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(1) All providers of service must maintain records which fully demonstrate the extent, nature and medical necessity of services and items provided to Montana Medicaid recipients. The records must support the fee charged or payment sought for the services and items and demonstrate compliance with all applicable requirements.

(a) All records which support a claim for a service or item must be complete within 90 days after the date on which the claim was submitted to Medicaid for reimbursement. A record that is required to be signed and dated, including but not limited to an order, prescription, certificate of medical necessity, referral or progress note, is not complete until it has been signed and dated.

(b) When reimbursement is based on the length of time spent in providing the service, the records must specify the time spent or the time treatment began and ended for each procedure billed to the nearest minute. Total time billed using one or multiple procedure codes may not exceed the total actual time spent with the Medicaid client.

(c) These records must be retained for a period of at least six years and three months from the date on which the service was rendered or until any dispute or litigation concerning the services is resolved, whichever is later.

(d) In maintaining financial records, providers shall employ generally accepted accounting methods. Generally accepted accounting methods are those approved by the National Association of Certified Public Accountants.

(e) The department shall have access to all records so maintained and retained regardless of a provider's continued participation in the program.

(f) In the event of a change of ownership, the original owner must retain all required records unless an alternative method of providing for the retention of records has been established in writing and approved by the department.

(g) If a provider cannot provide medical records to prove that a service billed to Medicaid was provided and meets all requirements for reimbursement, the service will be deemed not to be provided and reimbursable due to the lack of documentation, and the department will recover all reimbursement paid to the provider. This recovery is permissible regardless of whether the documentation was destroyed or lost due to an event such as, but not limited to, misplaced records, a data processing failure, fire, earthquake, flood, or other natural disaster. The provider must have a backup system in place to allow recovery of documentation destroyed or lost due to such events or any other cause.

(h) These record keeping requirements are the minimum requirements for records to support all Medicaid claims. In addition to complying with these minimum requirements, providers must also comply with any specific record keeping requirements applicable to the type of service the provider furnishes, which may be more restrictive than the minimum requirements of this rule.

(2) In addition to the recipient's medical records, any Medicaid information regarding a recipient or applicant is confidential and shall be used solely for purposes related to the administration of the Montana Medicaid program. This information shall not be divulged by the provider or his employees, to any person, group, or organization other than those listed below or a department representative without the written consent of the recipient or applicant. In addition, the provider must comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 USC 1320d et seq., and the Uniform Health Care Information Act, 50-16-501 et seq., MCA.

(3) The department, the designated review organization, the legislative auditor, the Department of Revenue, the Medicaid fraud control unit, and their legal representatives shall have the right to inspect or evaluate the quality, appropriateness, and timeliness of services performed by providers, and to inspect and audit all records required by this rule.

(a) Upon the department's request for records, the provider shall submit a true and accurate copy of each record of the service or item being reviewed as it existed within 90 days after the date on which the claim was submitted to Medicaid.

(b) Refusal to permit inspection, evaluation or audit of services shall result in the imposition of provider sanctions in accordance with the rules of the department.

(4) The provisions of this rule specifying the length of time for which records must be retained shall not be construed as a limitation on the period in which the department may recover overpayments or impose sanctions.

History: 53-6-113, MCA; IMP, 53-2-201, 53-6-101, 53-6-111, 53-6-113 and 53-6-141, MCA; NEW, 1980 MAR p. 1491, Eff. 5/16/80; AMD, 1997 MAR p. 474, Eff. 3/11/97; TRANS, from SRS, 2000 MAR p. 479; AMD, 2005 MAR p. 459, Eff. 4/1/05.

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