Common use of RECORD RETENTION AND PROVIDER/SUBCONTRACTOR DOCUMENTATION REQUIREMENTS Clause in Contracts

RECORD RETENTION AND PROVIDER/SUBCONTRACTOR DOCUMENTATION REQUIREMENTS. Provider/Subcontractor Documentation Requirements - The provider/subcontractor shall, at a minimum, maintain such records as are necessary to fully disclose the nature and extent of services provided, in accordance with N.J.S.A. 30:4D-12(d) and N.J.A.C. 10:49-9.8. The provider/subcontractor shall also comply with the documentation requirements set forth in this Section M, as applicable. To the extent that the Contractor has imposed more stringent requirements than those imposed by law, regulation or this Section M, the more stringent requirements shall prevail. The provisions of N.J.S.A 30:4D-12(e) and N.J.A.C. 10:49- 5.5(a)13.i. through iv. may apply to these documentation requirements. Record Retention Requirements - Records must be retained for the later of ten (10) years from the date of service or after the final payment is made under the provider contract/subcontract and all pending matters are closed. 1. Medical supplies and DME: a. Medical supplies and equipment require a legible, dated prescription or a dated Certificate of Medical Necessity (CMN) personally or electronically signed by the prescribing practitioner. Either document shall contain the following information: i. The beneficiary's name, address, gender and Medicaid/NJ FamilyCare eligibility identification number; ii. A detailed description of the specific supplies and/or equipment prescribed; 1) For example, the phrase "wheelchair" or "patient needs wheelchair" is insufficient. The order shall describe the type and style of the wheelchair; iii. The length of time the medical equipment items or supplies are required; iv. A diagnosis and summary of the patient's physical condition to support the need for the item(s) prescribed; and v. The prescriber’s printed name, address and signature. 2. Orders for laboratory tests: a. All orders for clinical laboratory services shall be in the form of an explicit order personally signed by the physician or other practitioner whose license permits them to request the services, or be in an alternative form of order specifically authorized in (b) (i) through (iii) below. All orders shall be patient specific, contain the specific clinical laboratory test(s) requested, seek only medically necessary tests, shall be on file with the billing laboratory, and shall be available for review by Medicaid/NJ FamilyCare representatives upon request. b. If a signed order is not utilized, then clinical laboratory services shall be ordered in one of the following ways: i. In the absence of a written order, the patient's chart or medical record may be used as the test requisition or authorization, but must be physically present at the laboratory at the time of testing and available to Federal or State representatives upon request; ii. A test request also may be submitted to the laboratory electronically if the system used to generate and transmit the electronic order has adequate security and system safeguards to prevent and detect fraud and abuse and to protect patient confidentiality. The system shall be designed to prevent and detect unauthorized access and modification or manipulation of records, and shall include, at a minimum, electronic encryption; or iii. Telephoned or other oral laboratory orders are also permissible, but shall be followed up with a written or electronic request within 30 days of the telephone or other oral request, which shall be maintained on file with the clinical laboratory. If the laboratory is unable to obtain the written or electronic request, it must maintain documentation of its efforts to obtain them. c. Standing orders shall be: i. Patient specific, and not blanket requests from the physician or licensed practitioner; ii. Medically necessary and related to the diagnosis of the recipient; and iii. Effective for no longer than a 12-month period from the date of the physician’s/practitioner’s orders. d. The laboratory must ensure that all orders described in (a) through (c) above contain the following information: i. The name and address or other suitable identifiers of the authorized person requesting the test and, if appropriate, the individual responsible for using the test results, or the name and address of the laboratory submitting the specimen, including, as applicable, a contact person to enable the reporting of imminently life-threatening laboratory results or panic or alert values; ii. The patient’s name or unique patient identifier; iii. The sex (if known) and date of birth of the patient; iv. The specific test(s) to be performed; v. The source of the specimen, when appropriate; vi. The date and, if appropriate, time of specimen collection; vii. For Pap smears, the patient’s last menstrual period, and indication of whether the patient had a previous abnormal report, treatment or biopsy; viii. For drug testing, the order shall indicate whether the test is for screening (presumptive) or confirmation (definitive) purposes and the specific drug classes to be tested as defined by the American Medical Association. ix. Any additional information relevant and necessary for a specific test to ensure accurate and timely testing and reporting of results, including interpretation, if applicable. e. All orders and results of the tests billed shall be on file with the billing laboratory performing the tests. The results of the tests, clinical and billing records shall be available for review by Medicaid/NJ FamilyCare representatives. f. The Medicaid/NJ FamilyCare program shall have the right to inspect all records, files and documents of in-State and out-of-State service and reference clinical laboratories which provide laboratory tests and services for Medicaid/NJ FamilyCare beneficiaries. g. All laboratory test orders shall be supported by documentation in the referring physician’s/practitioner’s medical records. h. If the laboratory uploads, transcribes or enters test requisition or authorization information into a record system or a laboratory information system, the laboratory must ensure that the information is transcribed or entered accurately. 