Requirements for Financial, Clinical and Other Records
(1)An enrolling provider shall:
(a)Develop and maintain adequate financial and clinical records and other documentation that supports the services for which payment has been requested;
(b)Ensure that all medical records 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;
(c)Ensure that patient account and financial records 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 in accurate and sufficient detail to substantiate the data reported;
(d)Ensure that clinical records sufficiently document that the client’s services were primarily for heart disease, stroke and diabetes;
(e)Ensure that each time a service is provided to a client, the client’s record is signed or initialed by the individual who provided the service or otherwise clearly indicates who provided the service;
(f)Ensure that the information contained in the record reflects that the standard of care for heart disease, stroke and diabetes screening and services were met;
(g)Have policies and procedures to ensure the confidentiality of medical records and that address the circumstances under which information may be released in accordance with federal and state law; and
(h)Retain client enrollment forms, clinical, financial and other records described in this rule for at least four years from the date of last activity.
(2)The Center, the Authority, the Oregon Department of Justice Medicaid Fraud Unit, the Oregon Secretary of State, or their authorized representatives (requestor) may request, in writing, any records related to an enrolling or ancillary provider’s participation in the WW Program, including client medical records. An enrolling or ancillary provider shall furnish requested records, 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 the requestor’s 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 its sole discretion, modify or extend the time for provision of such records for good cause shown.
(3)Failure to comply with requests for documents 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 333-010-0270 — Requirements for Financial, Clinical and Other Records,