Iowa Case Mix Payer Change Form

Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare

The afternoon of July 23, 2021, the Iowa Department of Human Services (DHS) and Iowa Medicaid Enterprise (IME) issued a second Informational Letter relating to Iowa Case Mix.

To view this IL, click here to view this document.  It will download to your taskbar where you can access it.

“This letter is intended to inform providers of changes made to the Case Mix Payer Change Form, 470-5667.

Effective July 1, 2021, the Case Mix Payer Change Form was moved from Telligen to the DHS website at  

To submit a payer change request, facilities should download the form from the DHS website and submit the form to the IME Quality Improvement Organization (QIO) at

Nursing facilities may submit a payer change form to change the payer type indicated on the case mix index roster. The payer source is identified by the most recent assessment available on the last day of each calendar year quarter that calculated a resource utilization group (RUG)-III score.

The Case Mix Payer Change form can ONLY update the PAY SOURCE and should not be used for RUG discrepancies or changes to Medicaid numbers. All payer source changes must be submitted by the cutoff date. Important case mix dates are available in the Iowa Medicaid Portal Access (IMPA) system and on the DHS website at:  

Please Note: If the Medicaid number has been entered incorrectly in the minimum data set (MDS), A0700, OR the member was pending Medicaid and was approved for Medicaid with the effective date being the month or months prior to the MDS assessment listed on the preliminary roster, the MDS assessment MUST be modified to correct or add the Medicaid number in A0700 and successfully transmitted prior to the preliminary cutoff date. All corrections to the preliminary case mix index report must be done by completing a modification, inactivation, and/or transmission of the MDS assessment and tracking record prior to the preliminary cutoff date.

Links to the Case Mix Payer Change Form, Case Mix Frequently Asked Questions (FAQs), Case Mix Rosters Important Dates, Case Mix User Guide, and the RUG-III calculation guide are available on the DHS website.”

Those links as well as contact information for questions are found on the second page of the IL.