3. Services Provided by a Psychologist a. Psychologists shall keep such individual records as may be necessary to disclose fully the kind and extent of services provided and shall make such information available when requested by the New Jersey Medicaid/NJ FamilyCare program or its agents. The recordkeeping shall document the services provided as they relate to the procedure code(s) used for reimbursement purposes (see N.J.A.C. 10:67-3, Healthcare Common Procedure Coding System). b. For the initial examination, the record shall include, as a minimum, the following: i. Date(s) of service rendered; ii. Signature of the psychologist; iii. Chief complaint(s); iv. Pertinent historical, social, emotional, and additional data; v. Reports of evaluation procedures undertaken or ordered; vi. Diagnosis; and vii. The intended course of treatment and tentative prognosis. c. For subsequent progress notes made for each Medicaid/NJ FamilyCare patient contact, the following shall be included on the psychotherapeutic progress note: i. Date(s) and duration of service (for example, hour, half-hour); ii. Signature of the psychologist; iii. Name(s) of modality used, such as individual, group, or family therapy; iv. Notations of progress, impediments, or treatment complications; and v. Other components, such as dates or information not included in (c)1 through 4 above, which may be important to the clinical description and prognosis. vi. One or more of the following components shall be recorded to delineate the visit and establish its uniqueness. (Not all of the components need be included): 1) Symptoms and complaints; 2) Affect; 3) Behavior; 4) Focus topics; and 5) Significant incidents or historical events. 4. Mental Health Services Provided by an Independent Clinic a. An intake evaluation shall be performed within 14 days of the first encounter or by the third clinic visit whichever is later, for each beneficiary being considered for continued treatment. This evaluation shall consist of a written assessment that: i. Evaluates the beneficiary’s mental condition; ii. Determines whether treatment in the program is appropriate, based on the beneficiary’s diagnosis; iii. Includes certification, in the form of a signed statement, by the evaluation team, that the program is appropriate to meet the beneficiary’s treatment needs; and iv. Is made a part of the beneficiary’s records. v. The evaluation for the intake process shall include a physician or advance practice nurse (APN) and an individual experienced in the diagnosis and treatment of mental illness. Both criteria may be satisfied by the same individual, if appropriately qualified. b. A written, individualized plan of care shall be developed for each beneficiary who receives continued treatment. The plan of care shall be designed to improve the beneficiary’s condition to the point where continued participation in the program, beyond occasional maintenance visits, is no longer necessary. The plan of care shall be included in the beneficiary’s records and shall consist of: i. A written description of the treatment objectives including the treatment regimen and the specific medical/remedial services, therapies, and activities that shall be used to meet the objectives. 1) Due to the nature of mental illness and the provision of program services, there may be instances in which a temporary deviation from the services written in the treatment plan occurs. In this event, the client may participate in alternate programming. The reason for the deviation should be clearly explained in the daily or weekly documentation. Deviations that do not resolve shall require a written change in the treatment plan; ii. A projected schedule for service delivery which includes the frequency and duration of each type of planned therapeutic session or encounter; iii. The type of personnel that will be furnishing the services; and iv. A projected schedule for completing the reevaluations of the beneficiary’s condition and updating the plan of care. c. The mental health clinic shall develop and maintain legibly written documentation to support each medical/remedial therapy service, activity, or session for which billing is made. i. This documentation, at a minimum, shall consist of: 1) The specific services rendered, such as individual psychotherapy, group psychotherapy, family therapy, etc., and a description of the encounter itself. The description shall include, but is not limited to, a statement of patient progress noted, significant observations noted, etc.; 2) The date and time that services were rendered; 3) The duration of services provided; 4) The signature of the practitioner or provider who rendered the services; 5) The setting in which services were rendered; and 6) A notation of unusual occurrences or significant deviations from the treatment described in the plan of care. d. Clinical progress, complications and treatment which affect prognosis and/or progress shall be documented in the beneficiary’s medical record at least once a week, as well as any other information important to the clinical picture, therapy and prognosis. e. The individual services under partial care shall be documented on a daily basis. More substantive documentation, including progress notes and any other information important to the clinical picture, are required at least once a week. f. Periodic review of the beneficiary’s plan of care shall take place at least every 90 days during the first year and every six months thereafter. i. The periodic review shall determine: 1) The beneficiary’s progress toward the treatment objectives; 2) The appropriateness of the services being furnished; and 3) The need for the beneficiary’s continued participation in the program. ii. Periodic reviews shall be documented in detail in the beneficiary’s records and made available upon request to the New Jersey Medicaid or NJ FamilyCare program or its agents.

