The purpose of Rule 59G-1.054, Florida Administrative Code, is to specify recordkeeping and documentation requirements for Florida Medicaid providers.

 

AGENCY FOR HEALTH CARE ADMINISTRATION

Medicaid

RULE NO.: RULE TITLE:

59G-1.054  Recordkeeping and Documentation Requirements

PURPOSE AND EFFECT: The purpose of Rule 59G-1.054, Florida Administrative Code, is to specify recordkeeping and documentation requirements for Florida Medicaid providers.

SUMMARY: The rule describes the required procedures in recordkeeping and documentation for Florida Medicaid providers.

SUMMARY OF STATEMENT OF ESTIMATED REGULATORY COSTS AND LEGISLATIVE RATIFICATION:

The Agency has determined that this will not have an adverse impact on small business or likely increase directly or indirectly regulatory costs in excess of $200,000 in the aggregate within one year after the implementation of the rule. A SERC has not been prepared by the Agency.

The Agency has determined that the proposed rule is not expected to require legislative ratification based on the statement of estimated regulatory costs or if no SERC is required, the information expressly relied upon and described herein: A checklist was prepared by the Agency to determine the need for a SERC. Based on this information at the time of the analysis and pursuant to section 120.541, Florida Statutes, the rule will not require legislative ratification.

Any person who wishes to provide information regarding a statement of estimated regulatory costs, or provide a proposal for a lower cost regulatory alternative must do so in writing within 21 days of this notice.

RULEMAKING AUTHORITY: 409.919 FS.

LAW IMPLEMENTED: 409.907, 409.913 FS.

A HEARING WILL BE HELD AT THE DATE, TIME AND PLACE SHOWN BELOW:

DATE AND TIME: April 27, 2016, 11:00 a.m. – 12:00 p.m.

PLACE: Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Tallahassee, Florida 32308-5407.

Pursuant to the provisions of the Americans with Disabilities Act, any person requiring special accommodations to participate in this workshop/meeting is asked to advise the agency at least 48 hours before the workshop/meeting by contacting: Ray Aldridge. If you are hearing or speech impaired, please contact the agency using the Florida Relay Service, 1(800)955-8771 (TDD) or 1(800)955-8770 (Voice).

THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE IS: Ray Aldridge, Bureau of Medicaid Policy, 2727 Mahan Drive, Mail Stop 20, Tallahassee, Florida 32308-5407, telephone: [phone], e-mail: [e-mail]. Official comments to be entered into the rule record will be received from the date of this notice until May 2, 2016. Comments may be e-mailed to [e-mail]. For general inquiries and questions about the rule, please contact the person specified above.

 

THE FULL TEXT OF THE PROPOSED RULE IS:

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 at the 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, Florida Statutes.

3. Initial rubber stamped signatures.

(b) Providers must document the following information for each service visit or encounter with a Florida Medicaid recipient:

1. Chief complaint of the visit.

2. Dates 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.

(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, Part 164, subpart C, where applicable.

(b) The Agency for Health Care Administration (AHCA) reserves the right to require modifications to a provider’s electronic records policy, if AHCA determines the provider’s electronic records policy does not adequately ensure the validity or security of the provider’s electronic records.

(c) 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, Florida Administrative Code, 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.

(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 must be reproduced onto paper copies unless otherwise authorized by the requestor.

Rulemaking Authority 409.919 FS. Law Implemented 409.907, 409.913 FS. History-New ________.

 

NAME OF PERSON ORIGINATING PROPOSED RULE: Ray Aldridge

NAME OF AGENCY HEAD WHO APPROVED THE PROPOSED RULE: Elizabeth Dudek

DATE PROPOSED RULE APPROVED BY AGENCY HEAD: January 13, 2016

DATE NOTICE OF PROPOSED RULE DEVELOPMENT PUBLISHED IN FAR: October 30, 2015