Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.205 - Recordkeeping and Disclosure

Current through Register 1525, July 5, 2024
(A) The
			 MassHealth agency will not pay a provider for services if the provider does not
			 have adequate documentation to substantiate the provision of services payable
			 under MassHealth. All providers must keep such records, including medical
			 records, as are necessary to disclose fully the extent and medical necessity of
			 services provided to, or prescribed for, members and must provide to the
			 MassHealth agency and the Attorney General's Medicaid Fraud Division, the State
			 Auditor and the United States Department of Health and Human Services on
			 request such information and any other information about payments claimed by
			 the provider for providing services or otherwise described in 130 CMR 450.205.
			 (
See e.g
.,
			 42 U.S.C.
			 1396a(a)(27).) All providers
			 must also disclose such records and information to any other state and federal
			 agency to which disclosure is required by law.
(B) All providers must maintain complete
			 patient account records. Patient account records must include complete
			 documentation of charges, indicate the date and amount of all debit and credit
			 transactions, and support the appropriateness of the amounts billed and paid.
			 Institutional providers must, in addition, provide on request all records
			 maintained by or within the institution about services provided to members by
			 other providers. Pharmacy providers must, in addition, keep photocopies of the
			 temporary MassHealth cards referenced when filling prescriptions, if
			 applicable, and must produce a copy of the card on request.
(C) A provider must maintain and disclose any
			 and all financial, statistical, and other information as may be required by the
			 MassHealth agency, the Center for Health Information and Analysis, or any other
			 agency described in 130 CMR 450.205(A). The required information must include,
			 but is not limited to, ownership and licensure information, cost reports,
			 charge books, audited financial statements, financial records, federal and
			 state tax returns, invoices, general ledgers, trial balances, remittance
			 advices, and explanations of benefits from health insurers and managed care
			 organizations. Such records and documents must be provided within the time
			 period specified by the requesting agency.
(D) All records including, but not limited
			 to, those containing signatures of medical professionals authorizing services,
			 such as prescriptions, must, at a minimum, be legible and comply with generally
			 accepted standards for recordkeeping within the applicable provider type as
			 they may be found in laws, rules, and regulations of the relevant board of
			 registration, professional treatises, and guidelines and other information
			 published, adopted, or promulgated by state or national professional
			 organizations and societies. All accounting records must be maintained in
			 accordance with generally accepted accounting principles. In those instances
			 where MassHealth regulations identify specific recordkeeping requirements for
			 particular types of providers, such regulations constitute an additional
			 standard against which the adequacy of records will be measured for the
			 purposes of 130 CMR 450.205. In no instance will the completion of the
			 appropriate MassHealth claim, the maintenance of a copy of such claim, or the
			 simple notation of service codes constitute sufficient documentation for the
			 purpose of 130 CMR 450.205.
(E)
			 Except as provided in 130 CMR 450.205(F), the records and information required
			 to be maintained or disclosed under
			 130 CMR 450.000 include
			 only those that relate in any manner to services provided to or prescribed for
			 members, provided, however, that disclosure may not be refused on the ground
			 that such records are commingled with records related to persons who are not
			 members. Such records and information must be made available to the MassHealth
			 agency and any other agency described in 130 CMR 450.205(A) for examination or
			 copying during reasonable office hours at the provider's place of business or
			 record depository. Alternatively, the requesting agency may require that the
			 provider submit copies of such records and information.
(F)
(1)
			 Providers subject to the federal requirements for employee education about
			 false claims laws under
			 42 U.S.C.
			 1396a(a)(68) must:
(a) provide written certification, on or
			 before June 30th of each year, or such other date as
			 specified by the MassHealth agency, signed under the pains and penalties of
			 perjury, of compliance with the federal requirements;
(b) make available to the MassHealth agency,
			 upon request, a copy of all written policies implemented in accordance with
			 42 U.S.C.
			 1396a(a)(68), any employee
			 handbook, and other information as the MassHealth agency may deem necessary to
			 determine compliance; and
(c)
			 initiate corrective actions necessary to comply with such federal
			 requirements.