RECORD RETENTION AND PROVIDER/SUBCONTRACTOR DOCUMENTATION REQUIREMENTS. Provider/Subcontractor Documentation Requirements - The provider/subcontractor shall, at a minimum, maintain such records as are necessary to fully disclose the nature and extent of services provided, in accordance with N.J.S.A. 30:4D-12(d) and N.J.A.C. 10:49-9.8. The provider/subcontractor shall also comply with the documentation requirements set forth in this Section M, as applicable. To the extent that the Contractor has imposed more stringent requirements than those imposed by law, regulation or this Section M, the more stringent requirements shall prevail. The provisions of N.J.S.A 30:4D-12(e) and N.J.A.C. 10:49- 10:49-5.5(a)13.i. through iv. may apply to these documentation requirements. Record Retention Requirements - Records must be retained for the later of ten (10) years from the date of service or after the final payment is made under the provider contract/subcontract and all pending matters are closed. 1. Medical supplies and DME: a. Medical supplies and equipment require a legible, dated prescription or a dated Certificate of Medical Necessity (CMN) personally or electronically signed by the prescribing practitioner. Either document shall contain the following information: i. The beneficiary's name, address, gender and Medicaid/NJ FamilyCare eligibility identification number; ii. A detailed description of the specific supplies and/or equipment prescribed; (1) For example, the phrase "wheelchair" or "patient needs wheelchair" is insufficient. The order shall describe the type and style of the wheelchair; iii. The length of time the medical equipment items or supplies are required; iv. A diagnosis and summary of the patient's physical condition to support the need for the item(s) prescribed; and v. The prescriber’s printed name, address and signature. 2. Orders for laboratory tests: a. All orders for clinical laboratory services shall be in the form of an explicit order personally signed by the physician or other practitioner whose license permits them to request the services, or be in an alternative form of order specifically authorized in (b) (i) through (iii) below. All orders shall be patient specific, contain the specific clinical laboratory test(s) requested, seek only medically necessary tests, shall be on file with the billing laboratory, and shall be available for review by Medicaid/NJ FamilyCare representatives upon request. b. If a signed order is not utilized, then clinical laboratory services shall be ordered in one of the following ways: i. In the absence of a written order, the patient's chart or medical record may be used as the test requisition or authorization, but must be physically present at the laboratory at the time of testing and available to Federal or State representatives upon request; ii. A test request also may be submitted to the laboratory electronically if the system used to generate and transmit the electronic order has adequate security and system safeguards to prevent and detect fraud and abuse and to protect patient confidentiality. The system shall be designed to prevent and detect unauthorized access and modification or manipulation of records, and shall include, at a minimum, electronic encryption; or iii. Telephoned or other oral laboratory orders are also permissible, but shall be followed up with a written or electronic request within 30 days of the telephone or other oral request, which shall be maintained on file with the clinical laboratory. If the laboratory is unable to obtain the written or electronic request, it must maintain documentation of its efforts to obtain them. c. Standing orders shall be: i. Patient specific, and not blanket requests from the physician or licensed practitioner; ii. Medically necessary and related to the diagnosis of the recipient; and iii. Effective for no longer than a 12-month period from the date of the physician’s/practitioner’s orders. d. The laboratory must ensure that all orders described in (a) through (c) above contain the following information: i. The name and address or other suitable identifiers of the authorized person requesting the test and, if appropriate, the individual responsible for using the test results, or the name and address of the laboratory submitting the specimen, including, as applicable, a contact person to enable the reporting of imminently life-threatening laboratory results or panic or alert values; ii. The patient’s name or unique patient identifier; iii. The sex (if known) and date of birth of the patient; iv. The specific test(s) to be performed; v. The source of the specimen, when appropriate; vi. The date and, if appropriate, time of specimen collection; vii. For Pap smears, the patient’s last menstrual period, and indication of whether the patient had a previous abnormal report, treatment or biopsy; viii. For drug testing, the order shall indicate whether the test is for screening (presumptive) or confirmation (definitive) purposes and the specific drug classes to be tested as defined by the American Medical Association. ix. Any additional information relevant and necessary for a specific test to ensure accurate and timely testing and reporting of results, including interpretation, if applicable. e. All orders and results of the tests billed shall be on file with the billing laboratory performing the tests. The results of the tests, clinical and billing records shall be available for review by Medicaid/NJ FamilyCare representatives. f. The Medicaid/NJ FamilyCare program shall have the right to inspect all records, files and documents of in-State and out-of-State service and reference clinical laboratories which provide laboratory tests and services for Medicaid/NJ FamilyCare beneficiaries. g. All laboratory test orders shall be supported by documentation in the referring physician’s/practitioner’s medical records. h. If the laboratory uploads, transcribes or enters test requisition or authorization information into a record system or a laboratory information system, the laboratory must ensure that the information is transcribed or entered accurately. 