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Florida Medicaid Documentation Requirements 

Record Retention

Records must be retained for a period of at least five (5) years from the date of service.

Types of Records That Must be Retained

Medicaid requires that the following types of records, as appropriate for the type of service provided, must be retained (the list is not all inclusive):

    • Medicaid claim forms and any documents that are attached;
    • Professional records, such as appointment books, patient treatment plans, and physician referrals;
    • Medical, dental, optometric, hearing, hospital, and other patient records;
    • Copies of sterilization and hysterectomy consents;
    • Prior and post authorization, and service authorization information;
    • Prescription records;
    • Orders for laboratory tests and test results;
    • X-ray, MRI, and CAT scan records;
    • Business records, such as accounting ledgers, financial statements, invoices, inventory records, check registers, cancelled checks, sales records, etc.;
    • Tax records, including purchase documentation;
    • Drug utilization reports by drug NDC;
    • Partnership records;
    • Patient counseling documentation;
    • Provider enrollment documentation;
    • Purchase documentation; and
    • Utilization review and continued stay approvals for psychiatric or substance abuse inpatient stays.

Requirements for Medical Records Medical records must state the necessity for and the extent of services provided. The following requirements may vary according to the service rendered:

    • Description of what was done during the visit;
    • History;
    • Physical assessment;
    • Chief complaint on each visit;
    • Diagnostic tests and results;
    • Diagnosis;
    • Treatment plan, including prescriptions;
    • Medications, supplies, scheduling frequency for follow-up or other services;
    • Progress reports, treatment rendered;
    • The author of each (medical record) entry must be identified and must authenticate his entry by signature, written initials or computer entry;
    • Dates of service; and
    • Referrals to other services.

Right to Review Records

Authorized state and federal agencies and their authorized representatives may audit or examine a provider’s or facility’s records. This examination includes all records that the agency finds necessary to determine whether Medicaid payment amounts were or are due. This requirement applies to the provider’s records and records for which the provider is the custodian. The provider must give authorized state and federal agencies, and their authorized representatives, access to all Medicaid patient records and to other information that cannot be separated from Medicaid-related records.

The provider must send, at his expense, legible copies of all Medicaid-related information to the authorized state and federal agencies and their authorized representatives upon request of AHCA. At the time of the request, all records must be provided regardless of the media format on which the original records are retained by the provider. All medical records must be reproduced onto paper copies unless otherwise authorized by the requestor.

Incomplete Records

Providers who are not in compliance with the Medicaid documentation and record retention policies described in this chapter may be subject to administrative sanctions and recoupment of Medicaid payments.

Medicaid payments for services that lack required documentation or appropriate signatures will be recouped.

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