Provider Forms

Form NumberForm Description
470-0254Iowa Medicaid Universal Provider Enrollment Application
470-2917Iowa Medicaid Universal HCBS Waiver Provider Application
470-2965Iowa Medicaid Provider Agreement General Terms
470-3174Iowa Medicaid Addendum to Dental Provider Agreement for Orthodontia
470-3372Home- and Community-Based Services (HCBS) Consumer-Directed Attendant Care (CDAC) Agreement (Fillable)
470-3495Iowa Medicaid Managed Care Wraparound Payment Request Form
470-3748Iowa Medicaid Enterprise Ambulance Verification of Compliance
470-3923Request for Medicaid Services Data Changes and Verifications
470-3924Request for IoWANS Changes
470-3969Pharmacy Fee-for-Service Claim Attachment Control Form
470-3970Pharmacy Fee-for-Service Prior Authorization Attachment Control Form
470-4202Electronic Fund Transfer (EFT) Authorization
470-4227Request and Acknowledgement to Conduct Registry and Record Check
470-4389Consumer-Directed Attendant Care (CDAC) Daily Service Record
470-4393Level of Care Certification for Facilities
470-4457Atypical Provider Declaration
470-4564Money Follows the Person Guardian Consent to Participate in Transition Planning
470-4566Money Follows the Person Consent to Begin Transition Planning
470-4582Money Follows the Person Consent to Proposed Transition
470-4608Iowa Medicaid Provider Address Change Request Form
470-4612Individual CDAC Disclosure
470-4815Early Periodic Screening Diagnosis and Treatment (EPSDT) Medical Needs Acuity Scoring Tool (MNAST) 
470-4816Early Periodic Screening Diagnosis and Treatment (EPSDT) Functional Needs Acuity Scoring Tool (FNAST)
470-4817Early Periodic Screening Diagnosis and Treatment (EPSDT) Social Needs Acuity Scoring Tool (SNAST) 
470-4829

Iowa Medicaid Nursing Facility Enhanced Medicaid Payment Report

470-4829 Instructions

470-4836Iowa Medicaid Nursing Facility Quality Assurance Assessment
470-4991Iowa Medicaid Meals and Lodging Claim
470-4996Iowa Medicaid Notice of Decision - Access2Care
470-5023CDAC Adjustment Cover Sheet
470-5030PACE Disenrollment Form
470-5047Certificate of Medical Necessity for Waiver Assistive Devices
470-5048Certificate of Medical Necessity for Consumer-Directed Attendant Care
470-5049Certificate of Medical Necessity for Environmental Modification
470-5050Certificate of Medical Necessity for Home and Vehicle Modification
470-5051Certificate of Medical Necessity for Prevocational Services
470-5100Iowa Medicaid Health Home Provider Agreement
470-5110Home- and Community-Based Services (HCBS) Intellectual Disability Waiver Priority Need Assessment – Statewide Waiting List
470-5111Iowa Medicaid Ordering/Referring Provider Enrollment Application
470-5112Iowa Medicaid Designated Contact Person
470-5151Money Follows the Person Referral Information
470-5156Level of Care Certification for Swing Bed Facility
470-5160Iowa Medicaid Integrated Health Home Provider Agreement General Terms
470-5168Medicaid/Hawki Review
470-5170

