Get Case Activity Report, Form 470-0042 - Iowa Department Of Human ... - Dhs Iowa

Completing the Case Activity Report, Form 470-0042, is essential for Medicaid applicants or members when they enter or leave a facility. This guide provides clear, step-by-step instructions for filling out this important document online.

Follow the steps to successfully complete and submit the Case Activity Report.

1. Press the ‘Get Form’ button to obtain the form and open it for editing.
2. Fill out section 1, Member Data. Include the individual's name, date they entered the facility, Social Security number, state ID, and case number. Make sure the state ID is entered in the correct format, consisting of seven digits followed by one letter.
3. Complete section 2, Facility Data. Enter the provider number or NPI number, select the type of facility from the options provided, and provide the facility name, DHS per diem, street address, city, state, and zip code. This section should also include your signature, date of completion, contact name, and contact phone number.
4. If applicable, fill out section 3, Level of Care. Indicate the level of care determined by the IME Medical Services Unit, Medicare, or a managed care contractor. If the individual is in a PMIC, specify whether it is for mental health or substance abuse, but skip this section for hospice patients.
5. In section 4, provide Medicare information if the patient is skilled or hospice. State whether you expect the stay to be covered by Medicare and list the expected dates of coverage.
6. Complete section 5 with discharge data if applicable. Include the date of discharge, reason for discharge, and relevant billing information such as total days in the facility.
7. Once all sections are completed, review your entries for accuracy. You may then save changes, download, print, or share the completed form.

Complete your documents online and ensure timely submissions.