Records

Providers must maintain records in sufficient detail to allow the Department to audit for compliance, medical necessity, quality assurance, and determination of payment methodology. The Department, the U.S. Department of Health and Human Services, and the Bureau of Compliance have the right to review pertinent records of providers and related entities receiving Medicaid reimbursement. These reviews may be conducted for audit purposes outside of processes in IDAPA 16.05.07. (7-1-26) 01. Provider Refusal. Refusal of a provider to permit the Department to review records pertinent to Medicaid will constitute grounds for: (7-1-26) a. Withholding payments until access to the requested information is granted; (7-1-26) b. Recoupment of payments; or (7-1-26) IDAHO ADMINISTRATIVE CODE IDAPA 16.03.26 Department of Health & Welfare Medicaid Plan Benefits Section 040 Page 29 c. Suspending the provider. (7-1-26) 02. Undocumented Services. Undocumented services are subject to recoupment. (7-1-26) 03. Availability of Records. Records must be available for audit, with or without prior notice, during any working day and regular business hours at the provider’s principal place of business. (7-1-26) 04. Retention of Records. Providers will retain records required under this rule for a period of five (5) years from the date of final payment under the provider agreement. Failure to retain records for the required period can void the Department’s obligation to pay for services. (7-1-26) 036. – 039. (RESERVED) GENERAL REIMBURSEMENT PROVISIONS FOR INSTITUTIONAL PROVIDERS (Sections 040-049)