3. Services Provided by a Psychologist a. Psychologists shall keep such individual records as may be necessary to disclose fully the kind and extent of services provided and shall make such information available when requested by the New Jersey Medicaid/NJ FamilyCare program or its agents. The recordkeeping shall document the services provided as they relate to the procedure code(s) used for reimbursement purposes (see N.J.A.C. 10:67-3, Healthcare Common Procedure Coding System). b. For the initial examination, the record shall include, as a minimum, the following: i. Date(s) of service rendered; ii. Signature of the psychologist; iii. Chief complaint(s); iv. Pertinent historical, social, emotional, and additional data; v. Reports of evaluation procedures undertaken or ordered; vi. Diagnosis; and vii. The intended course of treatment and tentative prognosis. c. For subsequent progress notes made for each Medicaid/NJ FamilyCare patient contact, the following shall be included on the psychotherapeutic progress note: i. Date(s) and duration of service (for example, hour, half-hour); ii. Signature of the psychologist; iii. Name(s) of modality used, such as individual, group, or family therapy; iv. Notations of progress, impediments, or treatment complications; and v. Other components, such as dates or information not included in (c)1 through 4 above, which may be important to the clinical description and prognosis. vi. One or more of the following components shall be recorded to delineate the visit and establish its uniqueness. (Not all of the components need be included): (1) Symptoms and complaints; (2) Affect; (3) Behavior; (4) Focus topics; and (5) Significant incidents or historical events. 4. Mental Health Services Provided by an Independent Clinic a. An intake evaluation shall be performed within 14 days of the first encounter or by the third clinic visit whichever is later, for each beneficiary being considered for continued treatment. This evaluation shall consist of a written assessment that: i. Evaluates the beneficiary’s mental condition; ii. Determines whether treatment in the program is appropriate, based on the beneficiary’s diagnosis; iii. Includes certification, in the form of a signed statement, by the evaluation team, that the program is appropriate to meet the beneficiary’s treatment needs; and iv. Is made a part of the beneficiary’s records. v. The evaluation for the intake process shall include a physician or advance practice nurse (APN) and an individual experienced in the diagnosis and treatment of mental illness. Both criteria may be satisfied by the same individual, if appropriately qualified. b. A written, individualized plan of care shall be developed for each beneficiary who receives continued treatment. The plan of care shall be designed to improve the beneficiary’s condition to the point where continued participation in the program, beyond occasional maintenance visits, is no longer necessary. The plan of care shall be included in the beneficiary’s records and shall consist of: i. A written description of the treatment objectives including the treatment regimen and the specific medical/remedial services, therapies, and activities that shall be used to meet the objectives. (1) Due to the nature of mental illness and the provision of program services, there may be instances in which a temporary deviation from the services written in the treatment plan occurs. In this event, the client may participate in alternate programming. The reason for the deviation should be clearly explained in the daily or weekly documentation. Deviations that do not resolve shall require a written change in the treatment plan; ii. A projected schedule for service delivery which includes the frequency and duration of each type of planned therapeutic session or encounter; iii. The type of personnel that will be furnishing the services; and iv. A projected schedule for completing the reevaluations of the beneficiary’s condition and updating the plan of care. c. The mental health clinic shall develop and maintain legibly written documentation to support each medical/remedial therapy service, activity, or session for which billing is made. i. This documentation, at a minimum, shall consist of: (1) The specific services rendered, such as individual psychotherapy, group psychotherapy, family therapy, etc., and a description of the encounter itself. The description shall include, but is not limited to, a statement of patient progress noted, significant observations noted, etc.; (2) The date and time that services were rendered; (3) The duration of services provided; (4) The signature of the practitioner or provider who rendered the services; (5) The setting in which services were rendered; and (6) A notation of unusual occurrences or significant deviations from the treatment described in the plan of care. d. Clinical progress, complications and treatment which affect prognosis and/or progress shall be documented in the beneficiary’s medical record at least once a week, as well as any other information important to the clinical picture, therapy and prognosis. e. The individual services under partial care shall be documented on a daily basis. More substantive documentation, including progress notes and any other information important to the clinical picture, are required at least once a week. f. Periodic review of the beneficiary’s plan of care shall take place at least every 90 days during the first year and every six months thereafter. i. The periodic review shall determine: (1) The beneficiary’s progress toward the treatment objectives; (2) The appropriateness of the services being furnished; and (3) The need for the beneficiary’s continued participation in the program. ii. Periodic reviews shall be documented in detail in the beneficiary’s records and made available upon request to the New Jersey Medicaid or NJ FamilyCare program or its agents.

