CHAPTER 80
PROCEDURE AND METHOD OF PAYMENT
[Prior to 7/1/83, Social Services[770] Ch 80]
441—80.1(249A) The fiscal agent function in medical assistance.
	80.1(1) General administrative responsibilities of fiscal agent. The fiscal agent designated by the department will perform the following primary functions:
	a. 	Receive, process and pay claims submitted by providers of medical and remedial care participating in the program.
	b. 	Make available instructional materials and billing forms to providers participating in the program.
	c. 	Provide reports, statistical and accounting information as required by the department.
	d. 	Participate with staff of the department in analysis and evaluation of policies and procedures.
	e. 	In cooperation with the department develop and carry out a continuous program of cost and utilization review which is applicable to all groups of providers participating in the program. The purpose of cost and utilization review is to ensure that only required medical and health services are being provided to recipients of medical assistance in accordance with department policy and that the cost of the services is not in excess of that charged the general public.
	80.1(2) Method of selection of fiscal agent. The department shall publish a request for proposal announcing the forthcoming selection of a fiscal agent for the medical assistance program and outline the elements of the fiscal agent contract. The department will receive sealed bids from prospective fiscal agents for the medical assistance program. Basis of competitive bidding will be a per claim rate which would be applicable to all claims processed by the fiscal agent under the program in combination with an evaluation of technical, business and financial aspects of the bidders. A certified check payable to the Iowa department of human services in the amount of $50,000 shall be filed with each proposal. This check may be cashed and the proceeds retained by the department as liquidated damages if the bidder fails to execute a contract and file security as required by the specifications issued by the department. Proposals containing any reservations not provided for in the specifications may be rejected and the department reserves the right to waive technicalities and to reject any or all bids.
	80.1(3) Reimbursement of fiscal agent for performance of contract. All allowable costs other than amount paid providers of medical and remedial care and services shall be referred to as administrative costs.
	a. 	Rate per claim. Administrative costs other than those not associated with the processing of claims as set forth below shall be based on a fixed rate per claim handled. The fiscal agent will bill the department once each month the sum of the bid price multiplied by the number of original adjudicated claims.
	b. 	Costs not associated with processing of claims. Costs not associated with processing claims will be established by contract with the fiscal agent. The fiscal agent will bill the department under separate voucher for these services according to the dates agreed upon by contract.
This rule is intended to implement Iowa Code section 249A.4.
441—80.2(249A) Submission of claims. Providers of medical and remedial care participating in the program will submit claims for services rendered to the fiscal agent on at least a monthly basis. Following audit of the claim the fiscal agent will make payment to the provider of care.
	80.2(1) Claims for payment for services provided recipients who are Medicare beneficiaries shall be submitted on forms specified for that program.
	80.2(2) Claims for payment for services provided recipients who are not Medicare beneficiaries shall be submitted on the following forms:
	a. 	Ambulance services shall submit claims on Form XIX AMB-1, Ambulance Claim.
	b. 	Audiologists and hearing aid dealers shall submit claims on HCFA-1500, Health Insurance Claim Form.
	c. 	Chiropractors shall submit claims on Form HCFA-1500, Health Insurance Claim Form.
	d. 	Community Mental Health Centers shall submit claims on Form HCFA-1500, Health Insurance Claim Form.
	e. 	Dentists shall submit claims on the dental claim form approved by the American Dental Association.
	f. 	Practitioners and institutions providing screening services shall submit claims on Form HCFA-1500, Health Insurance Claim Form.
	g. 	Practitioners and institutions providing family planning services shall submit claims on Form HCFA-1500, Health Insurance Claim Form.
	h. 	Home health agencies shall submit claims on Form UB-82-HCFA-1450.
	i. 	Hospitals providing inpatient care or outpatient services, including inpatient psychiatric hospitals, shall submit claims on Form UB-82-HCFA-1450.
	j. 	Laboratories shall submit claims on Form HCFA-1500, Health Insurance Claim Form.
	k. 	Medical equipment, appliance and sickroom supply dealers shall submit claims on Form HCFA-1500, Health Insurance Claim Form.
	l. 	Opticians shall submit claims on Form HCFA-1500, Health Insurance Claim Form.
