reglab/statecodes huggingface dataset:
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 441-79.9 - General Provisions for Medicaid Coverage Applicable to All Medicaid Providers and Services

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
				Medicare definitions and policies shall apply to services provided unless
				specifically defined differently.
(2) The services covered by Medicaid shall:
a. Be consistent with the diagnosis and
				treatment of the patient's condition.
b. Be in accordance with standards of good
				medical practice.
c. Be required to
				meet the medical need of the patient and be for reasons other than the
				convenience of the patient or the patient's practitioner or caregiver.
d. Be the least costly type of
				service which would reasonably meet the medical need of the patient.
e. Be eligible for federal financial
				participation unless specifically covered by state law or rule.
f. Be within the scope of the licensure of
				the provider.
g. Be provided with
				the full knowledge and consent of the recipient or someone acting in the
				recipient's behalf unless otherwise required by law or court order or in
				emergency situations.
h. Be
				supplied by a provider who is eligible to participate in the Medicaid program.
				The provider must use the billing procedures and documentation requirements
				described in 441-Chapters 78 and 80.
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 441-79.10 - Requests for Preadmission Review

Current through Register Vol. 47, No. 3, July 24, 2024
The inpatient hospitalization of Medicaid recipients is
				  subject to preadmission review by the Iowa Medicaid enterprise (IME) medical
				  services unit as required in rule
				  441-78.3
				  (249A).
(1) The patient's admitting
				physician, the physician's designee, or the hospital will contact the IME
				medical services unit to request approval of Medicaid coverage for the
				hospitalization, according to instructions issued to providers by the IME
				medical services unit and instructions in the Medicaid provider
				manual.
(2) Medicaid payment will
				not be made to the hospital if the IME medical services unit denies the
				procedure requested in the preadmission review.
(3) The IME medical services unit shall issue
				a letter of denial to the patient, the physician, and the hospital when a
				request is denied. The patient, the physician, or the hospital may request a
				reconsideration of the decision by filing a written request with the IME
				medical services unit within 60 days of the date of the denial
				letter.
(4) The aggrieved party may
				appeal a denial of a request for reconsideration by the IME medical services
				unit according to 441-Chapter 7.
(5) The requirement to obtain preadmission
				review is waived when the patient is enrolled in the managed health care option
				known as patient management and proper authorization for the admission has been
				obtained from the patient manager as described in 441-Chapter 73.
This rule is intended to implement Iowa Code section
				  249A.4.
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 441-79.11 - Requests for Preprocedure Surgical Review

Current through Register Vol. 47, No. 3, July 24, 2024
The Iowa Medicaid enterprise (IME) medical services unit
				  conducts a preprocedure review of certain frequently performed surgical
				  procedures to determine the necessity of the procedures and if Medicaid payment
				  will be approved according to requirements found in 441-subrules 78.1(19),
				  78.3(18), and 78.26(3).
(1) The
				physician must request approval from the IME medical services unit when the
				physician expects to perform a surgical procedure appearing on the department's
				preprocedure surgical review list published in the Medicaid provider manual.
				All requests for preprocedure surgical review shall be made according to
				instructions issued to physicians, hospitals and ambulatory surgical centers
				appearing in the Medicaid provider manual and instructions issued to providers
				by the IME medical services unit.
(2) The IME medical services unit shall issue
				the physician a validation number for each request and shall advise whether
				payment for the procedure will be approved or denied.
(3) Medicaid payment will not be made to the
				physician and other medical personnel or the facility in which the procedure is
				performed, i.e., hospital or ambulatory surgical center, if the IME medical
				services unit does not give approval.
(4) The IME medical services unit shall issue
				a denial letter to the patient, the physician, and the facility when the
				requested procedure is not approved. The patient, the physician, or the
				facility may request a reconsideration of the decision by filing a written
				request with the IME medical services unit within 60 days of the date of the
				denial letter.
(5) The aggrieved
				party may appeal a denial of a request for reconsideration by the IME medical
				services unit in accordance with 441-Chapter 7.
(6) The requirement to obtain preprocedure
				surgical review is waived when the patient is enrolled in the managed health
				care option known as patient management and proper authorization for the
				procedure has been obtained from the patient manager as described in
				441-Chapter 73.
This rule is intended to implement Iowa Code section
				  249A.4.
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 441-79.12 - Advance Directives

