M Factor Fee Schedule
Date: 08/27/20
Iowa Total Care would like to give providers an update to its reimbursement fee schedule, specifically related to M Factor Codes.
M Factor codes are codes in which the State’s Medicaid fee schedule contains no published fee amount (e.g. zero or blank). Since 7/1/2019, Iowa Total Care has been reimbursing these codes at a percentage of billed charges or by specific invoice cost.
Iowa Total Care now has available an updated fee schedule that includes reimbursement rates for many of the M Factor Codes. The reimbursement schedule is based on the following:
- Durable Medical Equipment including Diabetic supplies effective 6/1/2020; reimbursed at:
- Average Wholesale Price (AWP) less 10%, OR,
- Manufacturer Suggested Retail Price (MSRP) less 15%
- Rates are updated quarterly on the first day of the quarter.
- J-Codes - effective 6/1/2020 reimbursed at:
- AWP for National Drug Code (NDC) less 12%, less 5%, plus 1%
- Rates are updated quarterly on the first day of the quarter.
- All Other Codes effective 6/1/20; (Except Hearing Aid Services which have an effective date of 7/15/20) are reimbursed at:
- 100% of Medicare, OR,
- Gap fee based on median billed charges of historical claims data, OR,
- Priced at zero ($0) and pended for further review
Reason: some are priced at $0 because the codes do not exist on the Medicare fee schedule nor does ITC have any claims history to establish median fees.
Rates are updated annually on July 1st.
For questions or concerns, contact your Provider Relations Specialist.