Iowa HHS

Annual Electronic Visit Verification (EVV) Provider Attestation

For assisted living facilities (ALFs) and residential care facilities (RCFs), Electronic Visit Verification (EVV) is a requirement based on the 21st Century Cures Act for all personal cares services provided by shift workers.

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.


All ALF and RCF providers must complete a new EVV provider attestation identifying their exemption status with Iowa Medicaid by July 31, 2023, and by June 30 every year thereafter. 

 

Failure to comply with the attestation requirement initially, and annually by the due date may result in claim denials, disenrollment, sanction, termination, recoupment of funds, and/or liability under Iowa Code Chapter 685 or other federal and state laws and regulations.

















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

4. I and my entity agree to report any changes related to this certification to Iowa Medicaid by completing a new attestation. 

5. 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 Iowa Medicaid 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 Iowa Medicaid by completing a new attestation. 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.


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