Uniform Prior Authorization (PA) Forms:
- Outpatient Medicaid Prior Authorization Form, 470-5595
- Inpatient Medicaid Prior Authorization Form, 470-5594
- Supplemental Form (470-5619)
These forms are to be used for Managed Care (MC) and Fee-for-Service (FFS) PA submissions. For FFS medical services PA submissions, only the Outpatient Services and the Supplemental Form should be used.
Medical
Prior authorization is required for certain services and supplies. Submission of a prior authorization request form along with all supporting documentation is necessary to obtain these services and/or supplies:
- Audiology & Vision
- Clinical Trial Attestation
- Durable Medical Equipment (DME)
- DME Rental
- Enteral Nutrition
- Gene Analysis
- Home Health
- International Classification of Diseases - Procedure Coding System (ICD-PCS)
- Managed Care Organization (MCO) Prior Authorization Comparison Chart
- Medical Services
- Physician Administered Medications
- Radiology
Dental
Prior Authorization Submission Methods
- Fax: 515-725-1356
- Phone: 888-424-2070 (Toll Free)
- Email: paservices@dhs.state.ia.us
The Quality Improvement Organization (QIO) will review the prior authorization request for medical necessity, and the outcome of that review will be faxed to the provider who submitted the request.
Certain services and/or supplies require the submission of additional forms/documentation:
- Augmentative Communication System Selection Form 470-2145
- Certification of Enteral Nutrition (CEN) Form 470-4210
- Examiner Report of Need for a Hearing Aid Form 470-4767
- MNAST Form 470-4815
- FNAST Form 470-4816
- SNAST Form 470-4817
Additional Resources/Criteria
The Quality Improvement Organization (QIO) will review the prior authorization request for medical necessity, and the outcome of that review will be faxed to the provider who submitted the request.
Behavioral Health Services
Inpatient Psychiatric Hospital (IPP)
If requesting prior authorization or retroactive authorization for Inpatient Psychiatric Hospital stay, use Form 470-5473. For best results, save this document to your device, fill it out, and email to inptps@dhs.state.ia.us.
NOTE: If this is a request for continued stay you will also submit any related court orders or additional documentation to support continued stay.
Psychiatric Medical Institution for Children (PMIC)
If you are requesting prior authorization or retroactive authorization for PMIC stay, submit the PMIC Admission or Continued Stay Criteria checklist to PMIC2@dhs.state.ia.us.
Information Resources
- Nursing Facility Level of Care (LOC) Certification Form Tips (Video)
- 2020 New Prior Authorization Form Training (PDF)