RECORD RETENTION AND PROVIDER/SUBCONTRACTOR DOCUMENTATION REQUIREMENTS. Provider/Subcontractor Documentation Requirements - The provider/subcontractor shall, at a minimum, maintain such records as are necessary to fully disclose the nature and extent of services provided, in accordance with N.J.S.A. 30:4D-12(d) and N.J.A.C. 10:49-9.8. The provider/subcontractor shall also comply with the documentation requirements set forth in this Section M, as applicable. To the extent that the Contractor has imposed more stringent requirements than those imposed by law, regulation or this Section M, the more stringent requirements shall prevail. The provisions of N.J.S.A 30:4D-12(e) and N.J.A.C. 10:49- 5.5(a)13.i. 10:49-5.5(a)(13)(i) through (iv. ) may apply to these documentation requirements. Record Retention Requirements - Records must be retained for the later of ten (10) years from the date of service or after the final payment is made under the provider contract/subcontract and all pending matters are closed. 1. Medical supplies and DME: a. Medical supplies and equipment require a legible, dated prescription or a dated Certificate of Medical Necessity (CMN) personally or electronically signed by the prescribing practitioner. Either document shall contain the following information: i. The beneficiary's name, address, gender and Medicaid/NJ FamilyCare eligibility identification number; ii. A detailed description of the specific supplies and/or equipment prescribed; (1) For example, the phrase "wheelchair" or "patient needs wheelchair" is insufficient. The order shall describe the type and style of the wheelchair; iii. The length of time the medical equipment items or supplies are required; iv. A diagnosis and summary of the patient's physical condition to support the need for the item(s) prescribed; and v. The prescriber’s 's printed name, address and signature. 2. Orders for laboratory tests: a. All orders for clinical laboratory services shall be in the form of an explicit order personally signed by the physician or other practitioner whose license permits them to request the services, or be in an alternative form of order specifically authorized in (b) (i) through (iii) below. All orders shall be patient specific, contain the specific clinical laboratory test(s) requested, seek only medically necessary tests, shall be on file with the billing laboratory, and shall be available for review by Medicaid/NJ FamilyCare representatives upon request. b. If a signed order is not utilized, then clinical laboratory services shall be ordered in one of the following ways: i. In the absence of a written order, the patient's chart or medical record may be used as the test requisition or authorization, but must be physically present at the laboratory at the time of testing and available to Federal or State representatives upon request; ii. A test request also may be submitted to the laboratory electronically if the system used to generate and transmit the electronic order has adequate security and system safeguards to prevent and detect fraud and abuse and to protect patient confidentiality. The system shall be designed to prevent and detect unauthorized access and modification or manipulation of records, and shall include, at a minimum, electronic encryption; or iii. Telephoned or other oral laboratory orders are also permissible, but shall be followed up with a written or electronic request within 30 days of the telephone or other oral request, which shall be maintained on file with the clinical laboratory. If the laboratory is unable to obtain the written or electronic request, it must maintain documentation of its efforts to obtain them. c. Standing orders shall be: i. Patient specific, and not blanket requests from the physician or licensed practitioner; ii. Medically necessary and related to the diagnosis of the recipient; and iii. Effective for no longer than a 12-month period from the date of the physician’sphysician's/practitioner’s orders's order. d. The laboratory must ensure that all orders described in (a) through (c) above contain the following information: i. The name and address or other suitable identifiers of the authorized person requesting the test and, if appropriate, the individual responsible for using the test results, or the name and address of the laboratory submitting the specimen, including, as applicable, a contact person to enable the reporting of imminently life-threatening laboratory results or panic or alert values; ii. The patient’s 's name or unique patient identifier; iii. The sex (if known) and date of birth of the patient; iv. The specific test(s) to be performed; v. The source of the specimen, when appropriate; vi. The date and, if appropriate, time of specimen collection; vii. For Pap smears, the patient’s 's last menstrual period, and indication of whether the patient had a previous abnormal report, treatment or biopsy; viii. For drug testing, the order shall indicate whether the test is for screening (presumptive) or confirmation (definitive) purposes and the specific drug classes to be tested as defined by the American Medical Association.; ix. Any additional information relevant and necessary for a specific test to ensure accurate and timely testing and reporting of results, including interpretation, if applicable. e. All orders and results of the tests billed shall be on file with the billing laboratory performing the tests. The results of the tests, clinical and billing records shall be available for review by Medicaid/NJ FamilyCare representatives. f. The Medicaid/NJ FamilyCare program shall have the right to inspect all records, files and documents of in-State and out-of-State service and reference clinical laboratories which provide laboratory tests and services for Medicaid/NJ FamilyCare beneficiaries. g. All laboratory test orders shall be supported by documentation in the referring physician’sphysician's/practitioner’s 's medical records. h. If the laboratory uploads, transcribes or enters test requisition or authorization information into a record system or a laboratory information system, the laboratory must ensure that the information is transcribed or entered accurately. 