Get 470-0829 Request For Piror Authorization - Iowa Department Of ... - Dhs State Ia

Completing the 470-0829 Request For Prior Authorization form is a vital step in obtaining necessary services through Iowa's Medicaid program. This guide provides clear, step-by-step instructions to help you accurately fill out the form online, ensuring you do not miss any crucial information.

Follow the steps to accurately complete your request for prior authorization.

1. Press the ‘Get Form’ button to access the 470-0829 Request For Prior Authorization form. Once you have the form open, ensure you are prepared to input the required information carefully.
2. In section 1, enter the patient's last name, first name, and middle initial. Make sure the names are spelled correctly as this information is crucial for identification.
3. Fill in the patient's Medicaid identification number in section 2. This number is essential for tracking the patient's Medicaid status.
4. Provide the patient's date of birth in section 3 using the format Month/Day/Year.
5. In section 4, include the provider's taxonomy number to identify the type of services provided. Section 5 requires the dispensing provider's name, and section 6 requests the provider's phone number.
6. In section 7, list the provider's fax number, followed by section 8 where you enter the provider's NPI number.
7. Complete the service location by entering the street address in section 10 and the city, state, and zip code in section 11.
8. In section 12, leave space for the prior authorization number, which will be assigned by the Iowa Medicaid Enterprise after processing the request.
9. In section 13, provide specific reasons for the authorization request. If the space is insufficient, use additional sheets as necessary to elaborate on the medical necessity.
10. Sections 14 to 21 pertain to the services being authorized, including lines for procedure codes, supplies, drugs, and requested amounts. Ensure that you fill out these sections accurately, indicating any relevant codes, units, and details about the services intended.
11. In section 22, acknowledge that approval is based solely on medical necessity. Ensure that the requesting provider's signature is completed in section 23 with the date.
12. Finally, review the form for accuracy. You can save changes, download, print, or share the completed form as necessary for submission.

Complete the necessary documents online to facilitate your request for prior authorization efficiently.