N.J. Admin. Code § 8:85-1.13

Current through Register Vol. 56, No. 21, November 4, 2024

Section 8:85-1.13 - Clinical and related records

(a) An individual clinical record shall be maintained for each Medicaid beneficiary covering his or her medical, nursing, social and related care in accordance with accepted professional standards and licensing standards as set forth by the Standards for Licensure of Long-Term Care Facilities, N.J.A.C. 8:39. All entries on the clinical record shall be current, dated and signed by the appropriate staff member. The clinical record, HSDP approval letter and if appropriate, PASRR determination shall be readily available at the appropriate nurses' station for review by DHSS staff.

(b) The clinical record of a deceased resident shall be properly completed. It shall include:

1. Written reports of visits made by the physician during the critical stage of illness;

2. Written documentation of death pronouncement completed by the qualified health professional as specified by the NF's policies and procedures;

3. Complete nurse's notes containing all necessary and pertinent information documenting the resident's condition during the illness and apparent demise, notification of physician and next of kin;

4. Autopsy records where appropriate; and

5. A written record of the disposition of the body of the deceased individual.

(c) All clinical records of discharged residents shall be completed promptly and shall be filed and retained for the duration required by 26:8-5.

(d) If the resident is transferred to or from another health care facility, a copy of the resident's clinical record or an abstract thereof, including the most recent HSDP, MDS and, if applicable, current copy of the resident's PASRR, and/or the documentation that supports the resident's diagnosis of Alzheimer's disease or related organic dementia, shall accompany the resident.

(e) All information contained in the clinical record shall be treated as confidential and shall be disclosed only to authorized persons.

(f) If the NF does not have a full or part-time medical records librarian, an employee of the facility shall be assigned the responsibility for assuring that records are maintained, completed and preserved in accordance with accepted procedures. The designated individual shall be trained by, and must receive regular consultation from, a medical records librarian who is under written contract with the facility.

(g) Billing and financial records rules are as follows:

1. The Fiscal Agent Billing Supplement identifies the procedures required for the general use of the billing transaction forms and computer generated forms. All appropriate reports shall be retained until audited by the Department.

2. The facility shall establish and maintain appropriate and accurate records and accounts of all receipts and disbursements of Medicaid beneficiary funds, which shall be subject to review and fiscal audit by the State of New Jersey as may be required. A beneficiary shall be credited with the maximum amount of personal needs allowance funds authorized by Federal or State law for each month that such records or accounts are unavailable.

3. Any and all financial and other records relating to beneficiary's personal needs allowance accounts, income, cost reports, and billings to the Medicaid program shall be maintained and retained in accordance with professional standards and practices for the longest of the following periods of time:

i. At least one year after the resolution of audit findings or the conclusion of recovery proceedings arising out of those audit findings (whichever is later) for the records that are audited;

ii. One year after the conclusion of all hearings, appeals and/or other litigation with respect to audits of such records; or

iii. Seven years.

4. The records described in (g)3 above shall be made available for audit upon the request of appropriate State and/or Federal personnel or their agents.

5. Claims for NF services that are older than 12 months will be rejected.

i. A claim for payment for services shall be received by the fiscal agent no later than one year after the "from date of service" on the claim form (TAD). An adjustment request FD999 (see Appendix Q) for a paid claim shall be honored for 180 days from the original date of payment;

ii. For purposes of this time limitation, a claim is the submission of a TAD, provided by the fiscal agent for the New Jersey Medicaid program, indicating a request for reimbursement for authorized NF services provided to an eligible beneficiary and which has been returned to the fiscal agent within the time limit specified. An adjustment form (FD999) or an LTC-2 shall not constitute a claim for payment;

iii. Other timely filing information is located in the Administrative chapter at 10:49-7.2, Timeliness of claim submission and inquiry.

N.J. Admin. Code § 8:85-1.13

Recodified from N.J.A.C. 10:63-1.13 and amended by R.2005 d.389, effective 1/17/2006.
See: 36 New Jersey Register 4700(a), 37 New Jersey Register 1185(a), 38 New Jersey Register 674(a).
Rewrote the section.