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IAC 441—79.4(249A) — Reviews and audits

IowaregulationIowa Department of Health and Human Services· effective 2014-01-01

What this rule requires your agency to do

  • 1Any Medicaid provider may be audited or reviewed at any time, and authorized representatives of the department have the right, upon proper identification, to audit or review the provider's clinical and fiscal records (79.4(2) and "a").(IAC 441—79.4(249A) — Reviews and audits)
  • 2The department may require a provider to conduct a self-audit and report the results to the department (79.4(3)"f").(IAC 441—79.4(249A) — Reviews and audits)
  • 3Records not provided to the department during the review process under subrule 79.4(3) or 79.4(5) are inadmissible in any subsequent contested-case proceeding arising out of a finding and order for repayment (79.4(7)).(IAC 441—79.4(249A) — Reviews and audits)
  • 4The provider must cooperate with audit procedures, which may include comparing records with claims, interviews of members and employees, examining third-party payment records, and examining all documents related to the billed services (79.4(3)"d").(IAC 441—79.4(249A) — Reviews and audits)
  • 5In an on-site review or audit (announced with as little as one day's notice, or unannounced with no notice), records must be provided upon request and before the end of the on-site review or audit (79.4(3)"c").(IAC 441—79.4(249A) — Reviews and audits)
  • 6Upon a written request for records, the provider must submit all responsive records to the department or its authorized agent within 30 calendar days of the mailing date of the request, unless an extension of up to 15 days is granted for good cause requested before the due date (79.4(3)"a" and "b").(IAC 441—79.4(249A) — Reviews and audits)
  • 7The provider must have furnished the services to Medicaid members and must have retained clinical and fiscal records that substantiate claims submitted for payment, with goods or services provided in accordance with Iowa Medicaid policy (79.4(2)"a"(2),(3),(4)).(IAC 441—79.4(249A) — Reviews and audits)
  • 8To dispute sampling/extrapolation findings, the burden of proof of compliance rests with the provider, and any provider-arranged 100 percent audit must be paid for by the provider, conducted by a qualified expert or CPA, and submitted within 60 calendar days (79.4(5)"c").(IAC 441—79.4(249A) — Reviews and audits)

Applies to: personal care

Authorizes the department to audit or review any Medicaid provider's clinical and fiscal records at any time and sets the provider's obligations during audits: producing responsive records within 30 calendar days of a written request, cooperating with announced or unannounced on-site reviews, and preserving records that substantiate claims. Records not provided during the review process are inadmissible in later contested-case proceedings. National framework topic: Clinical Records / Provider Participation. Definitions of clinical and fiscal records cross-reference rule 441-79.3.

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