Current through Register Vol. 47, No. 3, July 24, 2024
"Advance directive" means a written instruction, such as a
				  living will or durable power of attorney for health care, recognized under
				  state law and related to the provision of health care when the person is
				  incapacitated. All hospitals, home health agencies, home health providers of
				  waiver services, hospice programs, and health maintenance organizations (HMOs)
				  participating in Medicaid shall establish policies and procedures with respect
				  to all adults receiving medical care through the provider or organization to
				  comply with state law regarding advance directives as follows:
(1) A hospital at the time of a person's
				admission as an inpatient, a home health care provider in advance of a person's
				coming under the care of the provider, a hospice provider at the time of
				initial receipt of hospice care by a person, and a health maintenance
				organization at the time of enrollment of the person with the organization
				shall provide written information to each adult which explains the person's
				rights under state law to make decisions concerning medical care, including the
				right to accept or refuse medical or surgical treatment and the right to
				formulate advance directives, and the provider's policies regarding the
				implementation of these rights.
(2)
				The provider or organization shall document in the person's medical record
				whether or not the person has executed an advance directive.
(3) The provider or organization shall not
				condition the provision of care or otherwise discriminate against a person
				based on whether or not the person has executed an advance directive.
(4) The provider or organization shall ensure
				compliance with requirements of state law regarding advance
				directives.
(5) The provider or
				organization shall provide for education for staff and the community on issues
				concerning advance directives.
Nothing in this rule shall be construed to prohibit the
				  application of a state law which allows for an objection on the basis of
				  conscience for any provider or organization which as a matter of conscience
				  cannot implement an advance directive.
This rule is intended to implement Iowa Code section
				  249A.4.
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 441-79.13 - Requirements for Enrolled Medicaid Providers Supplying Laboratory Services

Current through Register Vol. 47, No. 3, July 24, 2024
Medicaid enrolled entities providing laboratory services are
				  subject to the provisions of the Clinical Laboratory Improvement Amendments of
				  1988 (CLIA), Public Law 100-578, and implementing federal regulations published
				  at 42 CFR Part 493 as amended to December 29, 2000. Medicaid payment shall not
				  be afforded for services provided by an enrolled Medicaid provider supplying
				  laboratory services that fails to meet these requirements. For the purposes of
				  this rule, laboratory services are defined as services to examine human
				  specimens for the diagnosis, prevention or treatment of any disease or
				  impairment of, or assessment of, the health of human beings. This rule is
				  intended to implement Iowa Code section
				  249A.4.
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 441-79.14 - Provider Enrollment

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
				Application request. Iowa Medicaid providers, including those enrolled with a
				managed care organization, shall begin the enrollment process by completing the
				appropriate application on the Iowa Medicaid enterprise website. Managed care
				organizations and fiscal agents are exempt from completing an application.
a. Providers of home- and community-based
				waiver services shall submit Form 470-2917, Medicaid HCBS Provider Application,
				at least 90 days before the planned service implementation date.
b. Providers enrolling as ordering or
				referring providers shall submit Form 470-5111, Iowa Medicaid
				Ordering/Referring Provider Enrollment Application.
c. All other providers shall submit Form
				470-0254, Iowa Medicaid Provider Enrollment Application.
d. A nursing facility shall also complete the
				process set forth in 441-subrule 81.13(1).
e. An intermediate care facility for persons
				with an intellectual disability shall also complete the process set forth in
				441-subrule 82.3(1).
f. Qualified
				Medicare beneficiary (QMB) providers shall enroll using Form 470-5262,
				Qualified Medicare Beneficiaries (QMB) or Health Insurance Premium Payment
				(HIPP) Program Provider Enrollment Application.
g. Health insurance premium payment (HIPP)
				providers shall enroll using Form 470-5262, Qualified Medicare Beneficiaries
				(QMB) or Health Insurance Premium Payment (HIPP) Program Provider Enrollment
				Application.
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 441-79.15 - Education About False Claims Recovery

Current through Register Vol. 47, No. 3, July 24, 2024
The provisions in this rule apply to any entity that has
				  received medical assistance payments totaling at least $5 million during a
				  federal fiscal year (ending on September 30). For entities whose payments reach
				  this threshold, compliance with this rule is a condition of receiving payments
				  under the medical assistance program during the following calendar year
(1)
Policy requirements.
Any
				entity whose medical assistance payments meet the threshold shall:
a. Establish written policies for all
				employees of the entity and for all employees of any contractor or agent of the
				entity, including management, which provide detailed information about:
(1) The False Claims Act established under
				Title 31, United States Code, Sections 3729 through 3733;
(2) Administrative remedies for false claims
				and statements established under Title 31, United States Code, Chapter
				38;
(3) Any state laws pertaining
				to civil or criminal penalties for false claims and statements;
(4) Whistle blower protections under the laws
				described in subparagraphs (1) to (3) with respect to the role of these laws in
				preventing and detecting fraud, waste, and abuse in federal health care
				programs, as defined in Title 42, United States Code, Section 1320a-7b(f);
				and
(5) The entity's policies and
				procedures for detecting and preventing fraud, waste, and abuse.
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 441-79.16 - Electronic Health Record Incentive Program

