Ala. Admin. Code r. 560-X-47-.05

Current through Register Vol. 43, No. 1, October 31, 2024

Section 560-X-47-.05 - Requirements For Client Intake, Treatment Planning, And Service Documentation

(1) Requirements for intake, treatment planning, and service documentation are detailed in the Medicaid Provider Manual, Rehabilitative Services, Chapter 105, Section 105.2.3. Manuals may be downloaded from the Medicaid website at www.medicaid.alabama.gov.

(2) Documentation in the client's record for each session, service, or activity for which Medicaid reimbursement is requested shall comply with any applicable certification or licensure standards and shall include, at a minimum:

(a) the identification of the specific services rendered;

(b) the date and the amount of time that the services were rendered;

(c) the signature of the staff person who rendered the services;

(d) the identification of the setting in which the services were rendered;

(e) a written assessment of the client's progress, or lack thereof, related to each of the identified clinical issues discussed.

(3) The author of each entry must be identified and must authenticate his or her entry. Authentication must be consistent with signature requirements found in Chapter I of this Administrative Code.

(4) When clinical records are audited, the list of required documentation found at Rule 560-X-47-.05(2) will be applied to justify payment by Medicaid. Documentation failing to meet the minimum standards noted above will result in recoupment of payments.

Ala. Admin. Code r. 560-X-47-.05

Rule effective August 11, 1990. Amended: August 14, 1991. Emergency rule effective March 1, 1994. Amended: Filed May 6, 1994, effective June 14, 1994. Amended: Filed August 7, 2000; effective September 11, 2000. Amended: Filed May 12, 2005; effective June 16, 2005.

Amended by Alabama Administrative Monthly Volume XXXVII, Issue No. 04, January 31, 2019, eff. 2/25/2019.

Author: Karen M. Smith, Associate Director, Mental Health Programs

Statutory Authority:42 C.F.R. § 440.130(d); Social Security Act, Title XIX; Omnibus Budget Reconciliation Act of 1987, P.L. 100-203, §4105; State Plan for Medical Assistance, Attachment 3.1-A.