Health Service Records

Documentation: Health service records must be developed and maintained as a condition of payment by PrimeWest Health. Each occurrence of a health service must be documented in the member’s health record. PrimeWest Health funds paid for health care not documented in the health service record are subject to monetary recovery.

Health Service Records: Must contain the following information when applicable. There may also be other record obligations located throughout this manual specific to vendors of a particular service.

  1. The record must be legible, at a minimum, to the individual providing care.
  2. The member’s name must be on each page of the member’s record.
  3. Each entry in the health service record must contain:
  1. The date on which the entry is made;
  2. The date or dates on which the health service is provided;
  3. The length of time spent with the member, if the amount paid for the service depends on time spent;
  4. The signature and title of the person from whom the member received the service;
  5. Report of the member’s progress or response to treatment, and changes in the treatment or diagnosis;
  6. When applicable, the countersignature of the vendor or the supervisor as required under MN Rules parts 9505.0170 – 9505.0475; and
  7. Documentation of supervision by the supervisor.
  1. The record must state:
  1. The member’s case history and health condition as determined by the vendor’s examination or assessment;
  2. The results of all diagnostic tests and examinations; and
  3. The diagnosis resulting from the examination.
  1. The record must contain reports of consultations that are ordered for the member.
  2. The record must contain the member’s plan of care, individual treatment plan, or individual program plan.
  3. The record must contain documentation as to whether or not the member has executed a Health Care Directive (members 18 years and over).
  4. The record of a laboratory or X-ray service must document the provider’s order for service.
  5. Refer to PrimeWest Health Medical Record Policy QM06 in the Policies and Procedures section of the PrimeWest Health website. These are the basic medical record requirements for DHS.
  6. Ensure that each provider furnishing services to members maintains and shares, as appropriate, a health record in accordance with professional standards (see Title 42 Code of Federal Regulations [CFR] Part 438.208 for requirements).

Health Service Records of Specific Providers

The following vendors must follow additional requirements in their health service records:

Pharmacy service records must comply with Minnesota Rules relating to pharmacy licensing and operations and electronic data processing of pharmacy records. The pharmacy service record must be a hard copy made at the time of the request for service and must be kept for 10 years.

Medical supplies and equipment records must:

  1. Document that the medical supply or equipment is eligible for payment; and
  2. Contain a hard copy of the physician’s order or prescription, including the name and amount of the medical supply or equipment provided for the member.

For more information, please review Equipment and Supplies.

Rehabilitative and therapeutic service records must comply with requirements listed in Rehabilitation Services.

Record Keeping

Financial records, including written and electronically stored data, of a vendor who receives payment for a member’s services under PrimeWest Health must contain the following:

  1. Payroll ledgers, cancelled checks, bank deposit slips, and any other accounting records prepared by or for the vendor
  2. Contracts for services or supplies relating to the vendor’s costs and billings to PrimeWest Health for the member’s health services
  3. Evidence of the vendor charges to PrimeWest Health members and to persons who are not PrimeWest Health members, consistent with the requirements of the Minnesota Government Data Practices Act
  4. Evidence of claims for reimbursement, payments, settlements, or denials resulting from claims submitted to third party payers or programs
  5. The vendor’s appointment books for patient appointments and the provider’s schedules for patient supervision, if applicable
  6. Billing transmittal forms
  7. Records showing all persons, corporations, partnerships, and entities with an ownership or controlling interest in the vendor
  8. Employee records for those persons currently employed by the vendor (or who have been employed by the vendor at any time within the previous five years) which, under the Minnesota Government Data Practices Act, would be considered public data for a public employee, such as employee name, salary, qualifications, position description, job title, and dates of employment. In addition, employee records shall include the current home address of the employee or the last known address of any former employee.
  9. Nursing/board and care homes must, in addition to the foregoing, maintain purchase invoices, records of deposits, expenditures for patient personal needs, and allowance accounts.

Record Keeping (MN Rules part 9505.2185)

Recipient’s consent to access (MN Rules part 9505.2185, subp. 1): A recipient of Medical Assistance (Medicaid) is deemed to have authorized in writing a vendor or others to release to PrimeWest Health for examination according to MN Stat. sec. 256B.27, subd. 4, upon request, the Medical Assistance (Medicaid) recipient’s health service records related to services under a program. The Medical Assistance (Medicaid) recipient’s authorization of the release and review of health service records for services provided while the person is a Medical Assistance (Medicaid) member shall be presumed competent if given in conjunction with the person’s application for Medical Assistance (Medicaid). This presumption shall exist regardless of whether the application was signed by the person or the person’s guardian or authorized representative as defined in MN Rules part 9505.0015, subp. 8.

PrimeWest Health access to records (MN Rules part 9505.2185, subp. 2): A vendor shall grant PrimeWest Health or any business associate of PrimeWest Health access during the vendor’s regular business hours to examine health service and financial records related to a health service billed to a program. Access to a member’s health service records shall be for the purposes in MN Rules part 9505.2200, subp. 1. PrimeWest Health shall notify the vendor no less than 24 hours before obtaining access to a health service or financial record, unless the vendor waives notice.

Retention of Records (MN Rules part 9505.2190)

Retention required, general (MN Rules part 9505.2190, subp. 1): A vendor shall retain all health service and financial records related to a health service for which payment under a program was received or billed for at least 10 years after the initial date of billing (42 CFR 422.504[d]). Microfilm records satisfy the recordkeeping requirements of this subpart and MN Rules part 9505.2175, subp. 3, in the fourth and fifth years after the date of billing.

Record retention after vendor withdrawal or termination (MN Rules part 9505.2190, subp. 2): A vendor who withdraws or is terminated from a program must retain or make available to PrimeWest Health on demand the health service and financial records as required under MN Rules part 9505.2190, subp. 1.

Record retention under change of ownership (MN Rules part 9505.2190, subp. 3): If the ownership of a long-term care facility or vendor service changes, the transferor, unless otherwise provided by law or written agreement with the transferee, is responsible for maintaining, preserving, and making available to PrimeWest Health on demand the health service and financial records related to services generated before the date of the transfer as required under MN Rules part 9505.2190, subp. 1 and MN Rules part 9505.2185, subp. 2.

Record retention in contested cases (MN Rules 9505.2190, subp. 4): In the event of a contested case, the vendor must retain health service and financial records as required by MN Rules part 9505.2190, subp. 1 or for the duration of the contested case proceedings, whichever period is longer.

Copying Records (MN Rules part 9505.2195)

PrimeWest Health or any contracted PrimeWest Health business associate, at its own expense, may photocopy or otherwise duplicate any health service or financial record related to a health service for which a claim or payment is made under a PrimeWest Health program. Photocopying shall be done on the vendor’s premises unless removal is specifically permitted by the vendor. If a vendor fails to allow PrimeWest Health to use the department’s equipment to photocopy or duplicate any health service or financial record on the premises, the vendor must furnish copies at the vendor’s expense within two weeks of a request for copies by PrimeWest Health.

PW_03-18_089
Updated_03/07/2018