Current through Register Vol. 47, No. 3, July 24, 2024
The department has elected to participate in the electronic
				  health record (EHR) incentive program authorized under Section 4201 of the
				  American Recovery and Reinvestment Act of 2009 (ARRA), Public Law No. 111-5.
				  The electronic health record incentive program provides incentive payments to
				  eligible hospitals and professionals participating in the Iowa Medicaid program
				  that adopt and successfully demonstrate meaningful use of certified electronic
				  health record technology.
(1)
State elections.
In addition to the statutory provisions in
				ARRA Section 4201, the electronic health record incentive program is governed
				by federal regulations at 42 CFR Part 495 as amended to September 4, 2012. In
				compliance with the requirements of federal law, the department establishes the
				following state options under the Iowa electronic health record incentive
				program:
a. For purposes of the term
				"hospital-based eligible professional (EP)" as set forth in 42 CFR Section
				495.4 as
				amended to September 4, 2012, the department elects the calendar year preceding
				the payment year as the period used to gather data to determine whether or not
				an eligible professional is "hospital-based" for purposes of the
				regulation.
b. For purposes of
				calculating patient volume as required by 42 CFR Section 495.306 as amended to
				September 4, 2012, the department has elected that eligible providers may use
				either:
(1) The patient encounter methodology
				found in 42 CFR Section 495.306(c) as amended to September 4, 2012,
				or
(2) The patient panel
				methodology found in 42 CFR Section 495.306(d) as amended to September 4,
				2012.
c. For purposes of
				42 CFR Section 495.310(g)(1)(i)(B) as amended to September 4, 2012, the
				"12-month period selected by the state" shall mean the hospital fiscal
				year.
d. For purposes of 42 CFR
				Section 495.310(g)(2)(f) as amended to September 4, 2012, the "12-month period
				selected by the state" shall mean the hospital fiscal year.
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 441-79.17 - Requirements for Prescribing Controlled Substances

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Review of Iowa prescription
				monitoring program database.
A prescribing practitioner, as defined in
				Iowa Code section
				124.550, or the
				prescribing practitioner's designated agent, shall review patient information
				in the Iowa prescription monitoring program (PMP) database prior to issuing a
				prescription for a controlled substance as defined in
				42
				U.S.C. 1396w-3a, inclusive of Schedules II,
				III and IV, unless the patient is receiving inpatient hospice care or long-term
				residential facility care. Review shall be conducted in accordance with all
				requirements under the prescribing practitioner's specific professional
				licensing authority.
(2)
Documentation.
The prescribing practitioner shall include
				documentation in the patient file to demonstrate compliance with subrule
				79.17(1). Subject to the requirements under Iowa Code chapter 124, subchapter
				VI, if the prescribing practitioner is not able to conduct a review of the PMP
				database despite a good-faith effort, the prescribing practitioner must
				document in the patient file such good-faith effort, including the reasons why
				the prescribing practitioner was not able to conduct the review. The
				prescribing practitioner shall submit such documentation to the Iowa Medicaid
				program upon request.
This rule is intended to implement Iowa Code chapters 124 and
				  249A.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 80 - Procedure and Method of Payment › Rule 441-80.2 - Submission of Claims

