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MA Documentation and Medical Record Keeping
April 2, 2002

The Department of Public Welfare issued a Medical Assistance (MA) Bulletin on March 21, 2002 addressing documentation and medical record keeping. The Bulletin applies to psychologists, outpatient psychiatric clinics and psychiatric partial hospitalization programs enrolled in the MA Program's Fee-For-Service or Managed Care delivery systems. The purpose of the Bulletin is to reinforce documentation and medical record keeping requirements for providers that render behavioral health services to eligible MA recipients. The Bulletin indicates that a review by DPW found that providers are not meeting documentation and record keeping requirements. The documentation is used by DPW to determine the validity of claims, the medical necessity and the quality of services provided to MA recipients.

Providers are encouraged to review their record keeping practices to ensure compliance with Federal and State statutes as well as licensing standards.

The Bulletin is available on the DPW web site at www.dpw.state.pa.us/omap/provinf/mabull/290203.asp.

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