A provider must maintain all the records necessary to fully
disclose the nature, quality, amount and medical necessity of services
furnished to an eligible recipient who is currently receiving or who has
received services in the past. (42 CFR
431.107(b)). Services billed
to MAD not substantiated in the eligible recipient's records are subject to
recoupment. Failure to maintain records for the required time period is a
violation of the Medicaid Provider Act, Section 27-11-1, et. seq. NMSA 1978,
and a crime punishable under the Medicaid Fraud Act, Section 30.44-5 NMSA 1978.
See 8.351.2 NMAC, Sanctions and Remedies.
A. Detail required in records: Provider
records must be sufficiently detailed to substantiate the date, time, eligible
recipient name, rendering, attending, ordering or prescribing provider; level
and quantity of services; length of a session of service billed, diagnosis and
medical necessity of any service.
(1) When
codes, such as the international classification of disease (ICD) or current
procedural terminology (CPT), are used as the basis for reimbursement, provider
records must be sufficiently detailed to substantiate the codes used on the
claim form.
(2) Treatment plans or
other plans of care must be sufficiently detailed to substantiate the level of
need, supervision, and direction and service(s) needed by the eligible
recipient.
B.
Documentation of test results: Results of tests and services must be
documented, which includes results of laboratory and radiology procedures or
progress following therapy or treatment.
C. Services billed by units of time: Services
billed on the basis of time units spent with an eligible recipient must be
sufficiently detailed to document the actual time spent with the eligible
recipient and the services provided during that time unit.
D. Recipient funds accounting systems: If an
eligible recipient entrusts their personal funds to a nursing facility,
intermediate care facility for the intellectually disabled, or swing bed
hospital, or any other facility, the facility provider must establish and
maintain an acceptable system of accounting. See 42 CFR
445.22.
E. Record retention: A provider who receives
payment for treatment, services, or goods must retain all medical and business
records relating to any of the following for a period of at least six years
from the payment date:
(1) treatment or care
of any eligible recipient;
(2)
services or goods provided to any eligible recipient;
(3) amounts paid by MAD on behalf of any
eligible recipient; and
(4) any
records required by MAD for the administration of medicaid.
