Recordkeeping (Medical Records) Requirements

(A) Payment for any psychiatric hospital outpatient service reimbursable under MassHealth is conditioned upon its full and complete documentation in the member's medical record. If the information in the member's record is not sufficient to document the service for which payment is claimed by the provider, the MassHealth agency will not pay for the service or, if payment has been made, will consider such payment to be an overpayment subject to recovery as defined in the MassHealth administrative and billing regulations in 130 CMR 450.000. Medical record requirements as set forth in these regulations constitute the standard against which the adequacy of records will be measured, as set forth in 130 CMR 450.000. (B) The MassHealth agency may request, and the psychiatric inpatient hospital must furnish, any and all medical records (or clear photocopies of such records) corresponding to or documenting the services claimed, in accordance with M.G.L. c. 118E, § 38, and 130 CMR 450.000. All components of a member's complete medical record (such as lab slips and X rays) need not be maintained in one file as long as all components are accessible to the MassHealth agency upon its request. (C) The medical record must contain sufficient data to document fully the nature, extent, quality, and necessity of the care furnished to a member for each date of service claimed for payment, as well as any data that will update the member's medical course. The data maintained in the member's medical record must also be sufficient to justify any further diagnostic procedures, treatments, recommendations for return visits, and referrals. (D) The medical records for hospital outpatient services provided to members must include at least the following information (basic data collected during previous visits, such as identifying data, chief complaint, or history, need not be repeated in the member's medical record for subsequent visits): (1) the member's name and date of birth; (2) the date of each service; (3) the reason for the visit; (4) the name and title of the person who performed the service; (5) the member's medical history; (6) the diagnosis or chief complaint; (7) a clear indication of all findings, whether positive or negative, on examination; (8) any tests administered and their results; (9) a description of any treatment given; (10) any medications administered or prescribed, including strength, dosage, regimen, and duration of use; (11) any anesthetic agent administered; (12) any medical goods or supplies dispensed or supplied; (13) recommendations and referrals for additional treatments or consultations, when applicable; (14) such other information as is applicable for the specific service provided, or as is otherwise required in these regulations; and (15) for members under the age of 21, the CANS that was completed at the initial behavioral- health assessment and updated at least every 90 days thereafter. (E) When a member is referred from a private physician to the outpatient department of a psychiatric inpatient hospital exclusively for the purpose of a diagnostic test, the following information, at a minimum, must be included in the member's medical record: (1) the member's name and date of birth; (2) the signed referral from the private physician authorizing the procedure; (3) the date of service; (4) the name and title of the person who performed the service; and (5) a clear indication of all findings, whether positive or negative.