Electronic Visit Verification (EVV) Provider Attestation

For assisted living facilities (ALFs) and residential care facilities (RCFs), Electronic Visit Verification (EVV) is optional for all personal cares services provided by shift workers employed by the ALF or RCF.

ALFs and RCFs may opt-out of using EVV for documentation of personal cares services by submitting an attestation on the form below to request an exemption from the required use of the EVV system. By submitting this form, you are attesting that the ALF or RCF only bills for personal cares services provided by shift employees and, therefore, is eligible to opt-out from using EVV documentation of personal care services. The ALF or RCF must still fulfill all personal cares documentation requirements.

In order to avoid delays in claims processing and reimbursement, the attestation form must be submitted to the Department by July 31, 2021, and annually thereafter via the provider self-assessment thereafter.

The Department will share attestations with the Managed Care Organizations (MCOs).

Facility Information

Facility Name

Facility Address

Facility City

Provider Type

National Provider Identifier (NPI)

Attestation submitted by: (Attestation must be made by the CEO or a person, such as a director, that is accountable for the organization.)

First Name

Last Name

Email Address

Phone Number

Position Within Facility

Attestation (Current providers only):

On behalf of the entity I represent, I hereby certify that the following is true and accurate, and I hereby acknowledge that this certification is material to the State of Iowa payment obligations:

1. My entity provides and bills for personal cares services to residents in my entity's facility or facilities.

2. All personal cares services my entity provides to residents and bills to Medicaid are performed by employees as part of those employees' shift work at my entity's facility or facilities.

3. My entity hereby opts out of using EVV to document those personal cares services identified in paragraph Nos. 1 and 2 above.

4. My entity and its employees will continue to fulfill the documentation requirements for personal cares services otherwise required by state regulation.

5. I and my entity agree to report any changes related to this certification to Iowa Medicaid.

6. I and my entity understand that failure to comply with this certification or to update the information contained in this attestation may result in disenrollment, sanction, termination, recoupment of funds, and/or liability under Iowa Code Chapter 685 or other federal and state law and regulations.

Certification Statement:

Please certify that each of the statements below is true and accurate by checking the box. Each statement must be certified for the attestation to be completed.

I authorize the Iowa Medicaid Enterprise (IME) to verify the information submitted in this attestation form. I certify the information herein is true, correct, and complete. If I become aware that any information in the attestation form is not true, correct, or complete, I agree to notify IME immediately. I understand that any false statement, omission, or misrepresentation of a material fact may result in recovery of all funds paid as a result of such false statement, omission, or misrepresentation and may result in prosecution under state and federal laws.

By clicking "Yes" below, I and my entity are attesting to employing shift workers and therefore EVV is optional for all personal cares services provided by my entity.

By clicking "No" below, I and my entity are attesting to using non-shift workers for personal cares services and are required to use EVV beginning August 1, 2021.

By clicking "submit" below the provider is electronically signing this document in accordance with Iowa Code Chapter 554D.

YesNo

Contact Information