441—88.9 (249A) Records and reports.
	 88.9(1) Medical records system. The HMO shall comply with the provisions of rule 441—79.3(249A) regarding maintenance and retention of clinical and fiscal records and shall file a letter with the commissioner of insurance as described in Iowa Code section 228.7. In addition the HMO must maintain a medical records system which:
	  a.   	 Identifies each medical record by 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 HMOs.
	 88.9(2) Content of individual medical record. The HMO 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.
	 88.9(3) Confidentiality of records. HMOs 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 responsible party.
	  b.   	 Written consent is not required for the transmission of medical record information to physicians, other practitioners, or facilities who are providing services to enrolled recipients under a subcontract with the HMO. This provision also applies to specialty providers who are retained by the HMO to provide services which are infrequently used, provide a support system service to the operation of the HMO, or are of an unusual nature. This provision is also intended to waive the need for written consent for department staff assisting in the administration of the program, reviewers from the peer review organization (PRO), monitoring authorities from the Centers for Medicare and Medicaid Services (CMS), the HMO itself, and other subcontractors which require information as described under paragraph “e” of this subrule.
	  c.   	 Written consent is not required for the transmission of medical record information to physicians or facilities providing emergency care pursuant to rule 441—88.6(249A).
	  d.   	 Written consent is required for the transmission of the medical record information of a former enrolled recipient to any physician not connected with the HMO.
	  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 a facility requesting the information.
	  f.   	 Medical records maintained by subcontractors must meet the requirements of this rule.
	 88.9(4) Reports to the department. Each HMO shall submit reports to the department as follows:
	  a.   	 Annual audited financial statements no later than 120 days after the close of the HMO’s fiscal year or other additional terms as specified by the contract.
	  b.   	 Periodic financial, utilization, and statistical reports as required by the department under the contract.
	  c.   	 Time-specific reports required by the contract which define activity for child health care, grievances, and other designated activities which may, at the department’s discretion, vary among HMOs, depending on the services covered and other contractual differences.
	 88.9(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 HMO. The department or HHS may audit and inspect any records of an HMO, or the subcontractor of the HMO that 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.