441—92.8 (249A,249J) Benefits. Under IowaCare, payment will be made only for services and providers as specified in this rule. No payment will be made for any service provided elsewhere or by another provider.
	 92.8(1) Provider network. Except as provided in subrules 92.8(3) and 92.8(4), IowaCare members shall have medical assistance only for services provided to the member by:
	  a.   	 The University of Iowa Hospitals and Clinics; or
	  b.   	 Broadlawns Medical Center in Des Moines; or
	  c.   	 A state mental health institute, exclusive of the units providing substance abuse treatment, services to gero-psychiatric patients, or treatment for sexually violent predators; or
	  d.   	 Any physician, advanced registered nurse practitioner, or physician assistant who is part of a medical institution listed in this subrule. Physician assistants are able to render covered services as auxiliary personnel pursuant to 441—subrule 78.1(13).
	 92.8(2) Covered services. Services shall be limited to the services covered by the Iowa Medicaid program pursuant to 441—Chapter 78, 441—79.9(249A), and 441—Chapter 85, Division I. All conditions of service provision shall apply in the same manner as under the regular Iowa Medicaid program and pursuant to 441—Chapter 78, 441—79.3(249A), 441—79.5(249A), 441—79.6(249A), 441—79.8(249A) through 441—79.14(249A), and applicable provider manuals. These conditions include, but are not limited to, prior authorization requirements and exclusions for cosmetic procedures or those otherwise determined not to be required to meet the medical need of the patient.
	 92.8(3) Obstetric and newborn coverage. IowaCare members who qualify under 92.2(1)“b” or “c” are also eligible for the services specified in paragraph “a” or “b” from the providers specified in paragraph “c” or “d.”
	  a.   	 Covered services for pregnant women shall be limited to:
	 (1) 	 Inpatient hospital services when the diagnosis-related group (DRG) submitted for payment is between 370 and 384 and the primary or secondary diagnosis code is V22 through V24.9.
	 (2) 	 Obstetrical services provided in an outpatient hospital setting when the primary or secondary diagnosis code is V22 through V24.9.
	 (3) 	 Services from another provider participating in Medicaid if the claim form reflects that the primary or secondary diagnosis code is V22 through V24.9.
	  b.   	 Newborns will be eligible while hospitalized and for a period not to exceed 60 days from the date of birth.
	 (1) 	 Inpatient hospital services shall be payable when the diagnosis-related group (DRG) submitted for payment is between 385 and 391.7.
	 (2) 	 Services provided by a health care provider other than a hospital shall be covered as provided in subrule 92.8(2).
	  c.   	 For persons who reside in Cedar, Clinton, Iowa, Johnson, Keokuk, Louisa, Muscatine, Scott, or Washington County, the services listed in this subrule are covered only when provided by the University of Iowa Hospitals and Clinics.
	  d.   	 Persons who do not live in Cedar, Clinton, Iowa, Johnson, Keokuk, Louisa, Muscatine, Scott, or Washington County may obtain the services listed in this subrule from any provider that participates in Iowa Medicaid.
	 92.8(4) Routine preventive medical examinations. A routine preventive medical examination is one that is performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury.
	  a.   	 IowaCare members who qualify under paragraph 92.2(1)“b” or “c” are eligible to receive routine preventive medical examinations from:
	 (1) 	 Any provider specified under subrule 92.8(1), or
	 (2) 	 Any physician, advanced registered nurse practitioner, or physician assistant who participates in Iowa Medicaid, including but not limited to providers available through a free clinic, a rural health clinic, or a federally qualified health center. Physician assistants are able to render covered services as auxiliary personnel pursuant to 441—subrule 78.1(13).
	  b.   	 A provider that bills IowaCare for a routine preventive medical examination shall use diagnosis code V70 and evaluation and management CPT code 99202, 99203, 99204, 99212, 99213, or 99214, as appropriate to the level of service provided. Basic laboratory work may also be billed in association with the medical examination, as appropriate and necessary.