Code of Massachusetts Regulations
130 CMR - DIVISION OF MEDICAL ASSISTANCE
Title 130 CMR 455.000 - Urgent Care Clinic Services
Section 455.422 - Recordkeeping Requirements

Universal Citation: 130 MA Code of Regs 130.455

Current through Register 1531, September 27, 2024

(A) The urgent care clinic is responsible for ensuring the medical necessity of the services and maintaining test results in the member's health record. Payment for any service listed in 130 CMR 455.000 is conditioned upon its full and complete documentation in the member's medical record and must be maintained for at least six years. Payment for maintaining the member's medical record is included in the fee for the service.

(B) In order for a medical record to document completely a service or services to a member, that record must set forth the nature, extent, quality, and necessity of care provided to the member. When the information contained in a member's medical record is not sufficient to document the service for which payment is claimed by the provider, the MassHealth agency will disallow payment for the claimed service.

(C) The MassHealth agency may at its discretion request, and upon such request the UCC must provide, any and all medical records of members corresponding to or documenting the services claimed, in accordance with M.G.L. c. 118E, § 38, and 130 CMR 450.205: Recordkeeping and Disclosure. The MassHealth agency may produce, or at its option may require the UCC to produce, photocopies of medical records instead of actual records when compliance with 130 CMR 455.422(C) would otherwise result in removal of medical records from the UCC's office.

(D) The medical record must include, but is not limited to

(1) the date of each service;

(2) the member's name, address, telephone number, date of birth, and MassHealth identification number;

(3) the name, title, and signature of the person performing the service;

(4) the member's medical history;

(5) the diagnosis or chief complaint;

(6) a written order for the tests or treatment to be performed and the respective results;

(7) the name of the supervising physician;

(8) clear indication of all findings, whether positive or negative, on examination;

(9) any medications administered or prescribed, including strength, dosage, and regimen;

(10) a description of any treatment given;

(11) recommendations for additional treatments or consultations, when applicable;

(12) pertinent findings on examination; and

(13) any medical goods or supplies dispensed or prescribed.

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