Code of Maine Rules
10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES
144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL
Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL)
Chapter II - Specific Policies By Service
Section 144-101-II-93 - Opioid Health Home Services
Subsection 144-101-II-93.07 - DOCUMENTATION AND CONFIDENTIALITY

1. Name, address, birthdate, and MaineCare identification number;

2. Diagnoses that support eligibility for services herein, including the most recent documentation of diagnoses that substantiate ongoing eligibility for services;

3. The comprehensive assessment that must occur within the first thirty (30) days of initiating of services, and with any reassessments that occur;

4. The Plan of Care/ITP and any updates that occur;

5. Correspondence to and from other providers;

6. Release of information statements as necessary, signed by the member, including right notification, rules and regulations, confidentiality statement and release of information;

7. Documentation/record entries (i.e. progress notes) that clearly reflect implementation of the treatment plan and the member's response to treatment, as well as subsequent amendments to the plan. Progress notes for each service provided, including the date of service, the type of service, the place of the service or method of delivery (i.e., phone contact), the goal to which the service relates to, the duration of the service, the progress the member has made towards goal attainment, the signature and credentials of the individual performing the service, whether the individual has declined services in the Plan of Care/ITP, and timelines for obtaining needed services;

8. A record of discharge/transfer planning, beginning at admission and any referrals made; and

9. Adequate clinical documentation to support the phrase of treatment for which the provider is attesting.