Remittance Advice Provider Access Request Form
Organization Information
TAX ID:
In some cases the Provider TAX ID is also their SSN.
BILLING NPI:
An NPI that has been verified with IME and is associated with the tax id provided. The NPI entered must match an NPI that has appeared on a remittance advice statement for this tax id. NPIs for treating-only providers who are connected to groups cannot be used to create an account for a local administrator.
TRANSACTION CONTROL NUMBER:
A transaction control number (TCN) from a PAID claim within the last eight weeks. The claim must be associated with the NPI entered above.
IMPA USERNAME:
Please enter the USERNAME that you created on the IMPA Portal: https://secureapp.dhs.state.ia.us/impa/
Contact Information Of Person Completing This Form
Full Name:
First Name
Last Name
Phone #:
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EMAIL:
I am the Remittance Advice Administrator. Associate all available billing NPIs for my TAX ID to my account.
Select this OPTION if you are the Provider Administrator for your TAD ID (Organization).
LISTS OF PAY-TO NPI'S ASSOCIATED WITH THIS ACCOUNT
The form will be reviewed and approved or denied and an e-mail will be sent as soon as the process is complete to the address listed on the form. This should take no more than 2 business days. Thank you.
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