471 NAC 20-021. clinical records

021. clinical records. Clinical records must be arranged in a logical order such that the clinical information can be easily reviewed, audited, and copied. Each provider must maintain accurate, complete, and timely records and must always adhere to procedures that ensure the confidentiality of clinical data. 021.01 RECORDS REQUIREMENTS. Treatment provided to the beneficiary must be written legibly or typed in the clinical record in a manner and with a frequency to provide a full picture of the therapies provided, as well as an assessment of the beneficiary’s reaction to it. If three separate individuals cannot understand the information written in a record because of handwriting which is difficult to read, the program must provide a readable format. Reimbursement for services may be denied if claims or medical records are not legible. Recoupment of previous payments for services may result if appropriate, legible, and complete records are not maintained for the beneficiary . 021.02 INSPECTION. Providers of psychiatric services to beneficiaries age 21 and older must comply with Nebraska Medicaid requests to review clinical records. This review may be of photocopies or on-site at the discretion of Nebraska Medicaid .