Uniform Prior Authorization (PA) Forms: 

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:

 

Dental

 

Prior authorization requests can be submitted using the following methods: 

  • IMPA
  • 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: 

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