3. Services Provided by a Psychologist a. Psychologists shall keep such individual records as may be necessary to disclose fully the kind and extent of services provided and shall make such information available when requested by the New Jersey Medicaid/NJ FamilyCare program or its agents. The recordkeeping shall document the services provided as they relate to the procedure code(s) used for reimbursement purposes (see N.J.A.C. 10:67-3, Healthcare Common Procedure Coding System). b. For the initial examination, the record shall include, as a minimum, the following: i. Date(s) of service rendered; ii. Signature of the psychologist; iii. Chief complaint(s); iv. Pertinent historical, social, emotional, and additional data; v. Reports of evaluation procedures undertaken or ordered; vi. Diagnosis; and vii. The intended course of treatment and tentative prognosis. c. For subsequent progress notes made for each Medicaid/Medicaid/ NJ FamilyCare patient contact, the following shall be included on the psychotherapeutic progress note: i. Date(s) and duration of service (for example, hour, half-hour); ii. Signature of the psychologist; iii. Name(s) of modality used, such as individual, group, or family therapy; iv. Notations of progress, impediments, or treatment complications; and v. Other components, such as dates or information not included in (c)1 through 4 above, which may be important to the clinical description and prognosis. vi. One or more of the following components shall be recorded to delineate the visit and establish its uniqueness. (Not all of the components need be included): (1) Symptoms and complaints; (2) Affect; (3) Behavior; (4) Focus topics; and (5) Significant incidents or historical events. 4. Mental Health Services Provided by an Independent Clinic a. An intake evaluation shall be performed within 14 days of the first encounter or by the third clinic visit visit, whichever is later, for each beneficiary being considered for continued treatment. This evaluation shall consist of a written assessment that: i. Evaluates the beneficiary’s 's mental condition; ii. Determines whether treatment in the program is appropriate, based on the beneficiary’s 's diagnosis; iii. Includes certification, in the form of a signed statement, by the evaluation team, that the program is appropriate to meet the beneficiary’s 's treatment needs; and iv. Is made a part of the beneficiary’s 's records. v. The evaluation for the intake process shall include a physician or advance practice nurse (APN) and an individual experienced in the diagnosis and treatment of mental illness. Both criteria may be satisfied by the same individual, if appropriately qualified. b. A written, individualized plan of care shall be developed for each beneficiary who receives continued treatment. The plan of care shall be designed to improve the beneficiary’s 's condition to the point where continued participation in the program, beyond occasional maintenance visits, is no longer necessary. The plan of care shall be included in the beneficiary’s 's records and shall consist of: i. A written description of the treatment objectives including the treatment regimen and the specific medical/remedial services, therapies, and activities that shall be used to meet the objectives. (1) Due to the nature of mental illness and the provision of program services, there may be instances in which a temporary deviation from the services written in the treatment plan occurs. In this event, the client may participate in alternate programming. The reason for the deviation should be clearly explained in the daily or weekly documentation. Deviations that do not resolve shall require a written change in the treatment plan; ii. A projected schedule for service delivery which includes the frequency and duration of each type of planned therapeutic session or encounter; iii. The type of personnel that will be furnishing the services; and iv. A projected schedule for completing the reevaluations of the beneficiary’s 's condition and updating the plan of care. c. The mental health clinic shall develop and maintain legibly written documentation to support each medical/remedial therapy service, activity, or session for which billing is made. i. This documentation, at a minimum, shall consist of: (1) The specific services rendered, such as individual psychotherapy, group psychotherapy, family therapy, etc., and a description of the encounter itself. The description shall include, but is not limited to, a statement of patient progress noted, significant observations noted, etc.; (2) The the date and time that services were rendered; (3) The duration of services provided; (4) The signature of the practitioner or provider who rendered the services; (5) The setting in which services were rendered; and (6) A notation of unusual occurrences or significant deviations from the treatment described in the plan of care. d. Clinical progress, complications and treatment which affect prognosis and/or progress shall be documented in the beneficiary’s 's medical record at least once a week, as well as any other information important to the clinical picture, therapy therapy, and prognosis. e. The individual services under partial care shall be documented on a daily basis. More substantive documentation, including progress notes and any other information important to the clinical picture, are required at least once a week. f. Periodic review of the beneficiary’s 's plan of care shall take place at least every 90 days during the first year and every six months thereafter. i. The periodic review shall determine: (1) The beneficiary’s 's progress toward the treatment objectives; (2) The appropriateness of the services being furnished; and (3) The need for the beneficiary’s 's continued participation in the program. ii. Periodic reviews shall be documented in detail in the beneficiary’s 's records and made available upon request to the New Jersey Medicaid or NJ FamilyCare program or its agents.

