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LTC Record Documentation Standards

Sunshine Health providers must keep accurate and complete medical/case records for each Enrollee in accordance with 42.CFR 456.  Medical/case records shall include the quality, quantity, appropriateness and timeliness of services performed under contract with Sunshine Health.  Records shall include all reports from Participating Health Care Providers and all documentation required by applicable law, regulations, professional standards and the Provider Manual. Such records will enable providers to render the highest quality healthcare service to Enrollees. They will also enable Sunshine Health to review the quality and appropriateness of the services rendered.  Sunshine Health providers are required to document in the Covered Person’s medical or case record whether the Covered Person has executed an advanced directive and agrees to comply with all federal and State laws regarding advance directives. To ensure the Enrollee’s privacy, medical records should be kept in a secure location.  Medical/case records of Covered Persons are required to be treated as confidential so as to comply with all federal and State laws and regulations regarding the confidentiality of the patient records to ensure compliance with the privacy and security provisions of the Health Insurance Portability and Accountability Act (HIPAA).  See Enrollee Rights section of this manual for policies on Enrollee access to medical records.

In addition to keeping and maintaining an adequate record system, Sunshine Health providers are required to record services, charges, dates, and all other commonly accepted information elements for Covered Services rendered to Covered Persons.  Provider is also required to maintain books, records and documents (including electronic storage media) sufficient to reflect income and expenditures of funds provided by Health Plan and/or the Agency or the Department per contract agreement guidelines.  Records shall be maintained for a period not less than six (6) years from the close of the LTC Contract or longer as required by law and retained further if the records are under review or audit until the review or audit is complete.  In such case the records shall be retained for ten (10) years after the audit report is issued or until resolution of any audit findings or litigation based on the terms of this contract, at no additional cost to Health Plan or Department.  Upon demand, at no additional cost to Health Plan, the Agency or the Department, the Provider will facilitate the duplication and transfer of any records or documents during the required retention period.  Records shall be subject at all reasonable times to inspection, review, copying or auditing by Health Plan, Federal, State or other personnel duly authorized by the Agency or the Department as necessary and specifically pursuant to 45 CFR 92.36(i) (1) and s.20.055. F. S.  Provider may be required to provide financial and compliance audit results at the request of Sunshine Health, the Agency or the Department.  The provider will cooperate fully in any investigation by the Agency, MPI, MFCU or other state or federal entity and in any subsequent legal action that may result from such an investigation involving the contract.

All Enrollee medical/case records shall be confidential and shall not be released without the written authorization of the covered person or a responsible covered person’s legal guardian.  When the release of medical/case records is appropriate, the extent of that release should be based upon medical necessity or on a need to know basis.

Written authorization is required for the transmission of the medical/case record information of a current Sunshine Health Enrollee or former Sunshine health Enrollee to any provider not connected with Sunshine Health.

Sunshine Health, Department of Health & Human Services (DHHS), Agency for Health Care Administration (AHCA), Department of Elder Affairs ( DOEA), Medicaid Program Integrity (MPI), and Medicaid Fraud Control Unit (MFCU) shall have access and the right to inspect, evaluate and audit at reasonable times, to pertinent books, financial and medical/case records, and documents, papers and records of the Provider relating to the health care services provided to Covered Persons for Covered Services or financial transactions.