Application for Health Coverage and Help Paying Costs

470-5177Agreement for Participation as a Patient Manager in the Iowa Health and Wellness Plan (Wellness Plan)
470-5189Client Participation Notices Access Request
470-5194Medically Exempt Member Survey
470-5198Medically Exempt Attestation and Referral Form
470-5200Application for Certification to become a Qualified Entity (QE)
470-5201Qualified Entity (QE) Medicaid Presumptive Eligibility Portal (MPEP) Access Request Form
470-5210Dental Wellness Plan Wraparound Payment Request
470-5218Iowa Medicaid Accountable Care Organization (ACO) Agreement
470-5262Iowa Medicaid Qualified Medicare Beneficiaries (QMB) or Health Insurance Premium Payment (HIPP) Program Provider Enrollment Application
470-5267Chronic Health Home Program Patient Tier Assignment Tool (PTAT) Version 3.0
470-5268Chronic Condition Health Home Program Patient Tier Assignment Tool (PTAT) Guide
470-5273Iowa Medicaid Health Home Provider Application
470-5276Off Year Assessment 
470-5297Qualified Entity (QE) Medicaid Presumptive Eligibility Portal (MPEP) Recertification
470-5298Iowa Medicaid Provider Enrollment Application Fee Hardship Exemption Request
470-5324Core Standardized Assessment (CSA) Document Access Request for the Iowa Medicaid Portal Access (IMPA) System
470-5362Iowa Medicaid Memorandum of Understanding (MOU) for Value Based Purchasing Support Activities
470-5403Medicaid Member Documentation Upload Cover Sheet through the Iowa Medicaid Portal Access (IMPA) System
470-5417Long Term Care (LTC) File Upload for the Iowa Medicaid Portal Access (IMPA) System
470-5419Wraparound Supporting Claims Detail
470-5422Intermediate Care Facilities for Individuals with an Intellectual Disability Calculation Worksheet
470-5445Insurance Update Fee-for-Service (FFS) Members
470-5465Provider Request to Terminate Enrollment
470-5473Iowa Medicaid Inpatient Psychiatric Prior Authorization
470-5475Health Insurance Premium Payment (HIPP) Provider Invoice
470-5477Financial and Statistical Report for Home- and Community-Based Services
470-5480Iowa Medicaid Mileage Reimbursement Trip Log and Claim Form
470-5482Medicaid/State Supplementary Assistance Review
470-5484Family Planning Program Provider Attestation
470-5486Emergency Needs Assessment
470-5506Attestation of Compliance with Section 6032 of The Federal Deficit Reduction Act
470-5512340B, Federal Supply Schedule, and Nominal Price Attestation and Election
470-5526Authorized Representative for Managed Care Appeals
470-5528Certificate of Medical Necessity for Health and Disability Waiver Cap Increase
470-5551Community-Based Neurobehavioral Rehabilitation Services (CNRS) 2018 Provider Quality Management Self-Assessment
470-5582Integrated Health Homes (IHH) Managed Care Organizations (MCOs) Notification
470-5583Home- and Community-Based Services (HCBS) Brain Injury Waiver Emergency Need Assessment
470-5594Inpatient Medicaid Prior Authorization
470-5594 Resource Guide
470-5595

Outpatient Medicaid Prior Authorization

470-5595 Resource Guide

470-5619Medicaid Supplemental Information Prior Authorization
470-5635Children's Mental Health Waiver Level of Care Determination Request for Additional Information
470-5642Case Mix Request Access for Iowa Medicaid Portal Access (IMPA) System
470-5667Case Mix Payer Change Form
470-5710Chronic Condition Health Home Managed Care Organizations (MCOs) Notification

 

Medicaid Cost Report Forms by Provider Type

HHA EPSDT PDN/PC Cost Report

Financial and Statistical Report for Home Health Agencies (HHA) who provide Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Private Duty Nursing and Personal Care Services (PDN/PC).
View Instructions
 

RSP Cost Report
Financial and Statistical Report for Remedial Services Provider Identification Page

RSP Parent Cost Report
Financial and Statistical Report for Remedial Services Provider Identification Page (Parent)
 

CMHC Cost Report
Community Mental Health Center Financial & Statistical Report
View Instructions
 

FQHC
Federally Qualified Health Center (FQHC)
 

Hab. Svcs. - FS
Habilitation Services Financial and Statistical Report
 

Hab. Svcs. - Parent
Habilitation Services Parent Cost Report
 

HCBS Cost Report
Home- and Community-Based Services (HCBS)
HCBS Cost Report Instructions

Hospital-CAH
Hospital - Critical Access
 

Hospital
Hospital - Not Critical Access
 

Financial & Statistical Report
Nursing Facility (NF) / Intermediate Care Facility for the Intellectually Disabled (ICF/ID) / Residential Care Facility (RCF)
View Instructions
 

PMIC
Psych Medical Institution for Children (PMIC)
View Instructions
 

RHC - Hospital Based
Rural Health Clinic (RHC) - Hospital Based
 

RHC - Freestanding
Rural Health Clinic (RHC) - Freestanding
 

MHI
State Mental Health Institute (MHI)
 

Case Management
Targeted Case Management (TCM) Cost Report Template

 

Cooperative Agreement

  • LEA Agreement
    The purpose of this agreement is to assure the implementation of 34 CFR 300.
     I/T Contract
    The purpose of this agreement is to assure the implementation of 34 CFR 303.

PC-ACE Pro32 Help Documents

 

Iowa Provider Cost Audit Web Portal Forms

  • Iowa Provider Cost Audit Web Portal Registration Form
  • Iowa Provider Cost Audit Web Portal External User Guide

 

Department of Corrections Forms

  • Managed Care Organization Enrollment