An exception to policy request must be in writing. You can write a letter or complete a Petition for Exception to Policy form.
Please answer all questions on this form and be specific. Complete the Petition for Exception form online.
Once the form is completely filled out, click the submit button at the bottom of the form. Your request will be sent directly to the Appeals Section.
If you have additional documentation that will help support your request, please mail, fax or email the information to the Appeals Section so it can be used when making a decision on your request.
If the request is medical in nature, please provide documentation to prove that the item or service is medically necessary. You will need to include the costs or proposed savings of the request.
Mail, fax or email the additional documentation to:Department of Human Services Appeals Section 1305 E Walnut Street, 5th Floor Des Moines, IA 50319 Phone: 515-242-6302 FAX: 515-564-4118 Email: email@example.com
If you choose not to use the Petition for Exception to Policy form and you want to request an exception to policy, write a letter with the following:
List the name, address, and Medicaid number (state ID number) of the person who needs the exception.
If a home health agency is requesting an exception to policy on behalf of a consumer, the following should be included, as well as the information listed above:
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