Iowa Admin. Code r. 441-88.9 - [Effective 7/1/2025] Grievances and appeals
The PACE organization must have written policies and procedures for identifying and processing service determination requests, grievances, and appeals in accordance with 42 CFR 460.120 through 460.124 as amended to August 1, 2024.
(1)
Written
log. The PACE organization must maintain a written log of all
grievances and appeals, including all informal or verbal complaints. The log
must include progress notes and method of resolution.
(2)
Submission to the
department. Upon request by the department, the PACE organization must
provide documentation related to service determination requests, grievances,
and appeals, including the log described in subrule 88.9(1), to the department
at its mailing address or via email at pace@hhs.iowa.gov.
Notes
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(1) Medical records system. The PHP shall comply with the provisions of rule 441-79.3 (249A) regarding maintenance and retention of clinical and fiscal records and, in addition, the PHP must maintain a medical record system which:
a. Identifies each medical record by the departmentally assigned state identification number.
b. Identifies the location of every medical record.
c. Places medical records in a given order and location.
d. Provides a specific medical record on demand.
e. Maintains the confidentiality of medical records information and releases the information only in accordance with established policy pursuant to subrule 88.9(3).
f. Maintains inactive medical records in a specific place.
g. Permits effective professional review in medical audit processes.
h. Facilitates an adequate system for follow-up treatment including monitoring and follow-up of off-site referrals and inpatient stays.
i. Meets state and federal reporting requirements applicable to PHPs.
(2) Content of individual medical record. The PHP must have in effect arrangements which provide for an adequate medical record-keeping system which includes a complete medical record for each enrolled recipient in accordance with provisions set forth in the contract .
(3) Confidentiality of records. PHPs must maintain the confidentiality of medical record information and release the information only in the following manner:
a. All medical records of enrolled recipients shall be confidential and shall not be released without the written consent of the enrolled recipients or the responsible party acting on behalf of the enrolled recipient .
b. Written consent is not required for the transmission of medical record information to physicians, other practitioners, or facilities which are providing services to enrolled recipients under a subcontract with the PHP. This provision also applies to specialty providers who are retained by the PHP to provide services which are infrequently used or are of an unusual nature.
c. Written consent is not required for the transmission of medical record information to physicians or facilities providing emergency care pursuant to rule 441-89.26 (249A).
d. Written consent is required for the transmission of medical record information of a former enrolled recipient to any medical provider not connected with the PHP.
e. The extent of medical record information to be released in each instance shall be based upon tests of medical necessity and a "need to know" on the part of the practitioner or facility requesting the information.
f. Medical records maintained by subcontracting providers must meet the requirements of this rule.
(4) Reports to the department . Each PHP shall submit reports to the department as follows:
a. Annual audited financial statements no later than 120 days after the close of the PHP's fiscal year.
b. Periodic financial, utilization, and statistical reports as required by the department under the contract .
(5) Audits. The department or its designee and the U.S. Department of Health and Human Services (HHS) may evaluate through inspections or other means, the quality, appropriateness, and timeliness of services performed by the PHP. The department or HHS may audit and inspect any records of a PHP, or the subcontractors of a PHP, which pertain to services performed and the determination of amounts paid under the contract . These records will be made available at times, places, and in a manner as authorized representatives of the department , its designee, or HHS may request.