Prescribed Drugs Provider Manual - Iowa Department of Human ...

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IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage97DateAugust 1, 2013For medications payable on Iowa Medicaid, the POS staff will put an overrideon the point-of-sale system for the pharmacy to rebill the claims forreimbursement.3. Claim Attachment Control, Form 470-3969If you want to submit electronically a claim that requires an attachment, youmust submit the attachment on paper using the following procedure:♦ Complete form 470-3969, Claim Attachment Control. To view a sample ofthis form on line, click here.Complete the “attachment control number” with the same numbersubmitted on the electronic claim. IME will accept up to 20 characters(letters or digits) in this number. If you do not know the attachmentcontrol number for the claim, please contact the person in your facilityresponsible for electronic claims billing.♦ Staple the additional information to form 470-3969. Do not attach apaper claim.♦ Mail the Claim Attachment Control with attachments to:Medicaid ClaimsPO Box 150001Des Moines, IA 50315Once IME receives the paper attachment, it will manually be matched upto the electronic claim using the attachment control number and thenprocessed.4. Paper Claim SubmissionTraditional Universal Claim forms are no longer accepted. The new universalclaim forms PUCF-D01PT (VER 1.2) can be ordered by calling CommuniFormat 800-564-8140, or online at http://www.ncpdp.org/Universal-Claim-Forms.aspx.The following table contains information that will aid in the completion of thepharmacy claim form. The table follows the form by field name, giving a briefdescription of the information to be entered, and whether providinginformation in that field is required, optional, or conditional on the individualmember’s situation.
IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage98DateAugust 1, 2013FIELD NAME/DESCRIPTIONINSTRUCTIONS1 – CARDHOLDER ID MANDATORY. Enter the member’s Medicaid IDnumber. Copy this directly from the MedicalAssistance Eligibility Card. It consists of sevennumeric characters followed by a letter, i.e.,1234567A.2 – GROUP ID NOT USED. Leave blank.3 – LAST NOT USED. Submit information under Patientsegment.4 – FIRST NOT USED. Submit information under Patientsegment.5 – PLAN NAME IAMED6 – BIN NUMBER 0119337 – BIN NUMBER IAPOPPATIENT8 – PATIENT’S LAST NAME REQUIRED. Must be submitted.9 – PATIENT’S FIRST NAME REQUIRED. Must be submitted.10 – PERSON CODE NOT USED.11 – DATE OF BIRTH REQUIRED. Enter the member’s birth date using atwo-digit entry for each of the following: month,day, and year.12 – PATIENT GENDER CODE REQUIRED. Enter the gender.13 – RELATIONSHIP TOCARDHOLDERNOT USED.PHARMACY15 – SERVICE PROVIDER ID MANDATORY. Enter the pharmacy’s nationalprovider identifier (NPI).16 – SERVICE PROVIDER IDQUALIFIERMANDATORY. Enter “01” for national provideridentifier (NPI).
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