RECORD RETENTION AND PROVIDER/SUBCONTRACTOR DOCUMENTATION REQUIREMENTS. Provider/Subcontractor Documentation Requirements - The provider/subcontractor shall, at a minimum, maintain such records as are necessary to fully disclose the nature and extent of services provided, in accordance with N.J.S.A. 30:4D-12(d) and N.J.A.C. 10:49-9.8. The provider/subcontractor shall also comply with the documentation requirements set forth in this Section M, as applicable. To the extent that the Contractor has imposed more stringent requirements than those imposed by law, regulation or this Section M, the more stringent requirements shall prevail. The provisions of N.J.S.A 30:4D-12(e) and N.J.A.C. 10:49- 5.5(a)13.i. through iv. may apply to these documentation requirements. Record Retention Requirements - Records must be retained for the later of ten (10) years from the date of service or after the final payment is made under the provider contract/subcontract and all pending matters are closed. 1. Medical supplies and DME: a. Medical supplies and equipment require a legible, dated prescription or a dated Certificate of Medical Necessity (CMN) personally or electronically signed by the prescribing practitioner. Either document shall contain the following information: i. The beneficiary's name, address, gender and Medicaid/NJ FamilyCare eligibility identification number; ii. A detailed description of the specific supplies and/or equipment prescribed; (1) For example, the phrase "wheelchair" or "patient needs wheelchair" is insufficient. The order shall describe the type and style of the wheelchair; iii. The length of time the medical equipment items or supplies are required; iv. A diagnosis and summary of the patient's physical condition to support the need for the item(s) prescribed; and v. The prescriber’s printed name, address and signature. 2. Orders for laboratory tests: a. All orders for clinical laboratory services shall be in the form of an explicit order personally signed by the physician or other practitioner whose license permits them to request the services, or be in an alternative form of order specifically authorized in (b) (i) through (iii) below. All orders shall be patient specific, contain the specific clinical laboratory test(s) requested, seek only medically necessary tests, shall be on file with the billing laboratory, and shall be available for review by Medicaid/NJ FamilyCare representatives upon request. b. If a signed order is not utilized, then clinical laboratory services shall be ordered in one of the following ways: i. In the absence of a written order, the patient's chart or medical record may be used as the test requisition or authorization, but must be physically present at the laboratory at the time of testing and available to Federal or State representatives upon request; ii. A test request also may be submitted to the laboratory electronically if the system used to generate and transmit the electronic order has adequate security and system safeguards to prevent and detect fraud and abuse and to protect patient confidentiality. The system shall be designed to prevent and detect unauthorized access and modification or manipulation of records, and shall include, at a minimum, electronic encryption; or iii. Telephoned or other oral laboratory orders are also permissible, but shall be followed up with a written or electronic request within 30 days of the telephone or other oral request, which shall be maintained on file with the clinical laboratory. If the laboratory is unable to obtain the written or electronic request, it must maintain documentation of its efforts to obtain them. c. Standing orders shall be: i. Patient specific, and not blanket requests from the physician or licensed practitioner; ii. Medically necessary and related to the diagnosis of the recipient; and iii. Effective for no longer than a 12-month period from the date of the physician’s/practitioner’s orders. d. The laboratory must ensure that all orders described in (a) through (c) above contain the following information: i. The name and address or other suitable identifiers of the authorized person requesting the test and, if appropriate, the individual responsible for using the test results, or the name and address of the laboratory submitting the specimen, including, as applicable, a contact person to enable the reporting of imminently life-threatening laboratory results or panic or alert values; ii. The patient’s name or unique patient identifier; iii. The sex (if known) and date of birth of the patient; iv. The specific test(s) to be performed; v. The source of the specimen, when appropriate; vi. The date and, if appropriate, time of specimen collection; vii. For Pap smears, the patient’s last menstrual period, and indication of whether the patient had a previous abnormal report, treatment or biopsy; viii. For drug testing, the order shall indicate whether the test is for screening (presumptive) or confirmation (definitive) purposes and the specific drug classes to be tested as defined by the American Medical Association. ix. Any additional information relevant and necessary for a specific test to ensure accurate and timely testing and reporting of results, including interpretation, if applicable. e. All orders and results of the tests billed shall be on file with the billing laboratory performing the tests. The results of the tests, clinical and billing records shall be available for review by Medicaid/NJ FamilyCare representatives. f. The Medicaid/NJ FamilyCare program shall have the right to inspect all records, files and documents of in-State and out-of-State service and reference clinical laboratories which provide laboratory tests and services for Medicaid/NJ FamilyCare beneficiaries. g. All laboratory test orders shall be supported by documentation in the referring physician’s/practitioner’s medical records. h. i. If the laboratory uploads, transcribes or enters test requisition or authorization information into a record system or a laboratory information system, the laboratory must ensure that the information is transcribed or entered accurately. 