| Form Number | Form Description |
|---|---|
| 470-0254 | Iowa Medicaid Universal Provider Enrollment Application |
| 470-2917 | Iowa Medicaid Universal HCBS Waiver Provider Application |
| 470-2965 | Iowa Medicaid Provider Agreement General Terms |
| 470-3174 | Iowa Medicaid Addendum to Dental Provider Agreement for Orthodontia |
| 470-3372 | Home- and Community-Based Services (HCBS) Consumer-Directed Attendant Care (CDAC) Agreement (Fillable) |
| 470-3495 | Iowa Medicaid Managed Care Wraparound Payment Request Form |
| 470-3748 | Iowa Medicaid Enterprise Ambulance Verification of Compliance |
| 470-3923 | Request for Medicaid Services Data Changes and Verifications |
| 470-3924 | Request for IoWANS Changes |
| 470-4202 | Electronic Fund Transfer (EFT) Authorization |
| 470-4227 | Request and Acknowledgement to Conduct Registry and Record Check |
| 470-4389 | Consumer-Directed Attendant Care (CDAC) Daily Service Record |
| 470-4457 | Atypical Provider Declaration |
| 470-4564 | Money Follows the Person Guardian Consent to Participate in Transition Planning |
| 470-4566 | Money Follows the Person Consent to Begin Transition Planning |
| 470-4582 | Money Follows the Person Consent to Proposed Transition |
| 470-4608 | Iowa Medicaid Provider Address Change Request Form |
| 470-4612 | Individual CDAC Disclosure |
| 470-4815 | Early Periodic Screening Diagnosis and Treatment (EPSDT) Medical Needs Acuity Scoring Tool (MNAST) |
| 470-4816 | Early Periodic Screening Diagnosis and Treatment (EPSDT) Functional Needs Acuity Scoring Tool (FNAST) |
| 470-4817 | Early Periodic Screening Diagnosis and Treatment (EPSDT) Social Needs Acuity Scoring Tool (SNAST) |
| 470-4829 |
Iowa Medicaid Nursing Facility Enhanced Medicaid Payment Report |
| (Updated) 470-4836 | Iowa Medicaid Nursing Facility Quality Assurance Assessment |
|
Iowa Medicaid Meals and Lodging Claim |
|
|
Iowa Medicaid Notice of Decision - Access2Care |
|
|
CDAC Adjustment |
|
| 470-5030 |
PACE Disenrollment Form |
|
Certificate of Medical Necessity for Waiver Assistive Devices |
|
|
Certificate of Medical Necessity for Consumer-Directed Attendant Care |
|
|
Certificate of Medical Necessity for Environmental Modification |
|
|
Certificate of Medical Necessity for Home and Vehicle Modification |
|
|
Certificate of Medical Necessity for Prevocational Services |
|
| Iowa Medicaid Health Home Provider Agreement | |
| Home- and Community-Based Services (HCBS) Intellectual Disability Waiver Priority Need Assessment – Statewide Waiting List | |
|
Iowa Medicaid Ordering/Referring Provider Enrollment Application |
|
|
Designated Contact Person |
|
| 470-5151 | Money Follows the Person Referral Information |
|
Level of Care Certification for Swing Bed Facility |
|
|
Iowa Medicaid Integrated Health Home Provider Agreement General Terms |
|
|
Medicaid/Hawki Review |
|
|
Application for Health Coverage and Help Paying Costs
|
|
|
Iowa Wellness Plan Patient Manager Agreement |
|
|
Client Participation Notices Access Request |
|
|
Medically Exempt Member Survey |
|
|
Medically Exempt Attestation and Referral Form |
|
|
Application for Certification to become a Qualified Entity (QE) |
|
|
Qualified Entity (QE) Medicaid Presumptive Eligibility Portal (MPEP) Access Request Form |
|
|
Dental Wellness Plan Wraparound Payment Request |
|
|
Iowa Medicaid Accountable Care Organization (ACO) Agreement |
|
|
Iowa Medicaid Qualified Medicare Beneficiaries (QMB) or Health Insurance Premium Payment (HIPP) Program Provider Enrollment Application |
|
|
