Section VII: Record Keeping


Record keeping is required both for clinical reasons and documentation of the expenditures of Medicaid funds.

Clinically structured record keeping assists the provider in documenting the participant's desired goals and the accomplishment of these goals. The participant and waiver provider work together to develop a Detailed Plan that reflects the participant's goals, identifies strategies for intervention, and reviews the effectiveness of these interventions. This provides a better understanding of whether the goals have been met and when interventions and/or goals need to be revised.

Accurate and up-to-date record keeping is required of all Medicaid providers to substantiate Medicaid billing. The need to maintain the necessary records is described in the Provider Agreement, the eMedNY Provider Manual and in this Program Manual. It is the responsibility of the provider to have clear and accurate documentation to support all Medicaid claims.

Providers must adhere to all Medicaid confidentiality and Health Information Portability and Accountability Act (HIPAA) requirements and ensure the privacy of the waiver participant.

In addition, all waiver providers must maintain a policy and procedure that assures the appropriate safeguard of all records containing any identifiable information regarding waiver applicants and participants. These policies and procedures must be disseminated to all staff.

The policy must include, but is not limited to:

  • Maintaining records in a secured environment (e.g. locked files or locked Room) when they are not in use;
  • Preventing exposure of information when records are in use;
  • Identifying all information transmitted from one location to another as "confidential" in an appropriately secured manner;
  • Obtaining prior authorization from the appropriate supervisory staff before records are taken outside the agency, and the return of records within one (1) business day;
  • Properly informing applicants/participants of record collection procedures, access, utilization and dissemination of information;
  • Specify procedures related to employee access to information; and
  • Specify the disciplinary actions for violations of confidentiality statutes, regulations and policies.

All waiver providers must maintain waiver participant records for at least six (6) years after termination of waiver services.

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