Section 641.75.6. Reimbursement of providers.

       75.6(1) The University of Iowa Hospitals and Clinics and other hospitals will submit their billings on the UB 82, uniform hospital billing form, and physicians will submit their billings on the Health Care Financing Administration form HCFA 1500. Forms will be furnished by the providers.

       75.6(2) Providers will submit bills after delivery but not more than 60 days after the delivery or after determination of eligibility, whichever occurs later, to the department of public health.

       75.6(3) Reimbursement for physicians and hospitals will be based upon the Title XIX rates. Bills will be adjusted accordingly by the department of public health and forwarded to the department of revenue and finance for payment.

       75.6(4) Providers may be reimbursed for antepartum care prior to the patient becoming ineligible, as long as the patient is counted as a quota case.

       75.6(5) On an annual basis the department of public health will furnish participating physicians with a list of reimbursable procedure codes and maximum rate.

       75.6(6) The obstetrical indigent care fund is last pay. Private insurance shall be billed first.

       75.6(7) All providers of services to quota obstetrical and newborn patients shall agree to accept as full payment the reimbursements allowable under the medical assistance program established pursuant to Iowa Code chapter 249A, up to a maximum of medical assistance’s average reimbursement for the most recent fiscal year. When the medical assistance reimbursement methodologies change, the maximum reimbursement may be based upon projection.

       75.6(8) The obstetrical and newborn indigent program will pay, out of a set-aside fund, for certain cases that exceed the current year’s maximum reimbursement rate. Cases that can be paid out of this fund are:

        a.           Allowable physician and hospital costs associated with DRGs 370, 371, 372, 374, 375 for the woman. Costs associated with DRGs 383, 384 will be covered if followed by a qualifying delivery event.

        b.           Allowable physician and hospital costs for the newborn associated with DRGs 385, 385.1, 389, 390.

        c.           Care provided to newborns under DRGs 386, 386.1, 387, 387.1, 388, 388.1, 389.1, 390.1 are defined under rule 75.2(255A) as being outside the scope of this program. These services could, however, be covered by Iowa Code chapter 255 or medically needy programs.

        d.           Physicians who provide obstetrical or newborn care at the University of Iowa Hospitals and Clinics are not entitled to receive any compensation for the provision of such care to persons certified as eligible under this program.

       75.6(9) In all other cases, the maximum reimbursement level will apply. If the total reimbursable charges exceed the maximum reimbursement level, reimbursement to providers will be prorated based upon allowable reimbursement amounts.

       75.6(10) Certifications for quota cases received by June 30 will have medical assistance’s average reimbursement and the 10 percent fund encumbered.