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

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IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage123DateAugust 1, 20132. Remittance Advice Field DescriptionsField NameField DescriptionA R.A. No. Remittance Advice numberB Warrant Number Check number (usually zeros). Contact IME forcheck number.C Provider Name Name of the pay-to provider as registered with IMED Provider Address Address registered with IME for the mailing ofRemittance Advice and paper checksEImportant IMEInformationReminders and updates from IMEF Run Date Date the Remittance Advice was createdG Date Paid Date the Remittance Advice was mailed and checkwas releasedH Prov. Number National provider identifier (NPI) of the billing(pay-to) providerI Page Page numberJ Number of Claims Number of claims processed for each defined statusKBilled Amount of AllClaimsTotal dollar amount of claims billed for eachdefined statusL Subtotal Amount Paid Amount paid for each defined statusM Amount of Deposit Total check amount for claims paid on thisRemittance AdviceN EOB Code Explanation of benefits (EOB) code or denial codeO EOB Description Description of the denial EOBPNumber of ClaimsPosting EOBNumber of claims that denied for the EOB codedescribedQ Total Billed Amt. Total amount billed to Iowa Medicaid for claims inthis status sectionR Total Other Sources Third party insurance payment or spenddownamount applied for claims in this status sectionS Total Paid by Mcaid Total amount paid by Medicaid for claims in thisstatus sectionT Copay Amt. Members’ copayment amount (applied per date ofservice, when applicable) for claims in this status
IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage124DateAugust 1, 2013Field NameField Description1 Patient Name Name of the member as shown on the MedicalAssistance Eligibility Card (last name and firstinitial)2 Recipient Ident Num Member identification number (7 digits+letter)3 Trans-Control-Number4 Dispense Date Date of service5 National Drug Code 11-digit NDC number6 Sub Units Number of units billed7 Rx No. Prescription number17-digit transaction control number assigned toeach claim8 Billed Amt. Total amount billed to Iowa Medicaid for this claim9 Other Sources Third party insurance payment or spenddownamount applied to this claim10 Paid by Mcaid Total amount paid by Medicaid on this claim11 Copay Amt. Member’s copay amount (applied per date ofservice, when applicable)12 S Source of payment. Allowed charge source codesare as follows:A AnesthesiaB Billed chargeC Percentage of chargesD Inpatient per diem rateE EAC priced plus dispense feeF Fee scheduleG FMAC priced plus dispense feeH Encounter rateI Prior authorization rateK DeniedL Maximum suspend ceilingM Manually pricedN Provider charge rateO Professional componentP Group therapyQ EPSDT total over 17R EPSDT total under 18S EPSDT partial over 17SP Not yet pricedT EPSDT partial under 18
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