§ 51476. Keeping and Availability of Records.

(a) Each provider shall keep, maintain, and have readily retrievable, such records as are necessary to fully disclose the type and extent of services provided to a Medi-Cal beneficiary. Required records shall be made at or near the time at which the service is rendered. Such records shall include, but not be limited to the following:

(1) Billings.

(2) Treatment authorization requests.

(3) All medical records, service reports, and orders prescribing treatment plans.

(4) Records of medications, drugs, assistive devices, or appliances prescribed, ordered for, or furnished to beneficiaries.

(5) Copies of original purchase invoices for medication, appliances, assistive devices, written requests for laboratory testing and all reports of test results, and drugs ordered for or supplied to beneficiaries.

(6) Copies of all remittance advices which accompany reimbursement to providers for services or supplies provided to beneficiaries.

(7) Identification of the person rendering services. Records of each service rendered by nonphysician medical practitioners (as defined in Title 22, CCR, Section 51170) shall include the signature of the nonphysician medical practitioner and the countersignature of the supervising physician to the extent required by the applicable professional licensing statutes and regulations.

(b) Records of institutional providers shall include, in addition, the following:

(1) Records of receipts and disbursements of personal funds of beneficiaries being held in trust by the provider.

(2) Employment records including shifts, schedules and payroll records of employees.

(3) Book records of receipts and disbursements by the provider.

(4) Individual ledger accounts reflecting credit and debit balances for each beneficiary to whom services are provided.

(c) Records of providers shall document the meeting of Code I restrictions for medical supplies in the list established by the Department and for drugs listed in the Medi-Cal List of Contract Drugs as follows:

(1) The practitioner who issues a prescription for a Code I supply or drug shall document, in the patient's chart, the patient's diagnostic or clinical condition that fulfills the Code I restriction.

(2) The dispenser shall maintain readily retrievable documentation of the patient's diagnostic or clinical condition information that fulfills the Code I restriction. If this Code I diagnostic or clinical condition information is transmitted to the dispenser other than by personal handwritten order from the prescriber, the dispenser shall document the transmittal date and the name of prescriber or the employee or agent who is legally authorized to transmit such information. The documentation shall be personally signed by the dispenser.

(d) Every practitioner who issues prescriptions for Medi-Cal beneficiaries shall maintain, as part of the patient's chart, records which contain the following for each prescription:

(1) Name of the patient.

(2) Date prescribed.

(3) Name, strength and quantity of the item prescribed.

(4) Directions for use.

(e) Records of medical transportation providers shall include, in addition to (a):

(1) Time and date of service for each beneficiary.

(2) Odometer readings at each pick-up and delivery location.

(3) The provider assigned vehicle identification code and name of the operator providing the service.

(4) Names of beneficiaries transported in total or partial group runs.

(f) Records of providers of psychiatric and psychological services shall include in addition to (a), patient logs, appointment books or similar documents showing the date and time allotted for appointment of each patient or group of patients, and the time actually spent with such patients.

(g) A provider shall make available, during regular business hours, all pertinent financial books and all records concerning the provision of health care services to a Medi-Cal beneficiary, and all records required to be made and retained by this section, to any duly authorized representative of the Department acting in the scope and course of employment including, but not limited to, employees of the Attorney General, Medi-Cal Fraud Unit duly authorized and acting within the scope and course of their employment. Failure to produce records may result in sanctions, audit adjustments, or recovery of overpayments, in accordance with Section 51458.1 of this title.

HISTORY

1. Amendment filed 8-10-84; effective upon filing pursuant to Government Code Section 11346.2(d) (Register 84, No. 32). For prior history, see Register 81, No. 48.

2. Amendment of subsection (c) and Note filed 1-9-95; operative 3-1-95 (Register 95, No. 2).

3. Change without regulatory effect amending subsections (a)(7), (c) and (f) and amending Note filed 1-26-2009 pursuant to section 100, title 1, California Code of Regulations (Register 2009, No. 5).

4. Amendment of subsection (a)(7) and Note filed 5-17-2012; operative 6-16-2012 (Register 2012, No. 20).

5. Change without regulatory effect amending Note filed 12-16-2013 pursuant to section 100, title 1, California Code of Regulations (Register 2013, No. 51).

Note

Note: Authority cited: Section 20, Health and Safety Code; and Sections 10725, 14105 and 14124.5, Welfare and Institutions Code. Reference: Sections 14021, 14043.341, 14053, 14105.35, 14107, 14124.1, 14124.2, 14124.24, 14131, 14133, 14133.3 and 14170, Welfare and Institutions Code; and Title 42, Code of Federal Regulations, Sections 483.40(e) and 485.631(b)(iv).