	m. 	Optometrists shall submit claims on Form HCFA-1500, Health Insurance Claim Form.
	n. 	Orthopedic shoe dealers shall submit claims on Form HCFA-1500, Health Insurance Claim Form.
	o. 	Pharmacies shall submit claims on the Universal Pharmacy Claim Form.
	p. 	Independently practicing physical therapists shall submit claims on Form HCFA-1500, Health Insurance Claim Form.
	q. 	Physicians shall submit claims on Form HCFA-1500, Health Insurance Claim Form.
	r. 	Podiatrists shall submit claims on Form HCFA-1500, Health Insurance Claim Form.
	s. 	Rehabilitation agencies shall submit claims on Form UB-82-HCFA-1450.
	t. 	Rural health clinics shall submit claims on Form HCFA-1500, Health Insurance Claim Form.
	u. 	Medicare-certified nursing facilities wishing to receive Medicaid skilled payment shall submit claims on Form UB-82-HCFA-1450.
	v. 	Maternal health centers shall submit claims on Form HCFA-1500, Health Insurance Claim Form.
	w. 	Ambulatory surgical centers shall submit claims on Form HCFA-1500, Health Insurance Claim Form.
	x. 	Independently practicing psychologists shall submit claims on Form HCFA-1500, Health Insurance Claim Form.
	y. 	Genetic consultation clinics shall submit claims on Form HCFA-1500, Health Insurance Claim Form.
	z. 	Nurse-midwives shall submit claims on Form HCFA-1500, Health Insurance Claim Form.
	aa. 	Birth centers shall submit claims on Form HCFA-1500, Health Insurance Claim Form.
	ab. 	Area education agencies shall submit claims on Form HCFA-1500, Health Insurance Claim Form.
	ac. 	Psychiatric medical institutions for children shall submit claims on Form UB-82-HCFA-1450.
	ad. 	Case management providers shall submit claims on Form 470-2486, Claim for Targeted Medical Care.
	ae. 	All HCBS waiver service providers shall submit claims for a calendar month or less of service on Form 470-2486, Claim for Targeted Medical Care.
	af. 	Certified registered nurse anesthetist providers shall submit claims on Form HCFA-1500, Health Insurance Claim Form.
	ag. 	Hospice providers shall submit claims on Form UB-82-HCFA-1450.
	ah. 	Rescinded IAB 6/4/97, effective 7/1/97.
	ai. 	Rescinded IAB 6/4/97, effective 7/1/97.
	aj. 	Federally qualified health centers shall submit claims on Form HCFA-1500, Health Insurance Claim Form.
	ak. 	Independently practicing family or pediatric nurse practitioners shall submit claims on Form HCFA-1500, Health Insurance Claim Form.
	al. 	Rescinded IAB 6/4/97, effective 7/1/97.
	am. 	Nursing facilities for persons with mental illness shall submit claims on Form UB-82-HCFA-1450.
	an. 	Rehabilitative treatment providers shall submit claims on Form AA-2241-0, Purchase of Service Provider Invoice.
	ao. 	Lead inspection agencies shall submit claims on Form HCFA-1500, Health Insurance Claim Form.
	80.2(3) Providers shall purchase or copy their supplies of forms HCFA-1450 and HCFA-1500 for use in billing.
This rule is intended to implement Iowa Code section 249A.4.
441—80.3(249A) Amounts paid provider from other sources. The amount of any payment made directly to the provider of care by the recipient, relatives, or any source shall be deducted from the established cost standard for the service provided to establish the amount of payment to be made by the carrier.
441—80.4(249A) Time limit for submission of claims and claim adjustments.
	80.4(1) Submission of claims. Payment will not be made on any claim where the amount of time that has elapsed between the date the service was rendered and the date the initial claim is received by the fiscal agent exceeds 365 days except that payment for claims submitted beyond the 365-day limit shall be considered if retroactive eligibility on newly approved cases is made which exceeds 365 days or if attempts to collect from a third-party payer delay the submission of a claim.
Exception:  Rehabilitative treatment service providers shall submit claims pursuant to rule 441—185.121(234).
	80.4(2) Claim adjustments. A provider’s request for an adjustment to a paid claim must be received by the fiscal agent within one year from the date the claim was paid in order to have the adjustment considered.