Current through Register Vol. 47, No. 3, July 24, 2024
Providers of medical and remedial care participating in the
				  program shall submit claims for services rendered to the Iowa Medicaid
				  enterprise on at least a monthly basis. All nursing facilities and providers of
				  home- and community-based services shall submit claims for services after the
				  end of the calendar month in which the services are provided. Following audit
				  of the claim, Iowa Medicaid will make payment to the provider of care.
(1) Electronic submission. Providers are
				required to submit claims electronically whenever possible.
a. When filing electronic claims, pharmacies
				shall use the format prescribed by the National Council for Prescription Drug
				Programs.
b. Claims submitted
				electronically shall be filed on the American National Standards Institute
				(ANSI) Accredited Standards Committee (ASC) X12N 837 transaction, Health Care
				Claim.
(1) Providers listed as filing claims
				on Form CMS-1500 or on the Claim for Targeted Medical Care shall file claims on
				the professional version of the 837 Health Care Claim.
(2) Providers listed as filing claims on Form
				CMS-1450 or UB04 shall file the institutional version of the 837 Health Care
				Claim.
(3) Dentists shall file the
				dental version of the 837 Health Care Claim.
(4) Pharmacists providing drugs and
				injections shall use the format prescribed by the National Council for
				Prescription Drug Programs.
c. If a claim submitted electronically
				requires attachments or supporting clinical documentation and a national
				electronic attachment has not been adopted, the provider shall:
(1) Use the Iowa Medicaid portal access
				(IMPA) system to submit supporting documents when billing Medicaid fee for
				service claims; and
(2) Reference
				the attachment control number submitted on the ASC X12N 837 electronic
				transaction.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 80 - Procedure and Method of Payment › Rule 441-80.3 - Payment From Other Sources

Current through Register Vol. 47, No. 3, July 24, 2024
This rule applies to claims for the department, managed care
				  organizations, and the Public Health Associate Program (PHAP).
(1)
Payments deducted.
The
				amount of any payment made directly to the provider of care by the recipient,
				relatives, or any source shall be deducted from the established cost standard
				for the service provided to establish the amount of payment to be made by Iowa
				Medicaid.
(2)
Third-party
				liability.
a. When a third-party
				liability for medical expenses exists, this resource shall be utilized for
				payment of a claim before the Medicaid program makes payment unless:
(1) The department pays the total amount
				allowed under the Medicaid payment schedule and then seeks reimbursement from
				the liable third party. This "pay and chase" provision applies to claims for:
1. Preventive pediatric services,
				and
2. All services provided to a
				person for whom there is court-ordered medical support.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 80 - Procedure and Method of Payment › Rule 441-80.4 - Time Limit for Submission of Claims and Claim Adjustments

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Submission of claims.
Payment will not be made on any claim
				when the amount of time that has elapsed between the date the service was
				rendered and the date the initial claim is received by Iowa Medicaid exceeds
				365 days. The department shall consider claims submitted beyond the 365-day
				limit for payment only if retroactive eligibility on newly approved cases is
				made that exceeds 365 days or if attempts to collect from a third-party payer
				delay the submission of a claim. In the case of retroactive eligibility, the
				claim must be received within 365 days of the first notice of eligibility by
				the department.
(2)
Claim
				adjustments and resubmissions.
A provider's request for an adjustment
				to a paid claim or resubmission of a denied claim must be received by Iowa
				Medicaid within 365 days from the date the claim was last adjudicated in order
				to have the adjustment or resubmission considered. In no case will a claim be
				paid if the claim is received beyond two years from the date of
				service.
(3)
Definition.
For purposes of this rule, a claim is "received"
				when entered into the department's payment system with an action of pay, deny,
				or suspend. Any claim returned to the provider without such action is not
				"received."
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 80 - Procedure and Method of Payment › Rule 441-80.5 - Authorization Process

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Identification cards.
The department shall issue a Medical
				Assistance Eligibility Card to members for use in securing medical and health
				services available under the program except as provided in 441-Chapter 76.
a. The department shall issue the Medical
				Assistance Eligibility Card:
(1) When the
				member's eligibility is initially determined.
(2) Upon the member's request for replacement
				of a lost, stolen, or damaged card.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 80 - Procedure and Method of Payment › Rule 441-80.6 - Payment to Provider-exception

Current through Register Vol. 47, No. 3, July 24, 2024
Payments for medical services may be made only to the
				  provider of the services except as provided below:
(1)
Medical assistance corrective
				payments.
Payment may be made to the client or county relief agency in
				accordance with 441-Chapter 75.
(2)
Assignment.
Payment may be made in accordance with an
				assignment to a county for medical services received while the recipient was
				receiving interim assistance or while an appeal of a denial of medical
				assistance was pending.
(3)
Business agent of provider.
Payment may be made to a business
				agent that furnishes statements and receives payments in the name of the
				provider if the agent's compensation is:
a.
				Related to the cost of processing the billing.
b. Not related on a percentage or other basis
				to the amount that is billed or collected.
c. Not dependent upon the collection of the
				payment.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 80 - Procedure and Method of Payment › Rule 441-80.7 - Health Care Data Match Program

