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Iowa Medicaid 470-5595 Outpatient Prior Authorization

Iowa uses one outpatient prior authorization form, 470-5595, for Medicaid fee-for-service and all three managed care plans: Iowa Total Care, Wellpoint and Molina Healthcare. Ordering and servicing providers meet it whenever an outpatient service, procedure or extra units need approval. It carries diagnosis and procedure codes, dates, units and place of service, and plans decide standard requests within 7 calendar days and urgent ones within 72 hours.

Who completes it

The requesting provider completes the member, requesting provider, servicing provider and authorization sections and checks the member's plan. The supplemental page holds provider addresses and any additional diagnosis and procedure codes.

Submitting and payment

How to submit it
Fax the form with supporting clinical information to the member's plan, using the plan fax numbers and portal links on page 3, or the fee-for-service fax for members not in a managed care plan. Incomplete forms are rejected.
Who pays
An authorization is not a guarantee of payment: the member must be eligible when services are rendered, and the service must be a covered, medically necessary benefit.

Good to know

  • Mark Standard or Urgent on an initial request. Urgent is for conditions that could seriously jeopardize the member's life, health or ability to regain maximum function, and is decided within 72 hours (42 CFR 438.210).
  • To add units to an existing authorization, use the request-for-additional-units box and give the existing authorization and units.
  • Each line needs a CPT or HCPCS code with modifier, start and end dates, total units, visits or days, and a place of service code; the primary diagnosis must be an ICD-10 code.
  • Inpatient admissions use the companion form 470-5594, Inpatient Medicaid Prior Authorization, rather than this outpatient form.

Get the official form

Download the current version from the source each time; forms change without notice.

Outpatient Medicaid Prior Authorization Form

Official pagePDF

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.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

Can I use Iowa form 470-5595 for Iowa Total Care, Wellpoint and Molina members?

Yes. The 470-5595 is the state's common outpatient form, with checkboxes for Iowa Total Care, Wellpoint, Molina Healthcare and fee-for-service. Page 3 lists each plan's utilization management fax numbers and portals, so the request goes to the plan the member is enrolled in.

How long does an Iowa Medicaid outpatient prior authorization take?

The form states that standard requests are decided within 7 calendar days of receiving all necessary information, and urgent requests within 72 hours, citing 42 CFR 438.210. Missing clinical information can delay the decision, and a form with empty required fields is rejected.