Section 17b-262-925 - Documentation(a) Providers shall maintain (1) a specific record for all services provided to each client including, but not limited to: name, address, birth date, Medicaid identification number, pertinent diagnostic information, a current treatment plan signed by the licensed behavioral health clinician and (2) documentation of services provided, including, types of service or modalities, date of service, location of the service and the start and stop time of the service.(b) For treatment services, the provider shall document the treatment intervention and progress with respect to the client's goals as identified in the treatment plan.(c) Providers shall maintain all required documentation in its original form for a minimum of five years or longer if required by applicable statutes and regulations, subject to review by the department. In the event of a dispute concerning a service provided, the provider shall maintain documentation until the end of the dispute, five years or the time required by applicable statues and regulations, whichever is greater.(d) The department may disallow and recover any amounts paid to the provider for which required documentation is not maintained and provided to the department upon request.(e) The department may audit any relevant records and documentation and take any other appropriate quality assurance measures it deems necessary to assure compliance with these and other regulatory and statutory requirements.(f) Providers shall make all entries in ink or electronically and shall incorporate all documentation into a client's permanent medical record in a complete, prompt and accurate manner.(g) Providers shall make all documentation available to the department upon request in accordance with 42 CFR 431.107.Conn. Agencies Regs. § 17b-262-925
Effective December 28, 2012