Section 405 IAC 1-1.4-2 - Medical recordsAuthority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 12-7-2-38; IC 12-13-7-3; IC 12-15-13.5-6; IC 12-15-22
Sec. 2.
(a) Medicaid records shall be:(1) of sufficient quality to fully disclose and document the extent of services provided to individuals receiving Medicaid assistance; and(2) documented at the time the services are provided or rendered, and prior to associated claim submission.(b) All providers shall maintain, for a period of seven (7) years from the date Medicaid services are provided to a member, medical or other records as are necessary to fully disclose and document the extent of the services provided. A copy of a claim form that has been submitted by the provider for reimbursement is not sufficient documentation, in and of itself, to comply with this requirement. Providers must maintain records that are independent of claims for reimbursement. Medical or other records, or both, shall include, at the minimum, the following information and documentation: (1) The identity of the individual to whom service was rendered.(2) The identity, including dated signature or initials, of the provider rendering the service.(3) The identity, including dated signature or initials, and position of the provider employee rendering the service, if applicable.(4) The date on which the service was rendered.(5) The diagnosis of the medical condition of the individual to whom service was rendered, relevant to physicians and dentists only.(6) A detailed statement describing services rendered, including duration of services rendered.(7) The location at which services were rendered.(8) The amount claimed through Medicaid for each specific service rendered.(9) Written evidence of physician involvement, including signature or initials, and personal patient evaluation will be required to document the acute medical needs.(10) When required under Medicaid rules, physician progress notes as to the medical necessity and effectiveness of treatment and ongoing evaluations to assess progress and redefine goals.(11) X-rays, mammograms, electrocardiograms, ultrasounds, and other electronic imaging records.(c) Providers whose reimbursement is determined by the office shall maintain financial records for a period of not less than three (3) years following submission of financial data to the office. A provider shall disclose this financial data when the information is to be used during the rate determination process, as well as during audit proceedings.(d) Records maintained by providers under subsections (a), (b), and (c) shall be subject to prepayment and postpayment review by the office and shall be openly and fully disclosed and produced to the office upon reasonable notice and request. A notice and request may be made in person, in writing, or orally. Failure on the part of a provider to comply with this section shall subject the provider to sanctions under IC 12-15-22 and applicable federal law.(e) Services provided by a community mental health center (as defined in IC 12-7-2-38) as part of an ongoing plan of treatment or the documentation of specific treatment methods are subject to reporting requirements outlined in IC 12-15-13.5-6.Office of the Secretary of Family and Social Services; 405 IAC 1-1.4-2; filed 12/21/2018, 3:17 p.m.: 20190116-IR-405180251FRAFiled 4/24/2023, 10:44 a.m.: 20230524-IR-405220253FRAReadopted filed 5/30/2023, 11:54 a.m.: 20230628-IR-405230292RFA