General request for prior authorization of a non-preferred drug on the Iowa Medicaid Preferred Drug List.
- Completed by
- Prescriber
- Issued by
- Iowa Department of Health and Human Services (Iowa Medicaid pharmacy PA, Optum)
- Format
- Language
- English
Iowa Medicaid 470-4393: Level of Care for Facility
Iowa Medicaid requires form 470-4393 when a member is going to be admitted to a nursing facility or an intermediate care facility for persons with intellectual disabilities (ICF/ID), or when a resident has a significant change in condition. A medical professional checks skilled nursing needs and functional limitations. Iowa Medicaid's medical services unit makes the level-of-care determination when it receives the form.
Who completes it
An MD, DO, PA-C or ARNP completes pages 1 and 2, including skilled nursing needs, functional limitations and comments, and signs with their title. For ICF/ID admissions, the admitting facility or case manager completes page 3.
Submitting and payment
- How to submit it
- Fax the form to Iowa Medicaid and give a copy to the admitting facility. The completing professional or others arranging care, such as facility staff, discharge planners, case managers or family, may fax it.
- Who pays
- The form sets no fee for the medical professional; it supports Iowa Medicaid's facility level-of-care determination.
Good to know
- Attach the member's current medication list and diagnosis list with ICD codes separately; the form does not hold them.
- The form asks whether alternatives to facility placement were discussed, the date of that discussion and whether the stay is time-limited.
- Skilled needs include therapy 5 days a week, daily IV or IM medications, ventilator use 6 or more hours a day, tube feeding and stage 4 wound care.
- For ICF/ID, the psychological evaluation must be done before admission but no more than 3 months earlier. Swing beds use form 470-5156.
Get the official form
Download the current version from the source each time; forms change without notice.
Level of Care Certification for Facility
How this list is checked
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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Frequently asked questions
Who can complete Iowa form 470-4393?
A medical professional with an MD, DO, PA-C or ARNP credential must complete and sign the certification. Others may help with logistics: facility staff, a hospital discharge planner, a case manager or a family member can fax the completed form to Iowa Medicaid, and the ICF/ID section is completed by the facility or case manager.
When is a new 470-4393 needed in Iowa?
The instructions require the form when a Medicaid member is going to be admitted to a nursing facility or ICF/ID, and again when a member already living in one has a significant change in condition. Iowa Medicaid makes its level-of-care determination on receipt.