Forms

 
470-2917 Iowa Medicaid Universal HCBS Waiver Provider Application
470-3495 Iowa Medicaid Managed Care Wraparound Payment Request Form
470-3747 Iowa Medicaid Point of Sale Agreement
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
470-4564 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
470-4815 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

470-4829 Instructions

470-4836 Iowa Medicaid Nursing Facility Quality Assurance Assessment
470-4836 Instructions

470-4991

Iowa Medicaid Meals and Lodging Claim

470-4996

Iowa Medicaid Notice of Decision - Access2Care

470-5023

CDAC Adjustment

470-5030

PACE Disenrollment Form

470-5047

Certificate of Medical Necessity for Waiver Assistive Devices

470-5048

Certificate of Medical Necessity for Consumer-Directed Attendant Care

470-5049

Certificate of Medical Necessity for Environmental Modification

470-5050

Certificate of Medical Necessity for Home and Vehicle Modification

470-5051

Certificate of Medical Necessity for Prevocational Services

470-5100

Iowa Medicaid Health Home Provider Agreement

470-5110

Home- and Community-Based Services (HCBS) Intellectual Disability Waiver Priority Need Assessment – Statewide Waiting List

470-5111

Iowa Medicaid Ordering/Referring Provider Enrollment Application

470-5112

Designated Contact Person

470-5151 Money Follows the Person Referral Information

470-5156

Level of Care Certification for Swing Bed Facility

470-5160

Iowa Medicaid Integrated Health Home Provider Agreement General Terms

470-5170

Application for Health Coverage and Help Paying Costs

470-5177

Iowa Wellness Plan Patient Manager Agreement

470-5186

Iowa Medicaid Ownership and Control Disclosure

470-5189

Client Participation Notices Access Request

470-5194

Medically Exempt Member Survey

470-5198

Medically Exempt Attestation and Referral Form

470-5200

Application for Certification to become a Qualified Entity (QE)

470-5201

Qualified Entity (QE) Medicaid Presumptive Eligibility Portal (MPEP) Access Request Form

470-5210

Dental Wellness Plan Wraparound Payment Request

470-5218

Iowa Medicaid Accountable Care Organization (ACO) Agreement

470-5262

Iowa Medicaid Qualified Medicare Beneficiaries (QMB) or Health Insurance Premium Payment (HIPP) Program Provider Enrollment Application

470-5264

Iowa Wellness Plan ACO Readiness Application

470-5267

Chronic Health Home Program Patient Tier Assignment Tool (PTAT) Version 3.0

470-5268

Chronic Condition Health Home Program Patient Tier Assignment Tool (PTAT) Guide

470-5273

Iowa Medicaid Health Home Provider Application

470-5276

Off Year Assessment 

470-5297

Qualified Entity (QE) Medicaid Presumptive Eligibility Portal (MPEP) Recertification

470-5298

Iowa Medicaid Enterprise (IME) Provider Enrollment Application Fee Hardship Exemption Request

470-5324

Core Standardized Assessment (CSA) Document Access Request for the Iowa Medicaid Portal Access (IMPA) System

470-5362

Iowa Medicaid Memorandum of Understanding (MOU) for Value Based Purchasing Support Activities

470-5383

Nursing Facility Supplementation Payment Report

470-5403

Medicaid Member Documentation Upload Cover Sheet through the Iowa Medicaid Portal Access (IMPA) System
 

470-5417

Long Term Care (LTC) File Upload for the Iowa Medicaid Portal Access (IMPA) System

470-5419

Wraparound Supporting Claims Detail

470-5422

Intermediate Care Facilities for Individuals with an Intellectual Disability Calculation Worksheet

470-5445

Insurance Update Fee-for-Service (FFS) Members

470-5465

Provider Request to Terminate Enrollment

470-5466

Home- and Community-Based Services (HCBS) Residential Setting Member Assessment

470-5467

Home- and Community-Based Services (HCBS) Nonresidential Setting Assessment

470-5473

Iowa Medicaid Enterprise (IME) Inpatient Psychiatric Prior Authorization

470-5475

Health Insurance Premium Payment (HIPP) Provider Invoice

470-5477

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

HCBS Cost Report Instructions

470-5479

Wraparound Payment Request Access for the Iowa Medicaid Portal Access (IMPA) System

470-5480

Iowa Medicaid Mileage Reimbursement Trip Log and Claim Form

470-5484

Family Planning Program Provider Attestation

470-5486

Emergency Needs Assessment

470-5506

Attestation of Compliance with Section 6032 of The Federal Deficit Reduction Act

470-5512

340B, Federal Supply Schedule, and Nominal Price Attestation and Election

470-5526

Authorized Representative for Managed Care Appeals

470-5528

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

470-5583 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

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

Listing of updates to the FYE 2017 HCBS Cost Report

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.

Iowa Provider Cost Audit Web Portal Forms

PC-ACE Pro32 Billing Guides ICD-9

PC-ACE Pro32 Billing Guides ICD-10

Department of Corrections Forms