Chronic Health Home Program Patient Tier Assignment Tool (PTAT) Version 3.0 |
|
|
Chronic Condition Health Home Program Patient Tier Assignment Tool (PTAT) Guide |
|
|
Iowa Medicaid Health Home Provider Application |
|
|
Off Year Assessment |
|
|
Qualified Entity (QE) Medicaid Presumptive Eligibility Portal (MPEP) Recertification |
|
|
Iowa Medicaid Provider Enrollment Application Fee Hardship Exemption Request |
|
|
Core Standardized Assessment (CSA) Document Access Request for the Iowa Medicaid Portal Access (IMPA) System |
|
|
Iowa Medicaid Memorandum of Understanding (MOU) for Value Based Purchasing Support Activities |
|
|
Medicaid Member Documentation Upload Cover Sheet through the Iowa Medicaid Portal Access (IMPA) System |
|
|
Long Term Care (LTC) File Upload for the Iowa Medicaid Portal Access (IMPA) System |
|
|
Wraparound Supporting Claims Detail |
|
|
Intermediate Care Facilities for Individuals with an Intellectual Disability Calculation Worksheet |
|
|
Insurance Update Fee-for-Service (FFS) Members |
|
|
Provider Request to Terminate Enrollment |
|
|
Home- and Community-Based Services (HCBS) Residential Setting Member Assessment |
|
|
Home- and Community-Based Services (HCBS) Nonresidential Setting Assessment |
|
|
Iowa Medicaid Inpatient Psychiatric Prior Authorization |
|
|
Health Insurance Premium Payment (HIPP) Provider Invoice |
|
| 470-5477 | Financial and Statistical Report for Home- and Community-Based Services |
|
Wraparound Payment Request Access for the Iowa Medicaid Portal Access (IMPA) System |
|
|
Iowa Medicaid Mileage Reimbursement Trip Log and Claim Form |
|
| 470-5482 |
Medicaid/State Supplementary Assistance Review |
|
Family Planning Program Provider Attestation |
|
|
Emergency Needs Assessment |
|
|
Attestation of Compliance with Section 6032 of The Federal Deficit Reduction Act |
|
|
340B, Federal Supply Schedule, and Nominal Price Attestation and Election |
|
|
Authorized Representative for Managed Care Appeals |
|
|
Certificate of Medical Necessity for Health and Disability Waiver Cap Increase |
|
| 470-5551 |
Community-Based Neurobehavioral Rehabilitation Services (CNRS) 2018 Provider Quality Management Self-Assessment |
| 470-5582 | Integrated Health Homes (IHH) Managed Care Organizations (MCOs) Notification |
| 470-5583 | Home- and Community-Based Services (HCBS) Brain Injury Waiver Emergency Need Assessment |
| 470-5594 | Inpatient Medicaid Prior Authorization |
| 470-5595 | Outpatient Medicaid Prior Authorization |
| 470-5619 | Medicaid Supplemental Information Prior Authorization |
| 470-5635 | Children's Mental Health Waiver Level of Care Determination Request for Additional Information |
| 470-5642 | Case Mix Request Access for Iowa Medicaid Portal Access (IMPA) System |
| 470-5710 | Chronic Condition Health Home Managed Care Organizations (MCOs) Notification |
|
Medicaid Cost Report Forms by Provider Type
|
|
Cooperative Agreement
|
|
PC-ACE Pro32 Help Documents |
|
Iowa Provider Cost Audit Web Portal Forms |
PC-ACE Pro32 Billing Guides ICD-9
- Creating Institutional Claims - Nursing Facility
- Creating Institutional Claims - UB04
- Creating Professional Claims - CMS 1500
- Creating Professional Claims - Dental
- Creating Professional Claims - Waiver/Targeted Case Mgmt.
PC-ACE Pro32 Billing Guides ICD-10
- Creating Institutional Claims - Nursing Facility
- Creating Institutional Claims - UB04
- Creating Professional Claims - CMS 1500
- Creating Professional Claims - Dental
- Creating Professional Claims - Waiver/Targeted Case Mgmt.
Department of Corrections Forms