Record-keeping Requirements

(A) Federal and state regulations require that all MassHealth providers maintain complete written medical records of all patients who are MassHealth members. Medical records must comply with the provisions of 233 CMR 4.04: Insurance Requirements for Limited Liability Companies and Limited Liability Partnerships. All records must be kept for a minimum of six years after the date of service. Payment for maintaining the member's medical record is included in the fee for chiropractic services. Each medical record must contain sufficient information to document fully the nature, extent, quality, and necessity of the care furnished to the member for each date of service claimed for payment. If the documentation is not sufficient to justify 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, may consider such payment to be an overpayment subject to recovery in accordance with 130 CMR 450.000: Administrative and Billing Regulations. (B) The medical records must contain the following: (1) MassHealth member identification, including name, address, telephone number, date of birth, and the MassHealth member’s identification number; (2) a complete medical history; (3) examination results, including a description of the chief complaint and diagnosis; (4) a written referral from the member's primary-care provider or PCC; (5) copies of X-rays, with interpretations; (6) copies of all prior-authorization requests for out-of-state services; (7) the date and nature of each visit, including a complete description of services furnished, written and signed by the chiropractor; (8) when more than one visit is indicated, a treatment plan for future visits written and signed by the chiropractor, which is updated on an ongoing basis to reflect changes in the member’s presenting symptoms; (9) upon completion of treatment, a summary of the treatment and the member's current condition; (10) recommendations for additional treatment, signed and dated by the chiropractor; and (11) if the medical record or any component included therein is released for use by another party, the medical record must also contain a release form signed by the member. Release of the medical record to MassHealth for authorized use does not require the member's consent.