Current through Register Vol. 47, No. 3, July 24, 2024
As a condition of doing business in Iowa, health insurers
				  shall provide, upon the request of the state, information with respect to
				  individuals who are eligible for or are provided medical assistance under the
				  state's medical assistance state plan to determine (1) during what period the
				  member or the member's spouse or dependents may be or may have been covered by
				  a health insurer and (2) the nature of the coverage that is or was provided by
				  the health insurer. This requirement applies to self-insured plans, group
				  health plans as defined in the federal Employee Retirement Income Security Act
				  of 1974 (Public Law
				  93-406), service benefit plans, managed care
				  organizations, pharmacy benefits managers, and other parties that are, by
				  statute, contract, or agreement, legally responsible for payment of a claim for
				  a health care item or service.
(1)
Agreement required.
The parties shall sign a data use
				agreement for the purposes of this rule. A data use agreement shall prescribe
				the specific detail elements required, in addition to any privacy protections,
				in the manner in which information shall be provided to the department of human
				services, or its designee, and the acceptable uses of the information provided.
a. The initial provision of data shall
				include the data necessary to enable the department or its designee to match
				covered persons and identify third-party payers for the two-year period before
				the initial provision of the data. The data shall include the name, address,
				and identifying number of the plan.
b. Ongoing monthly matches may be limited to
				changes in the data previously provided, including additional covered persons,
				with the effective dates of the changes.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 81 - Nursing Facilities › Rule 441-81.3 - Initial Approval for Nursing Facility Care

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Need for nursing facility
				care.
Residents of nursing facilities must be in need of either
				nursing facility care or skilled nursing care. Payment will be made for nursing
				facility care residents only upon certification of the need for the level of
				care by a licensed physician of medicine or osteopathy and approval of the
				level of care by the department.
a. Decisions
				on level of care, subject to paragraph 81.3(1)
"b,"
shall be
				made for the department by the Iowa Medicaid enterprise (IME) medical services
				unit within two working days of receipt of medical information. The IME medical
				services unit determines whether the level of care provided or to be provided
				should be approved based on medical necessity and the appropriateness of the
				level of care under 441-subrules 79.9(1) and 79.9(2).
b. For residents subject to a Level II PASRR
				review pursuant to subrule 81.3(3), the level of care determination shall be
				made as part of the Level II PASRR review, based on medical necessity and the
				appropriateness of the level of care under 441-subrules 79.9(1) and
				79.9(2).
c. Adverse level of care
				decisions may be appealed to the department pursuant to 441-Chapter
				7.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 81 - Nursing Facilities › Rule 441-81.5 - Discharge and Transfer

Current through Register Vol. 47, No. 3, July 24, 2024
(See paragraph 81.13(6)
"c."
)
(1)
Notice.
When a Medicaid
				member requests transfer or discharge, or another person requests this for the
				member, the administrator shall promptly notify the department. This shall be
				done in sufficient time to permit a social service worker or case manager to
				assist in the planning for the transfer or discharge.
(2)
Case activity report.
A
				Case Activity Report, Form 470-0042, shall be submitted to the department
				whenever a Medicaid applicant or recipient enters the facility, changes level
				of care, or is discharged from the facility.
(3)
Plan.
The administrator
				and staff shall assist the resident in planning for transfer or discharge
				through development of a discharge plan.
(4)
Transfer records.
When a
				resident is transferred to another facility, transfer information shall be
				summarized from the facility's records in a copy to accompany the resident.
				This information shall include:
a. A transfer
				form of diagnosis.
b. Aid to daily
				living information.
c. Transfer
				orders.
d. Nursing care
				plan.
e. Physician's orders for
				care.
f. The resident's personal
				records.
g. When applicable, the
				personal needs fund record.
h.
				Resident care review team assessment.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 81 - Nursing Facilities › Rule 441-81.6 - Financial and Statistical Report and Determination of Payment Rate

