Requirements for Financial, Clinical and Other Records
(1)The Center is responsible for analyzing and monitoring the operation of ScreenWise BCC and for auditing and verifying the accuracy and appropriateness of payment, utilization of services, the quality of care, and access to care. The provider shall:
(a)Develop and maintain adequate financial and clinical records and other documentation which supports the services for which payment has been requested. Payment will be made only for services that are adequately documented.
(b)All medical records must document the service provided, primary diagnosis code for the services, the date on which the service was provided, and the individual who provided the services. Patient account and financial records must also include documentation of charges, identify other payment resources pursued, indicate the date and amount of all debit or credit billing actions, and support the appropriateness of the amount billed and paid. The records must be accurate and in sufficient detail to substantiate the data reported.
(2)Clinical records must sufficiently document that the client’s services were primarily for breast or cervical cancer screening or diagnosis of breast or cervical cancer. The client’s record must be annotated each time a service is provided and signed or initialed by the individual who provided the service or must clearly indicate the individual who provided the service. Information contained in the record must meet the standards of care for breast and cervical cancer screening and diagnosis, and must be appropriate in quality and quantity to meet the professional standards applicable to the provider or practitioner and any additional standards for documentation set forth in this rule.
(3)The provider must have policies and procedures to ensure the maintenance of the confidentiality of medical record information. These procedures ensure that the provider may release such information in accordance with federal and state statutes, ORS 179.505 (Disclosure of written accounts by health care services provider), 411.320 (Disclosure and use of records limited to purposes connected to administration of public assistance programs), 45 CFR 205.50.
(4)The provider must retain clinical, financial and other records described in this rule for at least four years from the date of last activity.
(5)Upon written request from the Center, the Authority, the Oregon Department of Justice Medicaid Fraud Unit, the Oregon Secretary of State, or their authorized representatives (Requestor), the provider must furnish requested documentation, without charge, immediately or within the time-frame specified in the written request. Copies of the documents may be furnished unless the originals are requested. At their discretion, representatives of the Requestor may review and copy the original documentation in the provider’s place of business. Upon the written request of the provider, the Requestor may, at their sole discretion, modify or extend the time for provision of such records if, in the opinion of the Center, good cause for such extension is shown. Factors used in determining whether good cause exists include:
(a)Whether the written request was made in advance of the deadline for production;
(b)If the written request is made after the deadline for production, the amount of time elapsed since that deadline;
(c)The efforts already made to comply with the request;
(d)The reasons the deadline cannot be met;
(e)The degree of control that the provider had over its ability to produce the records prior to the deadline; and
(f)Other extenuating factors.
(6)Access to records, inclusive of medical charts and financial records, does not require authorization or release from the client if the purpose of such access is to:
(a)Perform billing review activities;
(b)Perform utilization review activities;
(c)Review quality, quantity and services provided;
(d)Facilitate payment authorization and related services;
(e)Investigate a client’s fair hearing request;
(f)Facilitate investigation by the Authority;
(g)Where review of records is necessary to the operation of the program.
(7)Failure to comply with requests for documents and within the specified time-frames means that the records subject to the request may be deemed by the Authority not to exist for purposes of verifying appropriateness of payment, medical appropriateness, the quality of care, and the access to care in an audit or overpayment determination, and accordingly subjects the provider to possible denial or recovery of payments made by the Authority, or to sanctions.
Rule 333-010-0160 — Requirements for Financial, Clinical and Other Records,