Iowa Administrative Code 441—79.3(249A) — Maintenance of Records by Providers of Service

What this rule requires your agency to do

• 1For home- and community-based waiver services other than case management, the record must include the Notice of Decision, service plan, service logs/notes, mileage/transportation logs, and the HCBS Attendant Care Agreement and Attendant Care Service Record (subrule 79.3(2)"d"(35)).(Iowa Administrative Code 441—79.3(249A) — Maintenance of Records by Providers of Service)
• 2The service record for each service must document the specific procedures performed; the complete date (and beginning/ending date if over multiple days); the complete time including beginning and ending time for time-based billing; location where required; medication administration; and the first and last name, professional credentials, and signature (or logged initials) of the person providing the service (subrule 79.3(2)"c"(3)).(Iowa Administrative Code 441—79.3(249A) — Maintenance of Records by Providers of Service)
• 3A provider of a service charged to Medicaid shall maintain complete and legible records as required in this rule; failure to maintain or timely produce records shall result in claim denial or recoupment (rule 441—79.3, opening paragraph).(Iowa Administrative Code 441—79.3(249A) — Maintenance of Records by Providers of Service)
• 4For 24-hour care, documentation must be maintained for every shift of the services provided (subrule 79.3(2)"c"(3)11).(Iowa Administrative Code 441—79.3(249A) — Maintenance of Records by Providers of Service)
• 5Home health agency services records must include the plan of care/treatment, certifications and recertifications, service notes, and physician/practitioner orders (subrule 79.3(2)"d"(27)).(Iowa Administrative Code 441—79.3(249A) — Maintenance of Records by Providers of Service)
• 6Each page or electronic document of the medical record shall contain the member's first and last name, and the record shall associate the Medicaid ID number and date of birth with that name (subrule 79.3(2)"c"(1)).(Iowa Administrative Code 441—79.3(249A) — Maintenance of Records by Providers of Service)
• 7Corrections must be made or authorized by the person who provided the service or has first-hand knowledge, must not obliterate the original entry, and must be dated and signed by the person making the change; if a post-submission correction affects claim accuracy, an amended claim must be submitted (subrule 79.3(2)"e").(Iowa Administrative Code 441—79.3(249A) — Maintenance of Records by Providers of Service)
• 8Providers shall maintain records during the time the member receives services and for a minimum of five years from the date the claim was submitted (subrule 79.3(3)).(Iowa Administrative Code 441—79.3(249A) — Maintenance of Records by Providers of Service)