Current through Register Vol. 47, No. 3, July 24, 2024
With the exception of hospital-based nursing facilities that
				  are Medicare-certified and provide only the skilled level of care, herein
				  referred to as Medicare-certified hospital-based nursing facilities, all
				  facilities in Iowa wishing to participate in the program shall submit a
				  Financial and Statistical Report, Form 470-0030, to the Iowa Medicaid
				  enterprise provider cost audit and rate setting unit. All Medicare-certified
				  hospital-based nursing facilities shall submit a copy of their Medicare cost
				  report. These reports shall be based on the following rules.
(1)
Failure to maintain
				records.
Failure to adequately maintain fiscal records, including
				census records, medical charts, ledgers, journals, tax returns, canceled
				checks, source documents, invoices, and audit reports by or for a facility may
				result in the penalties specified in subrule 81.14(1).
(2)
Accounting procedures.
Financial information shall be based on that appearing in the audited financial
				statements of the facility. If the financial statements have been compiled,
				reviewed or audited by an outside firm, a copy of the compilation, review or
				audit, including notes, for the reporting period shall be included with the
				submission of the financial and statistical report. Adjustments to convert to
				the accrual basis of accounting shall be made when the records are maintained
				on other accounting bases.
a. Facilities which
				are a part of a larger health facility extending short-term, intensive, or
				other health care not generally considered nursing care may submit a cost
				apportionment schedule prepared in accordance with recognized methods and
				procedures. A schedule shall be required when necessary for a fair presentation
				of expense attributable to nursing facility patients.
b. Costs for patient care services shall be
				divided into the subcategories of "direct patient care costs" and "support care
				costs." Costs associated with food and dietary wages shall be included in the
				"support care costs" subcategory.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 81 - Nursing Facilities › Rule 441-81.7 - Continued Review

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Level of care.
The IME medical services unit shall review
				Medicaid members' need for continued care in nursing facilities, pursuant to
				the standards and subject to the appeals process in subrule 81.3(1). For all
				members enrolled with a managed care organization, the managed care
				organization shall review a Medicaid member's need for continued care in a
				nursing facility at least annually. The managed care organization must submit
				documentation to the IME medical services unit for all reviews that indicate a
				change in the member's level of care. The IME medical services unit shall make
				a final determination for any reviews that indicate a change in the level of
				care.
(2)
PASRR.
As a condition of payment for nursing facility care under the Medicaid program
				when there is a significant change in a resident's condition, the nursing
				facility shall, within 24 hours, initiate a PASRR review by the department's
				contractor for PASRR evaluations. For purposes of this subrule, "significant
				change in a resident's condition" means any admission or readmission to the
				facility immediately following an inpatient psychiatric hospitalization or any
				change that is likely to impact the resident's treatment needs related to a
				mental illness or intellectual disability. The evaluation shall determine:
a. Whether nursing facility care or skilled
				nursing care is medically necessary and appropriate for the resident under
				441-subrules 79.9(1) and 79.9(2);
b. Whether nursing facility services continue
				to be appropriate for the resident, as opposed to care in a more specialized
				facility or in a community-based setting; and
c. Whether the resident needs specialized
				services for mental illness or intellectual disability, as described in
				paragraph 81.3(3)
"b."
This rule is intended to implement Iowa Code sections
				  249A.2(1),
				  249A.3(3),
				  and
				  249A.4.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 81 - Nursing Facilities › Rule 441-81.9 - Records

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Content.
The facility shall as a minimum maintain the
				following records:
a. All records required by
				the department of public health and the department of inspections and
				appeals.
b. Records of all
				treatments, drugs, and services for which vendors' payments have been made or
				are to be made under the medical assistance program, including the authority
				for and the date of administration of the treatment, drugs, or
				services.
c. Documentation in each
				resident's records which will enable the department to verify that each charge
				is due and proper prior to payment.
d. Financial records maintained in the
				standard, specified form including the facility's most recent audited cost
				report.
e. All other records as may
				be found necessary by the department in determining compliance with any federal
				or state law or rule or regulation promulgated by the United States Department
				of Health and Human Services or by the department.
f. Census records to include the date, number
				of residents at the beginning of each day, names of residents admitted, and
				names of residents discharged.
(1) Census
				information shall be provided for all residents of the facility.
(2) Census figures for each type of care
				shall be totaled monthly to indicate the number admitted, the number
				discharged, and the number of patient days.
(3) Failure to maintain acceptable census
				records shall result in the per diem rate being computed on the basis of 100
				percent occupancy and a request for refunds covering indicated recipients of
				nursing care which have not been properly accounted for.
g. Resident accounts.
h. In-service education program
				records.
i. Inspection reports
				pertaining to conformity with federal, state and local laws.
j. Residents' personal records.
k. Residents' medical records.
l. Disaster preparedness reports.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 81 - Nursing Facilities › Rule 441-81.11 - Billing Procedures

