470 2486 Targeted Medical Care Claim Form – Fill Out and Use This PDF

The 470 2486 Targeted Medical Care Claim form is a crucial document facilitated by the Iowa Department of Human Services for medical providers aiming to claim payment for targeted medical care services rendered. This comprehensive form requires detailed input regarding member and provider information, the services provided, alongside pertinent insurance details to ensure accurate processing and compliance with Medicaid regulations. For professionals looking to submit their claims efficiently, completing and submitting this form accurately is imperative to facilitate timely reimbursements.

Ensure the accuracy and completeness of your submitted claims by clicking the button below to fill out the form.

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470 2486 Targeted Medical Care Claim Form PDF Details

The 470 2486 Targeted Medical Care Claim form, provided by the Iowa Department of Human Services, serves as a critical tool for healthcare providers seeking reimbursement for medical services rendered to members under the Iowa Medicaid Program. This document is designed with sections dedicated to capturing essential information including member identification, provider details, service specifics such as procedure codes, and financial aspects like total claim charges and third-party payments. Key to ensuring accurate processing, the form mandates the use of blue or black ink if filled out by hand, emphasizing the importance of precision in its completion. It also addresses the possibility of other insurance, necessitating providers to indicate whether another insurer has denied payment before Medicaid is billed. The completion of this form entails a certification by the provider, agreeing to adhere to various regulatory requirements, including maintaining necessary records, furnishing requested information, accepting Medicaid payments as full settlement (subject to certain conditions), and compliance with civil rights legislation. Furthermore, the form includes a section for documenting consumer-directed attendant care claims, enhancing its utility for a broader range of service types. Accessible online, this form is pivotal for the seamless operation of targeted medical care claims within Iowa, ensuring providers can efficiently claim payments while adhering to stipulated guidelines and legal responsibilities.

Question	Answer
Form Name	470 2486 Targeted Medical Care Claim Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	cdac claim form 470 2486, form 470 2486, claims from 470 2486, iowa dhs form 470 2486

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Iowa Department of Human Services

CLAIM FOR TARGETED MEDICAL CARE

(If handwritten, use blue or black ink only. Accuracy is important.)

This form may be downloaded at http://www.ime.state.ia.us/Providers/index.html

MEMBER INFORMATION:

STATE ID:

MEMBER’S NAME:

(LAST, FIRST, MI)

PROVIDER INFORMATION:

NPI PROVIDER NUMBER:

PROVIDER ADDRESS:

(STREET, CITY, STATE)

NAME:

ZIP CODE:

TAXONOMY CODE:

8 OTHER INSURANCE:

ο YES

9 OTHER INSURANCE DENIED:

ο YES

(IF NO, LEAVE BLANK)

10 SERVICES:

PROCEDURE CODE

* PLACE OF

FIRST DATE

LAST DATE

UNITS

TOTAL LINE CHARGE

SERVICE

MM/DD/YY

TOTAL CLAIM CHARGES:

CLIENT PARTICIPATION AMOUNT:

THIRD PARTY PAYMENT:

(IF NONE, LEAVE BLANK)

* PLACE OF SERVICE (REFER TO CODES ON BACK)

AUTHORIZED SIGNATURE(S):

I CERTIFY THAT THE STATEMENTS ON THE BACK

FOR CONSUMER-DIRECTED ATTENDANT CARE CLAIMS ONLY:

APPLY TO THIS BILL AND ARE MADE A PART OF IT.

PROVIDER SIGNATURE

DATE

MEMBER/GUARDIAN SIGNATURE

DATE

470-2486 (Rev. 7/08)

White: Iowa Medicaid Enterprise

Yellow: Provider

MEDICAID PAYMENTS

(PROVIDER CERTIFICATION)

I hereby agree:

♦To keep such records as are necessary to disclose fully the extent of services provided to individuals under the Iowa Medicaid Program, as specified in the Provider Manual and the Iowa Administrative Code.

♦To furnish records and other information regarding any payments claimed for providing such services as the Iowa Department of Human Services, its designee or Health and Human Services may request.

♦To accept, as payment in full, subject to audit, the amount paid by the Medicaid program for those claims submitted for payment under that program, with the exception of authorized deductibles, coinsurance, copayment, and spenddown.

♦To comply with the provisions of the Civil Rights Act of 1964 and Section 504 of the Rehabilitation Act of 1973.

I certify that:

♦The services shown on the front of this form were rendered to the consumer and were medically indicated and necessary for the health of the patient.

♦The charges for these services are just, unpaid, actually due according to law and program policy and not in excess of regular fees.

♦The information provided on the front of this claim is true, accurate, and complete.

I understand that any false claims, statements, or documents, or concealment of a material fact, may be prosecuted under applicable Federal or State laws.

		PLACE OF SERVICE CODES
11	Office	51	Inpatient psychiatric facility
12	Home	53	Community mental health center
21	Inpatient hospital	54	Intermediate care facility/MR
22	Outpatient hospital	55	Residential substance abuse treatment facility
23	ER room hospital	56	Residential psychiatric treatment facility
24	Ambulatory surgical center	61	Comp inpatient rehab facility
31	Skilled nursing facility	62	Comp outpatient rehab facility
32	Nursing facility	71	Public health clinic
33	Custodial care facility	99	Other
34	Hospice

Complete claim form instructions and a printable version of this form are available on our website: http://www.ime.state.ia.us/Providers/index.html

470-2486 (Rev. 7/08)

470 2486 Targeted Medical Care Claim Form – Fill Out and Use This PDF

470 2486 Targeted Medical Care Claim Form PDF Details

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