In the landscape of healthcare management and Medicaid services, the Health Home IMPA Access Request Form stands as a crucial document for health care providers. Designed to streamline the process of enrolling qualifying patients into Health Home programs, this form is a doorway for healthcare providers to access the Integrated Provider Management Architecture (IMPA). By submitting this form, providers, identified by their Taxpayer ID and National Provider Number, initiate a request to enroll patients into a coordinated care program. The form necessitates detailed contact information for the individual responsible for patient enrollment, ensuring a clear communication line between the healthcare provider and the Iowa Medicaid Enterprise. The completion and submission of this form, detailed for return by mail or fax, is a critical step in enabling healthcare staff to leverage IMPA for patient benefit. Upon review, the Iowa Medicaid Enterprise notifies the requester through email about the approval status, thereby encapsulating the process from initiation to confirmation. This mechanism underscores the importance of accurate and comprehensive completion of the IMPA Access Request Form for providers seeking to enhance care coordination under the Medicaid program.
| Question | Answer |
|---|---|
| Form Name | Impa Access Request Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | impa national iowa get, form impa, health home request, impa iowa |
Health Home IMPA Access Request Form
Please return this completed form to: Provider Services Unit, Iowa Medicaid Enterprise P.O. Box 36450 Des Moines, IA 50315 or fax to (515)
Health Home Information: (Enter the Taxpayer ID and National Provider Number enrolled with Medicaid as provider type 71)
1.Taxpayer ID:
2.National Provider Identifier:
Contact Information: (Enter the contact information for the staff person who will be responsible for patient enrollment into the Health Home)
Name:
Phone Number:
Email Address:
IMPA User Name:
The utilization of IMPA (referenced in Section 4 of the Health Home Provider Agreement) involves a resource (Health Home staff member) that will login and request Health Home enrollment of qualifying patients from the practice.
This form will be reviewed and approved or denied and an
Signature:
Date:
Questions in completing this form contact: Iowa Medicaid Enterprise Provider Services Unit at (800)