Recordkeeping Requirements

(A) Each program provider must maintain member records in accordance with 130 CMR 450.000: Administrative and Billing Regulations and 105 CMR 164.000: Licensure of Substance Use Disorder Treatment Programs. Member records must be complete, accurate, and properly organized. The member’s record must include a complete record of all services provided to members directly, referrals made, if the appointment was kept, and a progress note for each counseling session, including the treatment modality and duration and the therapist's discipline and degree, written and signed by the primary therapist. (B) Program Records. The substance use disorder treatment program must retain documentation reflecting compliance with the requirements of 105 CMR 164.000: Licensure of Substance Use Disorder Treatment Programs. (C) Availability of Records. All records must be made available to the MassHealth agency, upon request.