Providers for MMA

The following medical record standards apply to each enrollee’s record and will be used as a guide for the periodic on-site record reviews:

  • Each record must contain identifying information on the enrollee, including name, enrollee identification number (Medicaid #), date of birth and sex; and legal guardianship (if any).
  • Each record must contain a summary of significant surgical procedures, past and current diagnosis or problems, allergies, untoward reactions to drugs and current medications.
  • All records must contain all services provided by providers; such services must include, but not necessarily be limited to, family planning services, preventive services and services for the treatment of sexually transmitted diseases.
  • All records must contain documentation of referral services (including Health & Wellness Program if applicable)
  • Each record must be legible and maintained in detail.
  • Each record must contain an immunization history.
  • Each record must contain information on smoking/ETOH (ethyl alcohol)/substance abuse.
  • Each record must contain a record of emergency care and hospital discharge with appropriate medically indicated follow up.
  • All records must reflect the primary language spoken by the enrollee and translation needs of the enrollee.
  • All records must identify enrollees needing communication assistance in the delivery of health care services.
  • All entries in each record must be dated and signed by appropriate part.
  • All entries in each record must indicate the chief complaint or purpose of the visit; the objective findings of practitioner, diagnosis, or medical impression.
  • All entries in each record must indicate studies ordered, for example: lab, x-ray, EKG, and referral reports.
  • All entries in each record must indicate therapies administered and prescribed.
  • All entries in each record must include the name and profession of practitioner rendering services, for example: M.D., D.O., and O.D., including signature or initials of practitioner.
  • All entries in each record must include the disposition, recommendations, instructions to the patient, evidence of informed consent including risk and adverse outcome, whether there was follow-up, and outcome of services.
  • Records must contain copy of any consent or attestation form used or the court order for prescribed psychotherapeutic medication for a child under the age of thirteen (13).
  • All records must contain documentation that the enrollee was provided written information concerning the enrollee’s rights regarding advanced directives (written instructions for living will or power of attorney), and whether or not the enrollee has executed an advanced directive. The provider shall not, as a condition of treatment, require the enrollee to execute or waive an advanced directive in accordance with Section 765.110, F.S. All records must contain copy of any advance directives executed by the enrollee (ages 18 and older including emancipated minors / for enrollees under 18 or not emancipated – documentation of offered/discussion with parent/guardian).
  • All records must contain a Health Risk Assessment Form when one is returned by the enrollee and sent to the provider.
  • All records must contain documentation of significant findings and medical advice given to enrollee in person, by telephone, online or provided after-hours.
  • Records of enrollee treated elsewhere or transferred to another health care provider are present.
  • All records must contain a brief explanation of the use of telemedicine in each progress note; documentation of telemedicine equipment used for the particular covered services provided; and a signed statement from the enrollee or the enrollee’s representative indicating their choice to receive services through telemedicine (This statement may be for a set period of treatment or one-time visit, as applicable to the service(s) provided), for services provided through telemedicine. (Currently not applicable)

Behavioral health records must include – for each services provided, clear identification as to:

  • The physician or other service provider
  • The date of service
  • The units of services provided
  • The type of service provided