been advised that if they wish to be exempt from copayment, they are responsible to inform the providers or their income maintenance worker if they are pregnant.

- Services provided by an HMO.
- Emergency services. Emergency services are those services provided in a hospital, clinic, office, or other facility that is equipped to furnish the required care, after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain), that the absence of immediate attention could reasonable be expected to result in:
- Placing the member's health in serious jeopardy,
- Serious impairment to bodily functions, or
- Serious dysfunction to any bodily organ or part.
Diagnosis codes are used indicate the emergency service exemption from copayment. To view RC-0113 for the list of emergency diagnosis codes that meet the copayment exemption, click here.

4. Problems With Submitted Claims
After you have submitted a Medicaid claim, you will receive a Remittance Advice indicating whether the claim was paid, denied, or suspended. A sample of the Remittance Advice for your particular provider type is included in Chapter III of your provider manual.

You should review each Remittance Advice promptly to determine whether there were any problems with your claims. If so, note the "transaction control number" for that claim and contact the IME Provider Relations Unit.

a. Provider Inquiry, Form 470-3744
To inquire as to why a claim was denied or why a claim payment was not what you expected, please complete form 470-3744, Provider Inquiry.

You can obtain this form by printing or copying the sample in the manual or contacting the IME Provider Services Unit.

Attach copies of the claim, the Remittance Advice, and any supporting documentation you want to have considered, such as additional medical records.

Send these forms to: (Your State will obviously have different contact information - Visit your state link at: )

IME Provider Services Unit
PO Box 36450
Des Moines, Iowa 50315

b. Credit/Adjustment Request, Form 470-0040
To make an adjustment to a claim following receipt of the Remittance Advice, use form 470-0040, Credit/Adjustment Request. You can obtain this form by printing or copying the sample in the manual or contacting the IME Provider Services Unit. To view a sample of this form on line, click here.
Use the Credit/Adjustment Request to notify the IME to take an action against a paid claim, such as when:

- A paid claim amount needs to be changed, or
- Money needs to be credited back, or
- An entire Remittance Advice should be canceled. Do not use the Credit/Adjustment Request when a claim has been denied. Denied claims must be resubmitted.

NOTE: Requests for adjustments on paid claims will not be processed if more than one year has elapsed between the date of payment of the claim in question and the date the IME receives the request for adjustment.
Send these forms to:

IME Provider Services Unit
PO Box 36450
Des Moines, Iowa 50315

5. Appeals
You have the right to appeal a denied claim for services only after you have exhausted all administrative procedures with the IME. At that point, the IME issues an official notice that the service is not covered by Medicaid and notifies you of the right to an appeal.

Administrative procedures include, but are not limited to:
- Resubmitting the claim due to errors in completing the original claim.
- Providing all requested documentation.
When you wish to appeal a denied claim, you must submit a written request for a hearing within 30 days from the date of the official notice denying the claim.

To appeal in writing, do one of the following:
- Complete an appeal electronically at https://dhssecure.dhs.state.ia.us/forms/appealrequest.htm, or
- Write a letter telling us why you think a decision is wrong, or
- Fill out an Appeal and Request for Hearing form. You can get this form at thelocal DHS office. Specify in the request the nature of the complaint. If possible, include a copy of the official notice of the denial of the claim.

Take or mail the request to:(Refer to your States Rules)
Appeals Section
Iowa Department of Human Services
1305 E Walnut Street
Des Moines, Iowa 50319-0114
The Department's rules on appeal hearings are found at 441 Iowa Administrative Code Chapter 7.

6. Reviews and Audits
You may be audited at any time at the discretion of the Department. The legal reference for Medicaid provider reviews and audits is 441 Iowa Administrative Code 79.4(249A).

The Department will select the appropriate method of conducting a review and will protect the confidential nature of the records being reviewed. You may be required to furnish records to the Department. You may select the method of delivering any requested records to the Department.

Review procedures may include, but are not limited to, the following:
- Comparing clinical and fiscal records with each claim.
- Interviewing members of services and provider employees.
- Examining third-party payment records.
- Comparing Medicaid charges with private client charges to determine that the charge to Medicaid is not more than the customary and prevailing fee.

