Requirements for the Establishment and Maintenance of Medical Records Under Medicaid – 405 Ind. Admin. Code 1-5-1

All Medicaid participating providers must maintain records of services provided under the Medicaid program for seven years.  The records must accurately and fully detail the extent of services provided.  Providers must maintain records that are separate and apart from claims forms.  The records must include the following information:

1.      Identity of the patient;

2.      Identity of the provider;

3.      Identity of the person providing the service;

4.      Date of service;

5.      Medical diagnosis;

6.      Statement describing the services;

7.      Location services were provided;

8.      Amount claimed through the Medicaid program;

9.      Treatment plan or evidence of physician involvement;

10.  Physician progress notes for therapy.

Related Laws: 405 Ind. Admin. Code 1-5-2