Iowa Form 470 0040 PDF Details

Navigating the intricacies of Medicaid adjustments in Iowa can be a daunting task for providers, but understanding the Iowa 470 0040 form is essential for ensuring that claims are accurately processed and compensated. This form serves as a critical tool for healthcare providers who need to request adjustments on Medicaid claims. Common reasons for adjustments include correcting previously submitted claims, addressing denials, and updating patient liability or diagnosis codes, among others. It is imperative that the form is completed comprehensively, with a detailed explanation of the required adjustments, and that all relevant documents, such as a corrected claim or Medicare Explanation of Benefits (EOB), are attached. Additionally, the form necessitates specific identification numbers, including the 17-digit Transaction Control Number (TCN), National Provider Identifier (NPI), and the provider's taxonomy and state ID numbers. Each detail is crucial in processing the adjustment request promptly and accurately. By meticulously completing the Iowa 470 0040 form, healthcare providers can facilitate necessary corrections or updates, ensuring that they receive appropriate reimbursement for services rendered to Medicaid recipients. This demonstrates not just an exercise in administrative compliance but a vital step in sustaining vital healthcare delivery to the community's most vulnerable populations.

QuestionAnswer
Form NameIowa Form 470 0040
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesMoines, NPI, retracting, TCN

Form Preview Example

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:

 

Primary Insurance

Dates of Service

Medical Review Needed

Patient Liability

Diagnosis Code(s)

 

Medicare Adjustment (EOMB from Medicare must be attached)

Units

Line Number(s)

_______________

Billed Amount

Line Number(s) ________________

Procedure Code(s)

Line Number(s) ________________

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.

17-Digit TCN: _________________________

NPI Number:

__________________

Taxonomy:

_________________ Zip: ______

State ID:

______________

Patient Acct #: __________

 

 

 

 

Signature:

 

 

Date:

 

 

 

 

 

470-0040 (Rev. 8/11)

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