Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 79 - Other Policies Relating to Providers of Medical and Remedial Care › Rule 441-79.4 - Reviews and Audits

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Definitions.
"Authorized representative, "
within the
				  context of this rule, means the person appointed to carry out audit or review
				  procedures, including assigned auditors, reviewers or agents contracted for
				  specific audits, reviews, or audit or review procedures.
"Claim "
means each record received by the
				  department or the Iowa Medicaid enterprise that states the amount of requested
				  payment and the service rendered by a specific and particular Medicaid provider
				  to an eligible member.
"Clinical record"
means a legible electronic
				  or hard-copy history that documents the criteria established for medical
				  records as set forth in rule
				  441-79.3
				  (249A). A claim form or billing statement does not constitute a clinical
				  record.
"Confidence level"
means the statistical
				  reliability of the sampling parameters used to estimate the proportion of
				  payment errors (overpayment and underpayment) in the universe under
				  review.
"Customary and prevailing fee "
means a fee
				  that is both (1) the most consistent charge by a Medicaid provider for a given
				  service and (2) within the range of usual charges for a given service billed by
				  most providers with similar training and experience in the state of
				  Iowa.
"Extrapolation "
means that the total amount
				  of overpayment or underpayment will be determined by using sample data meeting
				  the confidence level requirement.
"Fiscal record"
means a legible electronic
				  or hard-copy history that documents the criteria established for fiscal records
				  as set forth in rule
				  441-79.3
				  (249A). A claim form or billing statement does not constitute a fiscal
				  record.
"Overpayment"
means any payment or portion
				  of a payment made to a provider that is incorrect according to the laws and
				  rules applicable to the Medicaid program and that results in a payment greater
				  than that to which the provider is entitled.
"Procedure code "
means the identifier that
				  describes medical or remedial services performed or the supplies, drugs, or
				  equipment provided.
"Random sample "
means a statistically valid
				  random sample for which the probability of selection for every item in the
				  universe is known.
"Underpayment"
means any payment or portion
				  of a payment not made to a provider for services delivered to eligible members
				  according to the laws and rules applicable to the Medicaid program and to which
				  the provider is entitled.
"Universe "
means all items or claims under
				  review or audit during the period specified by the audit or review.
(2)
Audit or review of clinical and
				fiscal records by the department.
Any Medicaid provider may be audited
				or reviewed at any time at the discretion of the department.
a. Authorized representatives of the
				department shall have the right, upon proper identification, to audit or review
				the clinical and fiscal records to determine whether:
(1) The department has correctly paid claims
				for goods or services.
(2) The
				provider has furnished the services to Medicaid members.
(3) The provider has retained clinical and
				fiscal records that substantiate claims submitted for payment.
(4) The goods or services provided were in
				accordance with Iowa Medicaid policy.