Fill a Valid Iowa 470 0040 Template
The Iowa 470 0040 form is an essential document for healthcare providers seeking to adjust previously submitted claims within the Iowa Medicaid system. This form facilitates the submission of adjustment requests, allowing providers to rectify errors or resubmit denied claims effectively. It requires specific information to ensure accurate processing, including the reason for the adjustment, which must be selected from a predefined list. Each request must be accompanied by the corrected claim or remittance advice, and it is crucial to avoid using red ink on the form. The document is divided into sections, with Section A focusing on the reasons for the adjustment and Section B collecting necessary identifying information such as the 17-digit Transaction Control Number (TCN), National Provider Identifier (NPI), and patient account number. Proper completion of the Iowa 470 0040 form is vital for maintaining compliance and ensuring timely reimbursement from the Iowa Medicaid Enterprise.
Iowa 470 0040 Preview
Adjustment Request
Return Requests to: Iowa Medicaid Enterprise PO Box 36450
Des Moines, IA 50315
Download this form @ http://www.ime.state.ia.us/Providers/Forms.html#DF
SECTION A: Reason for adjustment; please select at least one reason.
•A corrected claim and/or remittance advice (with changes, when applicable) must be attached with each request.
•Denied claims should be resubmitted
•Do not use red ink
Please select changes or corrections to be made: |
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Primary Insurance |
Dates of Service |
Medical Review Needed |
Patient Liability |
Diagnosis Code(s) |
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Medicare Adjustment (EOMB from Medicare must be attached) |
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Units |
Line Number(s) |
_______________ |
Billed Amount |
Line Number(s) ________________ |
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Procedure Code(s) |
Line Number(s) ________________ |
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Modifier(s) |
Line Number(s) ________________ |
|
Adding New Claim Detail |
Line Number(s) ________________ |
|
Please Specify the Reason for the Adjustment Request:
SECTION B: This section must be completed to process the request.
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• |
NPI Number: |
__________________ |
Taxonomy: |
_________________ Zip: ______ |
• |
State ID: |
______________ |
Patient Acct #: __________ |
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Signature: |
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Date: |
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Document Attributes
| Fact Name | Description |
|---|---|
| Form Purpose | The Iowa 470-0040 form is used to request adjustments to Medicaid claims. |
| Submission Address | Requests must be sent to Iowa Medicaid Enterprise, PO Box 36450, Des Moines, IA 50315. |
| Attachment Requirement | Each adjustment request must include a corrected claim or remittance advice when applicable. |
| Denied Claims | Denied claims should be resubmitted using this form. |
| Ink Color | Red ink should not be used on the form. |
| Adjustment Reasons | Applicants must select at least one reason for the adjustment in Section A. |
| Essential Information | Section B requires completion of critical details such as TCN, NPI Number, and Patient Account Number. |
| Form Revision Date | This version of the form was revised in August 2011 (Rev. 8/11). |
| Governing Law | The use of this form is governed by Iowa Medicaid regulations. |
| Download Link | The form can be downloaded from the Iowa Medicaid website at this link. |
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