Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 120 - MEDICAL ASSISTANCE PROGRAMS › Section 410-120-1360 - Requirements for Financial, Clinical and Other Records

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Authority shall analyze, monitor,
			 audit, and verify the accuracy and appropriateness of payment, utilization of
			 services, medical necessity, medical appropriateness, quality of care, and
			 access to care of the Medical Assistance Programs and the Children's Health
			 Insurance Program.
(2) The provider
			 or the provider's designated billing service or other entity responsible for
			 the maintenance of financial, clinical, and other records shall develop and
			 maintain adequate financial and clinical records and other documentation that
			 supports the specific care, items, or services for which payment has been
			 requested. Payment shall be made only for services that are adequately
			 documented. Documentation shall be completed before the service is billed to
			 the Division and meet the following requirements:
(a) All records shall document the specific
			 service provided, the number of services or items comprising the service
			 provided, the extent of the service provided, the dates on which the service is
			 provided, and the individual providing the service. Patient account and
			 financial records shall also include documentation of charges, identify other
			 payment resources pursued, indicate the date and amount of all debit or credit
			 billing actions, and support the appropriateness of the amount billed and paid.
			 For cost reimbursed services, the provider shall maintain adequate records to
			 thoroughly explain how the amounts reported on the cost statement were
			 determined. The records shall be accurate and in sufficient detail to
			 substantiate the data reported;
(b)
			 Clinical records, including records of all therapeutic services, shall document
			 the client's diagnosis and the medical need for the service. The client's
			 record shall be annotated each time a service is provided and signed or
			 initialed by the individual who provided the service or shall clearly indicate
			 the individual who provided the service. For purposes of medical review, the
			 Authority adopts Medicare's electronic signature policy as outlined in the CMS
			 Medicare Program Integrity Manual. Information contained in the record shall be
			 appropriate in quality and quantity to meet the professional standards
			 applicable to the provider or practitioner and any additional standards for
			 documentation found in this rule, the individual provider rules, and any
			 relevant contracts. When a provider maintains records electronically, within an
			 EHR, EMR or other electronic clinical trial management or billing system, the
			 provider must be able to provide:
(A) hard
			 copy versions, upon request; and
(B) an auditable means of demonstrating the
			 date the record was created, the identity of the creator of a record, the date
			 the record was modified, what was modified in the record, and the identity and
			 credentials of any individual who has modified the record.
(C) If the provider maintains records
			 electronically or permits the use of electronic signatures, the provider must
			 document any aspect of the provision of services. The provider must maintain
			 appropriate safeguards to assure the authenticity of the electronic records and
			 signatures.
(c)
			 Electronic Data Transmissions shall comply with the Uniform Electronic
			 Transactions Act cited in ORS chapter 84 and OAR 943-120-0100;
(d) Policies and procedures shall ensure the
			 maintenance of the confidentiality of medical record information. These
			 procedures ensure the provider may release information in accordance with
			 federal and state statutes, ORS
			 179.505 through
			 179.507,
			 411.320, and
			 433.045, 42 CFR part 2, 42 CFR
			 subpart F, 45 CFR
			 205.50.
(e) Retain clinical records for seven years
			 and financial and other records described in paragraphs (a) and (b) of this
			 rule for at least five years from the date(s) of service.
(f) Record requirements applicable only to
			 providers who are providing routine services for clinical trials:
(A) Information must be retained and provided
			 if requested for medical review, audit or investigation by Authority, DOJ MFCU
			 or other state or federal regulators and shall include:
(i) The trial name, sponsor, and
			 sponsor-assigned protocol number (This is the number assigned by the National
			 Library of Medicine (NLM) ClinicalTrials.gov).
(ii) A copy of the member's signed consent
			 form
(B) Record for
			 clinical trials must be maintained and accessible for 10 years
(C) The records be stored and protected
			 compliant with HIPAA and other applicable standards.