59G-1.054. Recordkeeping and Documentation Requirements

(1) This rule applies to providers rendering Florida Medicaid services to recipients.

(2) Documentation Requirements.

(a) All Florida Medicaid providers must:

1. Ensure medical records establish the medical necessity for and the extent of services provided.

2. Sign and date each medical record within two business days from the date and time of service, or otherwise authenticate the record by signature, written initials, or computer entry. Electronic signatures are permissible as defined in Chapter 668, Part I, F.S.

3. Initial rubber stamped signatures.

(b) Unless otherwise specified in Florida Medicaid coverage policies, providers must document the following information for each service visit or encounter with a Florida Medicaid recipient:

1. Chief complaint of the visit.

2. Date(s) of service.

3. Description of services rendered (as applicable).

4. Diagnosis.

5. Diagnostic tests and results (as applicable).

6. History and physical assessment (as applicable).

7. Prescribed or provided medications and supplies (as applicable).

8. Progress reports.

9. Referrals to other services (as applicable).

10. Scheduling frequency for follow-up or other services (as applicable).

11. Treatment plan (as applicable).

(3) Electronic Records.

(a) Providers that create or maintain electronic records must develop and implement an electronic records policy to comply with the applicable state and federal laws, rules, and regulations to ensure the validity and security of electronic records. Electronic record policies must address the technical safeguards required by Title 45, Code of Federal Regulations, section 164.312, where applicable.

(b) Providers that maintain electronic records must have the ability to produce electronic records in a paper format within a reasonable time, upon AHCA’s request.

(4) Recordkeeping Requirements. Providers must retain all business records, medical-related records, and medical records, as defined in Rule 59G-1.010, F.A.C., according to the requirements specified below, as applicable:

(a) Providers may maintain records on paper, magnetic material, film, or other media including electronic storage, except as otherwise required by law or Florida Medicaid requirements. All records must be accessible, legible, and comprehensible.

(b) Providers must retain all records related to services rendered to Florida Medicaid recipients for a period of at least five years from the date of service. Medicare crossover-only providers must retain health care service records for six years.

(5) Copying or Transferring Records.

(a) Providers may seek reimbursement from a recipient for copying medical records at the recipient’s request when the provider’s standard policy is to bill all patients for copying medical records and the recipient is notified of the copying charge before the records are copied.

(b) Providers may not seek reimbursement from the recipient or AHCA for copying records requested by AHCA or any other state or federal agency or their authorized representatives.

(6) Right to Review Records.

(a) Authorized state and federal agencies, and their authorized representatives, may audit or examine provider records. This examination includes all records these agencies find necessary to determine whether Florida Medicaid payment amounts were, or are, due. This requirement applies to the provider’s records and records for which the provider is the custodian. Providers must give authorized state and federal agencies, and their authorized representatives, access to all Florida Medicaid recipient records and any other information that cannot be separated from Florida Medicaid-related records.

(b) Providers must send, at their expense, legible copies of all Florida Medicaid-related information to the authorized state and federal agencies or their authorized representatives upon their request.

(c) All records must be provided regardless of the media format on which the original records are retained by the provider at the time of the request. All medical records may be reproduced electronically or onto paper copies as authorized by the requestor.

Rulemaking Authority 409.919 FS. Law Implemented 409.907, 409.913 FS. History‒New 7-17-16, Amended 5-8-17.