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Claims.
Claims for service must be sent to the Iowa Medicaid
				enterprise after the month of service and within 365 days of the date of
				service. Claims must be submitted electronically through Iowa Medicaid's
				electronic clearinghouse. A remittance advice of the claims paid may be
				obtained through the Iowa Medicaid portal access (IMPA) system. Adjustments to
				submitted claims may be made electronically as provided for by the Iowa
				Medicaid enterprise. A request for an adjustment to a paid claim must be
				received by the Iowa Medicaid enterprise within one year from the date the
				claim was paid in accordance with rule
				441-80.4
				(249A).
(2) Reserved.
This rule is intended to implement Iowa Code sections
				  249A.2(6) and 249A.3(2)
"a."
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 81 - Nursing Facilities › Rule 441-81.12 - Closing of Facility

Current through Register Vol. 47, No. 3, July 24, 2024
When a facility is planning on closing, the department and
				  the department's contracted managed care organizations with which the facility
				  is enrolled shall be notified at least 60 days in advance of the closing. Plans
				  for the transfer of residents receiving medical assistance shall be approved by
				  the resident's managed care organization or by the IME medical services unit
				  for residents not enrolled with a managed care organization.
This rule is intended to implement Iowa Code sections
				  249A.2(6)
				   and
				  249A.3(2)
"a."
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 81 - Nursing Facilities › Rule 441-81.13 - Conditions of Participation for Nursing Facilities

Current through Register Vol. 47, No. 3, July 24, 2024
All nursing facilities shall enter into a contractual
				  agreement with the department which sets forth the terms under which they will
				  participate in the program.
(1)
Procedures for establishing health care facilities as Medicaid
				facilities.
All survey procedures and certification process shall be
				in accordance with Department of Health and Human Services publication "State
				Operations Manual."
a. The facility shall
				obtain the applicable license from the department of inspections and appeals
				and must be recommended for certification by the department of inspections and
				appeals.
b. The facility shall
				request an application, Form 470-0254, Iowa Medicaid Provider Enrollment
				Application, from the Iowa Medicaid enterprise provider services
				unit.
c. The Iowa Medicaid
				enterprise provider services unit shall transmit an application form and a copy
				of the nursing facility provider manual to the facility.
d. The facility shall complete its portion of
				the application form and submit it to the Iowa Medicaid enterprise provider
				services unit.
e. The Iowa Medicaid
				enterprise provider services unit shall review the application form and verify
				with the department of inspections and appeals that the facility is licensed
				and has been recommended for certification.
f. Prior to requesting enrollment, the
				facility shall contact the department of inspections and appeals to schedule a
				survey. The department of inspections and appeals shall schedule and complete a
				survey of the facility.
g. The
				department of inspections and appeals shall notify the facility of any
				deficiencies and ask for a plan for the correction of the
				deficiencies.
h. The facility shall
				submit a plan of correction within ten days after receipt of written
				deficiencies from the health facilities division department of inspections and
				appeals. This plan must be approved before the facility can be
				certified.
i. The department of
				inspections and appeals shall evaluate the survey findings and plan of
				correction and either recommend the facility for certification or recommend
				denial of certification. The date of certification will be the date of approval
				of the plan of corrections.
j. When
				certification is recommended, the department of inspections and appeals shall
				notify the department recommending a provider agreement.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 81 - Nursing Facilities › Rule 441-81.14 - Audits

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Audit
				of financial and statistical report.
Authorized representatives of the
				department or the Department of Health and Human Services shall have the right,
				upon proper identification, to audit, using generally accepted auditing
				procedures, the general financial records of a facility to determine if
				expenses reported on the Financial and Statistical Report, Form 470-0030, are
				reasonable and proper according to the rules set forth in
				441-81.6
				(249A). The aforementioned audits may be done either on the basis of an on-site
				visit to the facility, their central accounting office, or office(s) of their
				agent(s).
a. When a proper per diem rate
				cannot be determined, through generally accepted and customary auditing
				procedures, the auditor shall examine and adjust the report to arrive at what
				appears to be an acceptable rate and shall recommend to the department that the
				indicated per diem should be reduced to 75 percent of the established payment
				rate for the ensuing six-month period and if the situation is not remedied on
				the subsequent Financial and Statistical Report, Form 470-0030, the health
				facility shall be suspended and eventually canceled from the nursing facility
				program, or
b. When a health
				facility continues to include as an item of cost an item or items which had in
				a prior audit been removed by an adjustment in the total audited costs, the
				auditor shall recommend to the department that the per diem be reduced to 75
				percent of the current payment rate for the ensuing six-month period. The
				department may, after considering the seriousness of the exception, make the
				reduction.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 81 - Nursing Facilities › Rule 441-81.16 - Nurse Aide Requirements and Training and Testing Programs

