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Medicaid Managed Care

Iowa's Medicaid program is managed through three managed care organizations: Amerigroup Iowa, AmeriHealth-Caritas Iowa and UnitedHealthcare Plan of the River Valley. IHA has created this Web page as a resource for hospitals as they work with these organizations and serve Medicaid beneficiaries.

Provider Resources

IHA Medicaid Payment Policy Workgroup (July 28)

IHA Medicaid Payment Policy Workgroup (April 12)

MCO Regional Consultant Maps and Contacts

Amerigroup

AmeriHealth - Caritas

United 

MCO Quick Reference Guide. This 13-page reference guide has helpful information for providers including contact information, claims submission information and more. (May 2016)

Claims Forms. Iowa Medicaid Enterprise released a flow chart that describes claims submission procedures. Each manged care orgaization will accept the same claims form, based on provider type. For professional providers, use Standard Centers for Medicare & Medicaid Services (CMS) 1550, for institutional providers, use Standard UB-04. (released March 30, 2016).

Prior Authorizations. A prior authorization matrix, describing each plan’s policy on which services require a prior authorization can be found here. (updated July 28, 2016)

Beneficiary Eligibility Determinations. The Eligibility and Verification Information System (ELVS) web portal can be accessed here. The ELVS system is used to verify that a member is eligible and which managed care organization the member belongs to. Verifications can also be used by calling the ELVS line at 1-800-967-7902. IME has stated the phone line will be very busy and encourages users to use the web portal. New users must submit this form to get access to the web portal. (released March 30, 2016)

Covered Benefits. Iowa Medicaid Enterprise has prepared a matrix of benefits offered for members based on the program they are enrolled in. The programs listed in the matrix include Medicaid, Iowa Health and Wellness, Iowa Family Planning Network and hawk-i. Each managed care organization would be required to cover these benefits. (released March 30, 2016)

Call Center Information. Here is a list of telephone numbers for member-specific and provider-specific call centers, broken down by managed care organization or Iowa Medicaid Enterprise.

Non-Emergency Medical Transport (NEMT). Iowa Medicaid Enterprise has released a list of NEMT providers each managed care organization has contracted with and their contact information. (released March 30, 2016)

MCO Resources. Each managed care organization (MCO) has a provider-specific web portal with provider resources such as provider manuals and claims processing tools. Click on the applicable MCO for these resources: Amerihealth CaritasAmerigroupUnitedHealthcare.

Roundtable with Managed Care Companies. Access a recorded roundtable discussion moderated by the Department of Human Services with managed care companies (April 2016). 

Informational Letters

Informational Letter NO.1652-MC includes hospital billing clarification for services received both prior to and after April 1.

  • Billing for inpatient services:
    • Services provided on or after April 1, should be submitted directly to the appropriate managed care organization (MCO). MCOs are responsible for admission dates after April 1.
    • Iowa Medicaid Enterprise (IME) will be responsible for services provided prior to April 1 with a discharge after April 1 for up to 60 days. 
    • If the patient is admitted prior to April 1st and the admission exceeds 60 days, the services should be “split billed”. Billing IME for the initial 60 days, and then billing any days after 60 days to the appropriate MCO.
  • Billing for observation status:
    • If the patient is admitted for observation on or before March 31 and discharged on or after April 1, the outpatient claim should be submitted for the full date to IME.
    • More information on observation status can be found here.

Informational Letter NO.1635-MC includes information about electronic billing. Providers can use any clearinghouse vendor to submit claims to managed care organizations (MCOs). However, this needs to be tested. Each of the three MCOs participate with Change Healthcare (formerly Emdeon). Iowa Medicaid Enterprise (IME) offers free software (the PC-ACE Pro32 Claims Management System) under Electronic Data Interchange Support Services to submit claims. Providers must work directly with the MCOs and their clearinghouses to test and certify that the provider can submit claims using PC-ACE Pro32.

Informational Letter No. 1644-MC addresses the reimbursement for prescriptions by referencing the Iowa Medicaid Preferred Drug List. No specific recognition of reimbursement practices is addressed in the letter.

Informational Letter No. 1619-MC explains the process for submitting crossover claims beginning April 1. From April 1 to July 1, Iowa Medicaid Enterprise (IME) will continue to receive Medicare claims but will issue a denial for any coordination of benefits crossovers for members enrolled in managed care organizations (MCOs). It will then be the provider’s responsibility to submit the crossover claim to the applicable MCO. Hospitals need to be aware of this responsibility. (March 21, 2016)

Information Letter No. 1628-MC, which deals with prior authorization processes effective April 1. (March 11, 2016)

Provider Manuals

IHA Positions and Analyses

2016 IHA Medicaid Managed Care Principles (April 1, 2016)

Webinar Video - Contracting Considerations for Hospitals - Martie Ross, principal for Pershing Yoakley & Associates, PC in Kansas (November 5)

IHA Medicaid Managed Care Policy Update Webinar - Slides (November 4)

IHA Question and Answer Memo on Rate Setting and Provider Networks (October)

IHA Guest Column: Medicaid Privatization Undermines Innovation, Access (October)

IHA Talking Points on Medicaid Managed Care (August)

IHA Comment Letter on Federal Waiver Documents (August)

IHA Talking Points on Federal Waiver Documents (July)

IHA Comment Letter to DHS (June)

IHA Managed Care Principles (June)

Managed Care RFP Issues for Hospitals (June)

State Resources

Medicaid Modernization Homepage (Iowa Medicaid Enterprise)

Request for Proposal and MCO Selection Process

Final state score cards document for the final 10 bidders

RFP Fact Sheet (Iowa Department of Human Services)

RFP Documents

Medicaid Managed Care Background

Medicaid Managed Care In Iowa (Medicaid.gov)

2012 Medicaid Manged Care Enrollment Report (Medicaid.gov)

Medicaid Managed Care: Key Data, Trends, and Issues (Kaiser Family Foundation, 2012)