470 2486 is the code used to bill for targeted medical care. This type of care is used to improve patient outcomes by focusing on specific needs identified by a physician. In order to receive reimbursement for this type of service, you will need to submit a targeted medical care claim form. The process for submitting and billing for this type of care can be complicated, so it is important to understand the requirements before you begin treatment. Our experts are available to help you every step of the way.
| 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 |
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)
1
2
PROVIDER INFORMATION:
NPI PROVIDER NUMBER:
PROVIDER ADDRESS:
(STREET, CITY, STATE)
3
5
NAME:
4
ZIP CODE:
6
TAXONOMY CODE:
7
8 OTHER INSURANCE: |
ο YES |
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9 OTHER INSURANCE DENIED: |
ο YES |
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(IF NO, LEAVE BLANK) |
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(IF NO, LEAVE BLANK) |
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10 SERVICES: |
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A. |
B. |
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C. |
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F. |
PROCEDURE CODE |
* PLACE OF |
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FIRST DATE |
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LAST DATE |
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UNITS |
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TOTAL LINE CHARGE |
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SERVICE |
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MM/DD/YY |
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TOTAL CLAIM CHARGES: |
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11 |
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CLIENT PARTICIPATION AMOUNT: |
12 |
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THIRD PARTY PAYMENT: |
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13 |
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(IF NONE, LEAVE BLANK) |
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(IF NONE, LEAVE BLANK) |
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* PLACE OF SERVICE (REFER TO CODES ON BACK) |
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AUTHORIZED SIGNATURE(S): |
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I CERTIFY THAT THE STATEMENTS ON THE BACK |
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FOR |
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APPLY TO THIS BILL AND ARE MADE A PART OF IT. |
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PROVIDER SIGNATURE |
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DATE |
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MEMBER/GUARDIAN SIGNATURE |
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DATE |
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White: Iowa Medicaid Enterprise |
Yellow: Provider |
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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.
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PLACE OF SERVICE CODES |
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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 |
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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