New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 77 - REHABILITATIVE SERVICES FOR CHILDREN
Subchapter 4 - BEHAVIORAL ASSISTANCE SERVICES
Section 10:77-4.12 - Required records for each beneficiary

Universal Citation: NJ Admin Code 10:77-4.12

Current through Register Vol. 56, No. 18, September 16, 2024

(a) Each provider entity shall maintain all records in accordance with Departmental contract rules (see N.J.A.C. 10:3) and in compliance with appropriate Federal and State laws, regulations and rules, including, but not limited to, 10:49-9.8.

(b) Providers shall keep such individual and legible records as are necessary to fully disclose the nature and extent of the services provided in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), P.L. 104-191, August 1996.

(c) Providers shall maintain any information required by the Department of Human Services, Children and Families, the designee of either Department, the contracted system administrator, or the care management organization for services rendered to a child receiving DCF services, including, but not limited to, the outcome measures listed at N.J.A.C. 10:77-4.10.

(d) Providers shall maintain the following data in support of all behavioral assistance services claims:

1. The name and address of the beneficiary;

2. The name and title of the individual providing the service;

3. The exact date(s), location(s) and time(s) of service;

4. The type of activity/service provided in accordance with the goals of the service plan; and

5. The length of face-to-face contact, excluding travel time to or from the location of the beneficiary contact.

(e) The provider shall maintain an individual service record for each child/youth or young adult which shall contain, at a minimum, the following information:

1. The dates of service and the number of care hours received;

2. The diagnosis provided with initial referral;

3. The reason for referral and involvement;

4. The individual behavioral assistance service plan;

5. Documentation of any and all crisis or emergency situations that occur during the provision of the services, including a summary of the corrective action taken and resolution of the situation; and

6. Weekly quantifiable progress notes toward defined goals as stipulated in the child/youth or young adult's BASP.

(f) All providers shall meet all Management Information Systems specifications as provided by the contracted system administrator (CSA) or other Department of Human Services or Children and Families-designated agent.

(g) Providers shall make the records described in (a) through (f) above available to the Department of Human Services, the Division of Medical Assistance and Health Services, the Division of Mental Health and Addiction Services, the Department of Children and Families, the Division of Child Protection and Permanency, the Children's System of Care, the contracted system administrator, or other authorized State agents, as requested.

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