Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.409 - Recordkeeping (Medical Records) Requirements

Current through Register 1525, July 5, 2024
(A) Payment for any outpatient service
			 covered by MassHealth is conditioned upon its full and complete documentation
			 in the member's medical record. If the information in the member's record is
			 not sufficient to document the service for which payment is claimed by the
			 provider, the MassHealth agency will not pay for the service or, if payment has
			 been made, will consider such payment to be an overpayment subject to recovery
			 as defined in the MassHealth administrative and billing regulations in
			 130 CMR 450.000:
Administrative and Billing Regulations
. Medical record
			 requirements as set forth in
			 130 CMR 410.000 constitute
			 the standard against which the adequacy of records is measured, as set forth in
			 130 CMR 450.000.
(B) The MassHealth agency may request, and
			 the hospital outpatient department must provide, any and all medical records
			 (or clear photocopies of such records) corresponding to or documenting the
			 services claimed, in accordance with M.G.L. c. 118E, § 38, and
			 130 CMR 450.000:
Administrative and Billing Regulations
. All components of a
			 member's complete medical record (such as lab slips and X-rays) do not need to
			 be maintained in one file as long as all components are accessible to the
			 MassHealth agency upon its request.
(C) The medical record must contain
			 sufficient data to document fully the nature, extent, quality, and necessity of
			 the care provided to a member for each date of service claimed for payment, as
			 well as any data that will update the member's medical course. The data
			 maintained in the member's medical record must also be sufficient to justify
			 any further diagnostic procedures, treatments, recommendations for return
			 visits, and referrals.
(D) Although
			 basic data collected during previous visits (such as identifying data, chief
			 complaint, or history) need not be repeated in the member's medical record for
			 subsequent visits, the medical records for outpatient hospital services
			 provided to members must include at least the following information:
(1) the member's name and date of
			 birth;
(2) the date of each
			 service;
(3) the reason for the
			 visit;
(4) the name and title of
			 the person who performed the service;
(5) the member's medical history;
(6) the diagnosis or chief
			 complaint;
(7) a clear indication
			 of all findings, whether positive or negative, on examination;
(8) any tests administered and their
			 results;
(9) a description of any
			 treatment given;
(10) any
			 medications administered or prescribed, including strength, dosage, regimen,
			 and duration of use;
(11) any
			 anesthetic agent administered;
(12)
			 any medical goods or supplies dispensed or supplied;
(13) recommendations and referrals for
			 additional treatments or consultations, when applicable;
(14) the federally required consent form for
			 sterilization or hysterectomy, when applicable; and
(15) such other information as is applicable
			 for the specific service provided, or as is otherwise required in
			 130 CMR
			 410.000.