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IAC 441—79.2(249A) — Sanctions

IowaregulationIowa Department of Health and Human Services· effective 2020-04-15

What this rule requires your agency to do

  • 1A person who has identified an overpayment (actual knowledge, reckless disregard, or deliberate ignorance) must report and return it in writing to the Program Integrity Unit of the Iowa Medicaid Enterprise with all specified elements and a refund in the amount of the overpayment (79.2(10)).(IAC 441—79.2(249A) — Sanctions)
  • 2Upon lawful demand, a provider must disclose or make available to the department, its agents, law enforcement, the Medicaid fraud control unit, and other authorized agencies its records of services provided to Medicaid members and payments made (79.2(2)"d").(IAC 441—79.2(249A) — Sanctions)
  • 3Providers must meet standards required by state or federal law for participation, including licensure, and must not engage in conduct violating any statute, rule, or contract relating to a health care program (79.2(2)"f," "m").(IAC 441—79.2(249A) — Sanctions)
  • 4Providers must not negligently, recklessly, or intentionally endanger the health, welfare, or safety of a person (79.2(2)"v").(IAC 441—79.2(249A) — Sanctions)
  • 5Providers must correct deficiencies in provider operations after receiving notice, and must submit any required self-assessment, corrective action plan, or overpayment repayment in a timely manner (79.2(2)"p," "x").(IAC 441—79.2(249A) — Sanctions)
  • 6Providers must provide and maintain quality services within accepted medical community standards, meaning services provided in accordance with the applicable rules and regulations governing the services (79.2(2)"e").(IAC 441—79.2(249A) — Sanctions)
  • 7Providers must not present, or cause to be presented, any false, intentionally misleading, or fraudulent claim for services or merchandise, or submit false information to obtain greater compensation or to meet prior authorization or level-of-care requirements (grounds 79.2(2)"a," "b," "c").(IAC 441—79.2(249A) — Sanctions)
  • 8Providers must not bill for services provided by an excluded, nonenrolled, terminated, suspended, or otherwise ineligible provider or person (79.2(2)"w").(IAC 441—79.2(249A) — Sanctions)

Applies to: personal care

Establishes the grounds for and types of sanctions the department may impose on Medicaid providers, including for failing to provide or maintain quality services within accepted community standards, endangering member health/welfare/safety, failing to correct deficiencies, and billing for services of excluded providers. Also imposes an affirmative duty on any person who has identified an overpayment to report and return it to the Program Integrity Unit in the specified form. National framework topic: Provider Participation / Quality of Care.

Regulatory information, not legal advice — always confirm against the cited official source. Verification reduces error; it does not certify compliance.