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

Universal Citation: 130 MA Code of Regs 130.410

Current through Register 1531, September 27, 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.

(E) When a member is referred from a private physician to a hospital outpatient department exclusively for the purpose of a diagnostic test, the following information, at a minimum, must be included in the member's medical record:

(1) the member's name and date of birth;

(2) the signed referral from the private physician authorizing the procedure;

(3) the date of service;

(4) the name and title of the person who performed the service; and

(5) a clear indication of all findings, whether positive or negative.

(F) For therapist services, in addition to the applicable information required in 130 CMR 410.409(D), the member's medical record must include at least the required records and information set forth in 130 CMR 410.453.

(G) For mental health services, in addition to the applicable information required in 130 CMR 410.409(D), the member's medical record must include at least the required records and information set forth in 130 CMR 410.478.

(H) Hospital pharmacies must maintain a record for each member of the drug and amount dispensed, the date, and the original prescription (see also 130 CMR 406.000: Pharmacy Services and 130 CMR 450.205: Recordkeeping and Disclosure).

(I) For vision care services, in addition to the applicable information required in 130 CMR 410.409(D), the record must fully disclose all pertinent information about the services provided, including the date of service, the dates on which materials were ordered and dispensed, and a description of materials (including the frame style and the manufacturer's name) ordered and dispensed. Additional recordkeeping requirements for vision care services that must be followed are set forth in 130 CMR 402.000: Vision Services.

(J) For laboratory services, in addition to the applicable information required in 130 CMR 410.409(D), the member's medical record must contain a suitable record of each specimen and laboratory test result for at least six years from the date on which the results were reported to the authorized prescriber. Such a record must contain at least the information as specified in the MassHealth Independent Clinical Laboratory regulations at 130 CMR 401.417: Recordkeeping Requirements (see also 130 CMR 410.458) .

Disclaimer: These regulations may not be the most recent version. Massachusetts 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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