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Deemed meeting of
				requirements.
A nurse aide is deemed to satisfy the requirement of
				completing a nurse aide training and competency evaluation approved by the
				department of inspections and appeals if:
a.
				The nurse aide successfully completed a nurse aide training and competency
				evaluation program before July 1, 1989, and
(1) At least 60 clock hours were substituted
				for 75 clock hours, and the person has made up at least the difference in the
				number of clock hours in the program the person completed and 75 clock hours in
				supervised practical nurse aide training or in regular in-service nurse aide
				education, or
(2) The person was
				found to be competent (whether or not by the state) after completion of a nurse
				aide training of at least 100 clock hours' duration, or
(3) The person can demonstrate that the
				person served as a nurse aide at one or more facilities of the same employer in
				Iowa for at least 24 consecutive months before December 19, 1989, or
(4) The person completed, before July 1,
				1989, a nurse aide training and competency evaluation program that the
				department of inspections and appeals determines would have met the
				requirements for approval at the time it was offered; or
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 81 - Nursing Facilities › Rule 441-81.18 - Sanctions

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Penalty
				for falsification of a resident assessment.
An individual, who
				willfully and knowingly certifies a material and false statement in a resident
				assessment, is subject to a civil money penalty of not less than $100 or more
				than $1,000 for each falsified assessment. An individual who willfully and
				knowingly causes another individual to certify a material and false statement
				in a resident assessment is subject to a civil money penalty of not less than
				$500 nor more than $5,000 for each falsified assessment. These fines shall be
				administratively assessed by the department of inspections and appeals.
a. Factors determining the size of fine. In
				determining the monetary amount of the penalty, the director of the department
				of inspections and appeals or the director's designee may consider evidence of
				the circumstances surrounding the violation, including, but not limited to, the
				following factors:
(1) The number of
				assessments willingly and knowingly falsified.
(2) The history of the individual relative to
				previous assessment falsifications.
(3) The intent of the individual who
				falsifies an assessment or causes an assessment to be falsified.
(4) The areas of assessment falsified or
				caused to be falsified and the potential for harm to the resident.
(5) The relationship of the falsification of
				assessment to falsification of other records at the time of the
				visit.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 81 - Nursing Facilities › Rule 441-81.20 - Out-of-state Facilities

Current through Register Vol. 47, No. 3, July 24, 2024
Payment will be made for care in out-of-state nursing
				  facilities. For members enrolled with a managed care organization,
				  authorization for admission must be obtained from the managed care organization
				  prior to admission. Out-of-state facilities shall abide by the same policies as
				  in-state facilities with the following exceptions:
(1)
Out-of-state providers.
Except for Medicare-certified hospital-based nursing facilities and special
				population nursing facilities, out-of-state providers shall be reimbursed at
				the same nursing facility rate they would receive from the Medicaid program in
				their state of residence or an amount equal to the sum of the Iowa non-state
				government owned nursing facility direct care rate component limit pursuant to
				subparagraph 81.6(16) "f"(1) plus the non-direct care rate limit pursuant to
				subparagraph 81.6(16) "f"(1), whichever is lower.
a. Medicare-certified hospital-based nursing
				facilities providing skilled care in other states shall be reimbursed at an
				amount equal to the sum of the Iowa Medicare-certified hospital-based nursing
				facility direct care rate component limit pursuant to subparagraph
				81.6(16)"f"(3) plus the non-direct care rate component limit pursuant to
				subparagraph 81.6(16) "f"(3) if one of the following criteria is met:
(1) The placement is recommended because
				moving the resident back to Iowa would endanger the resident's health, because
				services are not readily available in Iowa, or because the out-of-state
				placement is cost-effective.
(2) The
				placement is temporary until services are available to the resident in Iowa or
				until the program of treatment is completed.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 81 - Nursing Facilities › Rule 441-81.21 - Outpatient Services

Current through Register Vol. 47, No. 3, July 24, 2024
Medicaid outpatient services provided by certified skilled
				  nursing facilities are defined in the same way as the Medicare program.
This rule is intended to implement Iowa Code section
				  249A.4 and
				  1991 Iowa Acts, House File 479, section 132, subsection 1, paragraph
"i.
				  "