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  • Provider Inquiry Claim Form 470 3744

Get Provider Inquiry Claim Form 470 3744

Iowa Department of Human Services Iowa Medicaid Program PROVIDER INQUIRY Please check the type of inquiry below Inquiry about payment or medical determination of a specific claim TCN below General Issue regarding Medicaid policy an example TCN may be reference below Attach supporting documentation. Check applicable boxes Claim form Remittance copy Other pertinent information for possible claim reprocessing 1. 17-DIGIT TCN Required if about a spec.

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Form 470-5526 shall be completed by the Medicaid member or their parent, if the member is a minor. The member and the authorized representative must both sign the form. Once completed, the form should be submitted to the Medicaid member's MCO, if for a managed care appeal, or to HHS, if for a state fair hearing.

2010BB NM109 Payer Identifier The payer primary identifier is '18049'.

You must file for an appeal within 60 calendar days from the time you get the Notice of Adverse Determination. 515-327-7012 (TTY 711). Amerigroup Iowa, Inc.

You also may call the Appeals Section at (515) 281-3094 or send us an email at appeals@dhs.state.ia.us if you have questions. We accept collect phone calls.

Medically Exempt Individuals: Individuals with disabling mental disorders, chronic substance use disorders, serious and complex medical conditions, physical, intellectual or developmental disability that significantly impairs their ability to perform 1 or more activities of daily living, or a disability determination.

To request an appeal or grievance: Call Member Services at 1-833-404-1061 (TTY: 711). Send it electronically by fax to 1-833-809-3868. Email AppealsGrievances@IowaTotalCare.com.

Generally, a person wanting to contest a judgment or order must file a notice of appeal with the clerk of court in the county where the judgment or order was entered. There is a limited time to appeal, and there are different periods of time to appeal depending on the type of case.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232