Exception:  Rehabilitative treatment service providers shall have claim adjustments processed pursuant to rule 441—185.121(234).
This rule is intended to implement Iowa Code sections 249A.3, 249A.4 and 249A.12.
441—80.5(249A) Authorization process.
	80.5(1) Identification cards. A medical identification card shall be issued to recipients for use in securing medical and health services available under the program. The cards are issued by the department on a monthly basis and are valid only for the month of issuance. Payment will be made for services provided an ineligible recipient when verification establishes that the recipient was issued a medical identification card for the month in which the service was provided.
	80.5(2) Third -party liability. When a third-party liability for medical expenses exists, this resource shall be utilized before payment is made by the Medicaid program unless the pay and chase provisions defined in rule 441—75.25(249A) are applicable or when otherwise authorized by the department.
441—80.6(249A) Payment to provider—exception. Payments for medical services may be made only to the provider of the services except as provided below:
	80.6(1) Medical assistance corrective payments. Payment may be made to the client or county relief agency in accordance with rule 441—75.8(249A).
	80.6(2) Assignment. Payment may be made in accordance with an assignment to a county for medical services received while the recipient was receiving interim assistance or while an appeal of a denial of medical assistance was pending.
	80.6(3) Business agent of provider. Payment may be made to a business agent that furnishes statements and receives payments in the name of the provider if the agent’s compensation is:
	a. 	Related to the cost of processing the billing.
	b. 	Not related on a percentage or other basis to the amount that is billed or collected.
	c. 	Not dependent upon the collection of the payment.
These rules are intended to implement Iowa Code section 249A.4.
[Filed March 11, 1970; amended September 5, 1973]
[Filed 6/25/76, Notice 5/17/76—published 7/12/76, effective 8/16/76]
[Filed 12/9/76, Notice 11/3/76—published 12/29/76, effective 2/2/77]
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[Filed 4/29/82, Notice 12/9/81—published 5/26/82, effective 7/1/82]
[Filed emergency 5/20/83—published 6/8/83, effective 6/1/83]
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[Filed 4/28/86, Notice 2/26/86—published 5/21/86, effective 7/1/86]
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[Filed emergency 6/9/88—published 6/29/88, effective 7/1/88]
[Filed 9/2/88, Notice 6/29/88—published 9/21/88, effective 11/1/88]
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[Filed emergency 12/8/88 after Notices 10/19/88, 11/2/88—
published 12/28/88, effective 1/1/89]
[Filed 7/14/89, Notices 4/19/89, 5/31/89—published 8/9/89, effective 10/1/89]
[Filed 9/15/89, Notice 8/9/89—published 10/4/89, effective 12/1/89]
[Filed emergency 12/15/89 after Notice 10/4/89—published 1/10/90, effective 1/1/90]
[Filed 4/13/90, Notice 11/29/90—published 5/2/90, effective 8/1/90]
[Filed 7/13/90, Notice 5/30/90—published 8/8/90, effective 10/1/90]
[Filed 10/12/90, Notice 8/8/90—published 10/31/90, effective 2/1/91]
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[Filed 8/8/91, Notice 6/26/91—published 9/4/91, effective 11/1/91]
[Filed 9/18/91, Notice 7/10/91—published 10/16/91, effective 12/1/91]
[Filed emergency 1/16/92 after Notice 11/29/91—published 2/5/92, effective 3/1/92]
[Filed 3/12/92, Notice 2/5/92—published 4/1/92, effective 7/1/92]
[Filed 1/14/93, Notice 11/11/92—published 2/3/93, effective 4/1/93]
[Filed without Notice 8/12/93—published 9/1/93, effective 11/1/93]
[Filed 12/16/93, Notice 9/1/93—published 1/5/94, effective 3/1/94]
[Filed 4/14/94, Notice 2/16/94—published 5/11/94, effective 7/1/94]
[Filed 4/11/97, Notice 2/12/97—published 5/7/97, effective 7/1/97]
[Filed emergency 5/14/97 after Notice 3/12/97—published 6/4/97, effective 7/1/97]
[Filed 6/12/97, Notice 4/23/97—published 7/2/97, effective 9/1/97]