![]() ![]() Home- and Community-Based Services (HCBS) Brain Injury Waiver Emergency Need Assessment Integrated Health Homes (IHH) Managed Care Organizations (MCOs) Notification Medicaid/State Supplementary Assistance Reviewįamily Planning Program Provider AttestationĪttestation of Compliance with Section 6032 of The Federal Deficit Reduction Actģ40B, Federal Supply Schedule, and Nominal Price Attestation and ElectionĪuthorized Representative for Managed Care AppealsĬertificate of Medical Necessity for Health and Disability Waiver Cap IncreaseĬommunity-Based Neurobehavioral Rehabilitation Services (CNRS) 2018 Provider Quality Management Self-Assessment Iowa Medicaid Mileage Reimbursement Trip Log and Claim Form ![]() Wraparound Payment Request Access for the Iowa Medicaid Portal Access (IMPA) System Home- and Community-Based Services (HCBS) Cost Report Health Insurance Premium Payment (HIPP) Provider Invoice Iowa Medicaid Enterprise (IME) Inpatient Psychiatric Prior Authorization Home- and Community-Based Services (HCBS) Nonresidential Setting Assessment Home- and Community-Based Services (HCBS) Residential Setting Member Assessment Insurance Update Fee-for-Service (FFS) Members Intermediate Care Facilities for Individuals with an Intellectual Disability Calculation Worksheet Long Term Care (LTC) File Upload for the Iowa Medicaid Portal Access (IMPA) System Nursing Facility Supplementation Payment Report Iowa Medicaid Memorandum of Understanding (MOU) for Value Based Purchasing Support Activities Iowa Medicaid Enterprise (IME) Provider Enrollment Application Fee Hardship Exemption RequestĬore Standardized Assessment (CSA) Document Access Request for the Iowa Medicaid Portal Access (IMPA) System Qualified Entity (QE) Medicaid Presumptive Eligibility Portal (MPEP) Recertification Iowa Medicaid Health Home Provider Application Iowa Wellness Plan ACO Readiness ApplicationĬhronic Health Home Program Patient Tier Assignment Tool (PTAT) Version 3.0Ĭhronic Condition Health Home Program Patient Tier Assignment Tool (PTAT) Guide Iowa Medicaid Qualified Medicare Beneficiaries (QMB) or Health Insurance Premium Payment (HIPP) Program Provider Enrollment Application Iowa Medicaid Accountable Care Organization (ACO) Agreement Qualified Entity (QE) Medicaid Presumptive Eligibility Portal (MPEP) Access Request Formĭental Wellness Plan Wraparound Payment Request Medically Exempt Attestation and Referral FormĪpplication for Certification to become a Qualified Entity (QE) Iowa Wellness Plan Patient Manager AgreementĬlient Participation Notices Access Request Iowa Medicaid Integrated Health Home Provider Agreement General TermsĪpplication for Health Coverage and Help Paying Costs ![]() Level of Care Certification for Swing Bed Facility Money Follows the Person Referral Information Iowa Medicaid Ordering/Referring Provider Enrollment Application Home- and Community-Based Services (HCBS) Intellectual Disability Waiver Priority Need Assessment – Statewide Waiting List Iowa Medicaid Health Home Provider Agreement Iowa Medicaid Notice of Decision - Access2CareĬertificate of Medical Necessity for Waiver Assistive DevicesĬertificate of Medical Necessity for Consumer-Directed Attendant CareĬertificate of Medical Necessity for Environmental ModificationĬertificate of Medical Necessity for Home and Vehicle ModificationĬertificate of Medical Necessity for Prevocational Services Iowa Medicaid Nursing Facility Quality Assurance Assessment Iowa Medicaid Nursing Facility Enhanced Medicaid Payment Report Iowa Medicaid Provider Address Change Request FormĮarly Periodic Screening Diagnosis and Treatment (EPSDT) Medical Needs Acuity Scoring Tool (MNAST)Įarly Periodic Screening Diagnosis and Treatment (EPSDT) Functional Needs Acuity Scoring Tool (FNAST)Įarly Periodic Screening Diagnosis and Treatment (EPSDT) Social Needs Acuity Scoring Tool (SNAST) Money Follows the Person Consent to Proposed Transition Money Follows the Person Consent to Begin Transition Planning Money Follows the Person Guardian Consent to Participate in Transition Planning Request for Medicaid Services Data Changes and Verifications Iowa Medicaid Enterprise Ambulance Verification of Compliance Iowa Medicaid Managed Care Wraparound Payment Request Form Iowa Medicaid Addendum to Dental Provider Agreement for Orthodontia Iowa Medicaid Universal HCBS Waiver Provider Application ![]() Iowa Medicaid Universal Provider Enrollment Application ![]()
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