Records of privately paying clients will be requested by subpoena. The Department's procedures for auditing Medicaid providers may include the use of random sampling and extrapolation. When the Department's audit findings have been generated through sampling and extrapolation, and you disagree with the findings, the burden of proof of compliance rests with you.

7. Overpayments
When an overpayment is found, the Department may proceed with one or more of the following:
- Request repayment in writing.
- Impose sanctions provided for in 441 Iowa Administrative Code 79.2(249A), which may include:
- A term of probation for participation in the Iowa Medicaid program.
- Termination from participation in the Iowa Medicaid program.
- Suspension from participation in the Iowa Medicaid program.
- Suspension or withholding of your payments.
- Referral to peer review.
- Prior authorization of services.
- Review of all of your claims before payment.
- Referral to the state licensing board for investigation.
- Investigate and refer to an agency empowered to prosecute under applicable federal or state laws.

If a sanction is imposed and you have a total Medicaid credit balance of more than $500 for more than 60 consecutive days without repaying or reaching written agreement to repay the balance, you will be charged interest at 10 percent per year on each overpayment. The interest shall begin to accrue retroactively to the first full month that you had a credit balance over $500.
You must make repayment or reach agreement with the Iowa Medicaid Enterprise. Overpayments and interest charged may be withheld from your future payments.

8. Penalties
Section 1909 of the Social Security Act provides that whoever furnishes items or services to a person for which payment is or may be made in total or in part out of federal Medicaid funds shall be guilty of a misdemeanor when they solicit, offer, or receive any:

- Kickback or bribe in connection with the furnishings of the items or services or the making or receipt of such payment, or
- Rebate of any fee or charge for referring any such person to another person for the furnishing of the items or services.
Upon conviction, the penalty is a fine not more than $10,999, imprisonment for not more than one year, or both.

As you may be aware, there is a new requirement for prescriptions provided to Medicaid patients that took effect on April 1. All hand-written Medicaid prescriptions are required to be written on tamper-resistant prescription paper/pads. To help you with this process, we are providing information about the new requirement that will help you comply with the requirements.

Review of CMS Requirements
By April 1, 2008 a prescription pad/paper must contain a feature with at least one of the following three characteristic categories:

1. One or more industry recognized features designed to prevent unauthorized copying of a completed or blank prescription.

2. One or more industry recognized features designed to prevent the erasure or modification of information written on the prescription by the prescriber.

3. One or more industry recognized features designed to prevent the use of
counterfeit prescriptions.

By October 1, 2008, a prescription pad/paper must contain at least one feature in all three categories above. The Centers for Medicare and Medicaid Services (CMS) has said these requirements also pertain to computer-generated prescriptions that are printed using paper inserted into a printer.

Suggested Actions

I. Contact a prescription pad vendor to secure an appropriate supply of tamper-resistant prescription pads that will meet your state's requirements on October 1, 2008.

We encourage you to work with your current vendors to incorporate the tamper-resistant features into your prescription pads/paper required by CMS. If your current vendor cannot meet the needs of the requirement, visit www.securerxpad.com Click to visit SecureRxPad homepage.

The tamper-resistant prescription pads at www.securerxpad.com meet or exceed all three CMS requirements. It should take 5 days for your new prescriptions pads/paper to arrive once you have placed your order.

Impact on Medicaid Patients
In order to ensure that patients do not see any adverse impact regarding their access to medications, it is critical to use secure tamper-resistant prescription pads as soon as possible. In an emergency situation, prescriptions written on non-tamper resistant pads will be permitted as long as the prescriber provides a verbal, faxed, electronic, or compliant written prescription within 72 hours after the date on which the prescription was filled.

Thank you for your efforts to comply with this new Federal requirement.

About SecureRxPad.com
Through SecureRXPad.com safe and secure online ordering site physicians can personalize, proof, and order their prescription pads. These prescription pad layouts accommodate Medicaid's requirements, multiple physicians, and options for uploading your logo on a single physician prescription form

See great solutions at www.securerxpad.comThis goes to the SecureRxPad homepage.