New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 79B - COMMUNITY SUPPORT SERVICES FOR ADULTS WITH MENTAL ILLNESS
Subchapter 2 - PROGRAM STANDARDS
Section 10:79B-2.5 - Recordkeeping

Universal Citation: NJ Admin Code 10:79B-2.5

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

(a) All CSS providers shall keep such legible records as are necessary to fully disclose the kind and extent of services provided, who provided the service along with their credential, and must meet the requirements of N.J.A.C. 10:37B, as well as describe the medical necessity for such services, and the place, date, and the total units of service that were provided.

(b) Recordkeeping for CSS services shall include clinical records, reports for each individual beneficiary, and all documentation required under 30:4D-12 , N.J.A.C. 10:37B and 10:49, and this chapter. These reports shall minimally cover the medical, nursing, social, and health-related care rendered to the beneficiary, in accordance with accepted professional standards.

(c) The IRP shall identify those services to be provided, the credential of the practitioner providing the service, the amount of time that will be devoted to the provision of the service, and the location of services to be provided. Only those services provided as described in the IRP are reimbursable. The IRP must be amended as required if services not previously documented in the IRP are determined necessary for the beneficiary's treatment in order to ensure proper billing.

(d) The provider shall maintain, at a minimum, the following documentation in support of all claims for payment.

1. The name and Medicaid/NJ FamilyCare health benefits identification number of the beneficiary;

2. The date(s) of service(s);

3. The type(s) of service(s) provided;

4. The duration of the service(s) provided;

5. The name, credential, and title of the employee providing the service;

6. The specific location at which the service was provided;

7. CRNA;

8. IRP; and

9. Prior and Continued Stay Authorization Form.

(e) All records shall be made available upon request to representatives of the Department of Human Services or its authorized agents.

(f) All records must be available to all CSS staff working with the client. All staff must have access to review the IRP and documentation of the services provided. All documentation shall be entered into the record within one calendar week.

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