3. Services Provided by a Psychologist a. Psychologists shall keep such individual records as may be necessary to disclose fully the kind and extent of services provided and shall make such information available when requested by the New Jersey Medicaid/NJ FamilyCare program or its agents. The recordkeeping shall document the services provided as they relate to the procedure code(s) used for reimbursement purposes (see N.J.A.C. 10:67-3, Healthcare Common Procedure Coding System). b. For the initial examination, the record shall include, as a minimum, the following: i. Date(s) of service rendered; ii. Signature of the psychologist; iii. Chief complaint(s); iv. Pertinent historical, social, emotional, and additional data; v. Reports of evaluation procedures undertaken or ordered; vi. Diagnosis; and vii. The intended course of treatment and tentative prognosis. c. For subsequent progress notes made for each Medicaid/NJ FamilyCare patient contact, the following shall be included on the psychotherapeutic progress note: i. Date(s) and duration of service (for example, hour, half-hour); ii. Signature of the psychologist; iii. Name(s) of modality used, such as individual, group, or family therapy; iv. Notations of progress, impediments, or treatment complications; and v. Other components, such as dates or information not included in (c)1 through 4 above, which may be important to the clinical description and prognosis. vi. One or more of the following components shall be recorded to delineate the visit and establish its uniqueness. (Not all of the components need be included): (1) Symptoms and complaints; (2) Affect; (3) Behavior; (4) Focus topics; and (5) Significant incidents or historical events. 4. Mental Health Services Provided by an Independent Clinic a. An intake evaluation shall be performed within 14 days of the first encounter or by the third clinic visit whichever is later, for each beneficiary being considered for continued treatment. This evaluation shall consist of a written assessment that: i. Evaluates the beneficiary’s mental condition; ii. Determines whether treatment in the program is appropriate, based on the beneficiary’s diagnosis; iii. Includes certification, in the form of a signed statement, by the evaluation team, that the program is appropriate to meet the beneficiary’s treatment needs; and iv. Is made a part of the beneficiary’s records. v. The evaluation for the intake process shall include a physician or advance practice nurse (APN) and an individual experienced in the diagnosis and treatment of mental illness. Both criteria may be satisfied by the same individual, if appropriately qualified. b. A written, individualized plan of care shall be developed for each beneficiary who receives continued treatment. The plan of care shall be designed to improve the beneficiary’s condition to the point where continued participation in the program, beyond occasional maintenance visits, is no longer necessary. The plan of care shall be included in the beneficiary’s records and shall consist of: i. A written description of the treatment objectives including the treatment regimen and the specific medical/remedial services, therapies, and activities that shall be used to meet the objectives. (1) Due to the nature of mental illness and the provision of program services, there may be instances in which a temporary deviation from the services written in the treatment plan occurs. In this event, the client may participate in alternate programming. The reason for the deviation should be clearly explained in the daily or weekly documentation. Deviations that do not resolve shall require a written change in the treatment plan; ii. A projected schedule for service delivery which includes the frequency and duration of each type of planned therapeutic session or encounter; iii. The type of personnel that will be furnishing the services; and iv. A projected schedule for completing the reevaluations of the beneficiary’s condition and updating the plan of care. c. The mental health clinic shall develop and maintain legibly written documentation to support each medical/remedial therapy service, activity, or session for which billing is made. i. This documentation, at a minimum, shall consist of: (1) The specific services rendered, such as individual psychotherapy, group psychotherapy, family therapy, etc., and a description of the encounter itself. The description shall include, but is not limited to, a statement of patient progress noted, significant observations noted, etc.; (2) The date and time that services were rendered; (3) The duration of services provided; (4) The signature of the practitioner or provider who rendered the services; (5) The setting in which services were rendered; and (6) A notation of unusual occurrences or significant deviations from the treatment described in the plan of care. d. Clinical progress, complications and treatment which affect prognosis and/or progress shall be documented in the beneficiary’s medical record at least once a week, as well as any other information important to the clinical picture, therapy and prognosis. e. The individual services under partial care shall be documented on a daily basis. More substantive documentation, including progress notes and any other information important to the clinical picture, are required at least once a week. f. Periodic review of the beneficiary’s plan of care shall take place at least every 90 days during the first year and every six months thereafter. i. The periodic review shall determine: (1) The beneficiary’s progress toward the treatment objectives; (2) The appropriateness of the services being furnished; and (3) The need for the beneficiary’s continued participation in the program. ii. Periodic reviews shall be documented in detail in the beneficiary’s records and made available upon request to the New Jersey Medicaid or NJ FamilyCare program or its agents.