Get 470 4708 Form

This guide provides detailed instructions on filling out the 470 4708 Form online, specifically designed for submitting services to Iowa Medicaid that were previously billed to Medicare. By following this guide, users can ensure a smooth and accurate completion of the form.

Follow the steps to complete the 470 4708 Form online effectively.

1. Click ‘Get Form’ button to access the 470 4708 Form digitally.
2. Begin by entering Medicare information in the designated fields, such as Medicare's ICN and Medicare payment date, ensuring to format the date as MM/DD/YY.
3. Provide the member information, including the member's name and Medicaid ID number, both of which are required fields. Optionally, you can include the patient account number.
4. Fill in the provider information, starting with the billing provider's NPI, name, and address. Each of these fields is essential to accurately identify the billing provider.
5. In the other health insurance information section, indicate if any additional insurance denied coverage and provide any amounts paid by other insurance if applicable.
6. Enter diagnosis codes. Ensure to accurately input the primary and any additional ICD-9-CM diagnosis codes as required.
7. Complete the service information, which includes entering covered days, type of bill, and the dates of service. Remember to use the dates provided in the Medicare Explanation of Benefits.
8. Review all filled-out fields for accuracy. Once you are confident that all information is correct, you can save changes, download, print, or share the completed form as needed.

Start filling out your documents online today for a hassle-free experience.