Section 457.410 - Recordkeeping RequirementsFBCs are governed by recordkeeping provisions at MassHealth regulations 130 CMR 457.410 and 130 CMR 450.000: Administrative and Billing Regulations, and DPH regulations at 105 CMR 140.000: Licensure of Clinics.
(A) Payment for any service listed in 130 CMR 457.000 is conditioned upon its full and complete documentation in the member's medical record. An FBC must maintain a record of all medical services provided to a member for at least six years following the date of service. Payment for maintaining the member's medical record is included in the fee for the FBC service. Each medical record must contain sufficient information to document fully the nature, extent, quality, and necessity of the care furnished to the member for each date of service claimed for payment. If the documentation is not sufficient to justify the service for which payment is claimed by the FBC, the MassHealth agency will not pay for the service or, if payment has been made, may consider such payment to be an overpayment subject to recovery in accordance with 130 CMR 450.000: Administrative and Billing Regulations.(B) The medical record for each member must contain, at a minimum, the following information:(1) member's name, date of birth, home address and telephone number, and spouse or other person to contact in an emergency;(2) date of each member visit with FBC staff;(3) obstetrical and medical history;(4) diagnostic observations, evaluations, and therapeutic plans;(5) orders for any medication, test, or treatment;(6) records of any administration of medications, treatment, or therapy;(7) laboratory, radiology, and other diagnostic reports;(9) reports of any consultations, special examinations, or procedures;(11) discharge summary where appropriate; and(12) in addition to items 1 through 11 above, in regard to each newborn, the medical record must include the following:(a) the condition of the infant at birth to include Apgar Score (or its equivalent) at one minute and five minutes, time of sustained respiration, details of physical abnormalities, and pathological states;(b) date and hour of birth, birth weight, and period of gestation;(c) number of cord vessels and any abnormalities of the placenta;(d) verification of eye prophylaxis;(f) treatments, medications, and special procedures; and(g) condition at discharge or transfer.Adopted by Mass Register Issue 1517, eff. 3/15/2024.