Appeals - Exceptions to Policy

An exception to policy request must be in writing. You can write a letter or complete a Petition for Exception to Policy form.

Petition for Exception to Policy form

Please answer all questions on this form and be specific. Complete the Petition for Exception form online.

Once the form is completely filled out, click the submit button at the bottom of the form. Your request will be sent directly to the Appeals Section.

If you have additional documentation that will help support your request, please mail, fax or email the information to the Appeals Section so it can be used when making a decision on your request.

If the request is medical in nature, please provide documentation to prove that the item or service is medically necessary. You will need to include the costs or proposed savings of the request.

Mail, fax or email the additional documentation to:

Department of Human Services

1305 E Walnut Street, 5th Floor

Des Moines, IA 50319

What information do I need to include in my exception to policy request?

If you choose not to use the Petition for Exception to Policy form and you want to request an exception to policy, write a letter with the following:

List the name, address, and Medicaid number (state ID number) of the person who needs the exception.

• Describe what the person needs.
• Explain why it is needed. If it is medical in nature, include the medical necessity of the item or service.
• Include the costs and/or proposed savings of the request.
• Tell what has been tried in the past with the person.

If a home health agency is requesting an exception to policy on behalf of a consumer, the following should be included, as well as the information listed above:

• Explain the services needed, including the hours requested and the level of care involved.
• Identify what other programs are involved with the consumer, such as waiver, in-home health-related care, etc.
• Describe the cost breakdown, salary, fringe benefits, and mileage of the person who is doing the care.
• Incorporate the plan of care or the plan of treatment.
• Include the past 30 days of care notes.

Exception to Policy Review

What criteria is used to decide if an exception to policy will be granted?

An exception to policy is granted when the item or service being requested would improve the quality of life of a consumer at no additional cost to the state, or when it would result in savings to the state.

The criteria used to decide if an exception to policy can be approved is:

• Is there an extreme need for an item or service?
• Are there exceptional circumstances that justify an exception to policy?
• Would an exception to policy result in net savings to the state?
• Have all other possible sources been exhausted?
• What is the cost to the state and are there funds in the Department's budget?

Who decides if an exception to policy will be granted?

An exception to policy is granted at the discretion of the Director of the Department of Health and Human Services.

What can I do if I disagree with an exception to policy recommendation?

If you disagree with an exception to policy recommendation, you can ask to have your request reconsidered. You may write a letter or complete the Petition for Exception to Policy form.

Petition for Exception to Policy form

Please answer all questions on this form and be sure to be specific. Complete the Petition for Exception form online.

Once the form is completely filled out, click the submit button at the bottom of the form. Your request will be sent directly to the Appeals Section.

If you have additional documentation that will help support your request, please mail, fax or e-mail the information to the Appeals Section so it can be used when making a decision on your request.

If the request is medical in nature, please provide documentation to prove that the item or service is medically necessary. You will need to include the costs or proposed savings of the request.

Mail, fax or email the additional documentation to:

Department of Human Services

Appeals Section
1305 E Walnut Street, 5th Floor
Des Moines, IA 50319
FAX: 515-564-4118

There are no appeal rights on an exception to policy request.