Follow the steps to complete your claim accurately.

1. Click the ‘Get Form’ button to download the Claim For Targeted Medical Care form and open it in your preferred editor.
2. Begin by entering the member's Medicaid ID number in the designated field. This number can be found on the Iowa Medicaid Eligibility Card and should consist of seven digits followed by a letter (for example, 1234567A).
3. Next, enter the member's full name, including their last name, first name, and middle initial.
4. Provide the NPI (National Provider Identifier) of the healthcare provider in the corresponding field.
5. Fill in the provider's name as it appears on official documents.
6. Enter the complete address of the provider including street, city, and state.
7. Input the zip code that corresponds to the provider's address.
8. Indicate whether the member has other health insurance that covers the services billed by selecting 'yes' or 'no'.
9. If applicable, specify whether the other health insurance has denied payment by checking the appropriate option.
10. If there has been a payment made by other insurance, enter the total amount received. Remember to format the amount to include both dollars and cents (for example, $150.00).
11. If the member owes a contribution, indicate the total client participation amount in the designated field, also formatted with dollars and cents.
12. In the procedure code section, enter the five-digit code for each service being billed.
13. Complete the modifier section if necessary, though it should be left blank for services prior to July 1, 2012.
14. Enter the place of service code corresponding to where the service was delivered.
15. Record the first date that services were rendered in the format MM/DD/YY.
16. Input the last date of service using the same MM/DD/YY format.
17. Enter the total number of units for each service, using whole numbers only.
18. Fill in the total line charge for each service billed, ensuring both dollars and cents are included.
19. On the final page, sum up the total charges for the claim and include this in the total claim charges section.
20. Ensure the provider signs and dates the form. If services were provided through Consumer Directed Attended Care, the member or their guardian must also sign.
21. Once you have completed all the fields accurately, save changes, and choose whether to download, print, or share the form as needed.

Complete your documents online today for a smooth claims process.