Florida Administrative Code
59 - AGENCY FOR HEALTH CARE ADMINISTRATION
59G - Medicaid
Chapter 59G-1 - GENERAL MEDICAID
Section 59G-1.054 - Recordkeeping and Documentation Requirements
Universal Citation: FL Admin Code R 59G-1.054
Current through Reg. 50, No. 187; September 24, 2024
(1) This rule applies to providers rendering Florida Medicaid services to recipients.
(2) Documentation Requirements.
(a) All Florida Medicaid providers must:
1. Ensure medical records establish the
medical necessity for and the extent of services provided.
2. Sign and date each medical record within
two business days from the date and time of service, or otherwise authenticate
the record by signature, written initials, or computer entry. Electronic
signatures are permissible as defined in Chapter 668, Part I, F.S.
3. Initial rubber stamped
signatures.
(b) Unless
otherwise specified in Florida Medicaid coverage policies, providers must
document the following information for each service visit or encounter with a
Florida Medicaid recipient:
1. Chief complaint
of the visit.
2. Date(s) of
service.
3. Description of services
rendered (as applicable).
4.
Diagnosis.
5. Diagnostic tests and
results (as applicable).
6. History
and physical assessment (as applicable).
7. Prescribed or provided medications and
supplies (as applicable).
8.
Progress reports.
9. Referrals to
other services (as applicable).
10.
Scheduling frequency for follow-up or other services (as applicable).
11. Treatment plan (as
applicable).
(3) Electronic Records.
(a) Providers that create or maintain
electronic records must develop and implement an electronic records policy to
comply with the applicable state and federal laws, rules, and regulations to
ensure the validity and security of electronic records. Electronic record
policies must address the technical safeguards required by Title 45, Code of
Federal Regulations, section 164.312, where applicable.
(b) Providers that maintain electronic
records must have the ability to produce electronic records in a paper format
within a reasonable time, upon AHCA's request.
(4) Recordkeeping Requirements. Providers must retain all business records, medical-related records, and medical records, as defined in Rule 59G-1.010, F.A.C., according to the requirements specified below, as applicable:
(a) Providers may maintain records on paper,
magnetic material, film, or other media including electronic storage, except as
otherwise required by law or Florida Medicaid requirements. All records must be
accessible, legible, and comprehensible.
(b) Providers must retain all records related
to services rendered to Florida Medicaid recipients for a period of at least
five years from the date of service. Medicare crossover-only providers must
retain health care service records for six years.
(5) Copying or Transferring Records.
(a) Providers may seek reimbursement from a
recipient for copying medical records at the recipient's request when the
provider's standard policy is to bill all patients for copying medical records
and the recipient is notified of the copying charge before the records are
copied.
(b) Providers may not seek
reimbursement from the recipient or AHCA for copying records requested by AHCA
or any other state or federal agency or their authorized
representatives.
(6) Right to Review Records.
(a) Authorized state
and federal agencies, and their authorized representatives, may audit or
examine provider records. This examination includes all records these agencies
find necessary to determine whether Florida Medicaid payment amounts were, or
are, due. This requirement applies to the provider's records and records for
which the provider is the custodian. Providers must give authorized state and
federal agencies, and their authorized representatives, access to all Florida
Medicaid recipient records and any other information that cannot be separated
from Florida Medicaid-related records.
(b) Providers must send, at their expense,
legible copies of all Florida Medicaid-related information to the authorized
state and federal agencies or their authorized representatives upon their
request.
(c) All records must be
provided regardless of the media format on which the original records are
retained by the provider at the time of the request. All medical records may be
reproduced electronically or onto paper copies as authorized by the
requestor.
Rulemaking Authority 409.919 FS. Law Implemented 409.907, 409.913 FS.
New 7-17-16, Amended 5-8-17.
Disclaimer: These regulations may not be the most recent version. Florida may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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