Cal. Code Regs. Tit. 22, § 58078 - Records Maintenance

(a) Each Issuer shall maintain information as stipulated in subsection (f) on all Policy or Certificate holders who have ever received any benefit under the Policy or Certificate. Such information shall be updated at least Quarterly. This requirement for updating shall not require the conduct of any assessment, reassessment, or other evaluation of the Policy or Certificate holder's condition which is not otherwise required by federal or State statute or regulation.

(b) When a Policy or Certificate holder who has received any benefit dies or lapses or his or her Policy or Certificate for any reason, the Issuer must retain the stipulated information for a period of at least five (5) years after the time when the Policy ceases to be in force. Unless notified by the Department of Health Services to the contrary during this period, after the five (5) years, the Service Summary provided by the Issuer will be deemed to comply with all Medi-Cal Property Exemption reporting, record keeping, auditing and quality control requirements of this rule. The Issuer may use microfiche, microfilm, optical storage media, or any other cost effective method of record storage as alternatives to storage of paper copies of stipulated information.

(c) At the time the Policy or Certificate ceases to be in force, the Issuer shall notify the Policy or Certificate holder of his or her right to request his or her service records as stipulated in subsection (f).

(d) The Issuer shall also, upon request in writing, provide such Policy or Certificate holder or the Policy or Certificate holder's Authorized Designee, if any, with a copy of the Issuer's service records as required in subsection (f) which are necessary to establish the Medi-Cal Property Exemption. These records shall be provided to the Policy or Certificate holder or the Policy or Certificate holder's Authorized Designee, if requested, within sixty (60) days of the request. The Issuer may charge a reasonable fee to cover the costs of providing each set of requested service record copies.

(e) The Issuer shall enclose with the records a statement advising the former Policy or Certificate holder that it is in his or her interest to retain the records if he or she may ever wish to establish eligibility for the Medi-Cal Program.

(f) The information to be maintained includes the following:

(1) evidence that the Benefit Eligibility has taken place;

(A) Benefit Eligibility must be documented by a Care Management Provider Agency, or its Qualified Official Designee, as part of the initial assessment of the client or as part of a subsequent reassessment.

(B) These assessments must be based on direct observations and interviews in conjunction with a medical record review. The Care Manager carrying out the assessment or their Care Management Supervisor must sign and certify the completion of the assessment. Each individual who completes a portion of such assessment shall sign and certify as to the accuracy of that portion of the assessment.

(2) description of services provided under the Policy or Certificate, including the following:

(A) name, address, phone number, and license number, if applicable, of provider;

(B) amount, date, and type of services provided, and whether the services qualify for Medi-Cal Property Exemption;

(C) dollar amounts paid by the Issuer, whether on an indemnity, expense incurred, or other basis;

(D) the charges of the service providers, including copies of invoices for all services counting towards Medi-Cal Property Exemption; and

(E) identification of the Care Management Provider Agency and copies of all assessments and reassessments.

(3) In order for services to qualify for a Medi-Cal Property Exemption, these services must be in accord with a Plan of Care developed by a Care Management Provider Agency. If the Policy or Certificate holder has received any benefits delivered as part of a Plan of Care, the Issuer must retain the following:

(A) a copy of the original Plan of Care; and

(B) a copy of any changes made in the Plan of Care. Such services shall count towards the Medi-Cal Property Exemption after the Care Management Provider Agency adds the documented need for and description of the new services to the Plan of Care. In cases when the service must begin before the revisions to the Plan of Care are made, the new services will only count towards a Medi-Cal Property Exemption if the revisions to the Plan of Care are made within ten (10) business days of the commencement of the new services. Care Management Provider Agencies must act upon requests for changes in the Plan of Care in an expeditious manner. Issuers must maintain initial assessments and subsequent reassessments as part of Benefit Eligibility documentation.

Notes

Cal. Code Regs. Tit. 22, § 58078

1. New section filed 8-30-93 as an emergency; operative 8-30-93 (Register 93, No. 36). Submitted for printing only pursuant to section 22009, Welfare and Institutions Code.
2. Certificate of Compliance as to 8-30-93 order transmitted to OAL 12-30-93 and filed 1-28-94 (Register 94, No. 4).
3. Amendment of subsections (f)(1), (f)(1)(A) and (f)(3)(B) filed 10-1-98 as an emergency; operative 10-1-98. Submitted to OAL for printing only pursuant to Welfare and Institutions Code section 22009(d) (Register 98, No. 41). A Certificate of Compliance must be transmitted to OAL by 1-29-99 or emergency language will be repealed by operation of law on the following day.
4. Certificate of Compliance as to 10-1-98 order transmitted to OAL 1-28-99 and filed 3-15-99 (Register 99, No. 12).

Note: Authority cited: Section 22009(a), Welfare and Institutions Code. Reference: Sections 22004, 22005 and 22006, Welfare and Institutions Code.

1. New section filed 8-30-93 as an emergency; operative 8-30-93 (Register 93, No. 36). Submitted for printing only pursuant to section 22009, Welfare and Institutions Code.
2. Certificate of Compliance as to 8-30-93 order transmitted to OAL 12-30-93 and filed 1-28-94 (Register 94, No. 4).
3. Amendment of subsections (f)(1), (f)(1)(A) and (f)(3)(B) filed 10-1-98 as an emergency; operative 10-1-98. Submitted to OAL for printing only pursuant to Welfare and Institutions Code section 22009(d) (Register 98, No. 41). A Certificate of Compliance must be transmitted to OAL by 1-29-99 or emergency language will be repealed by operation of law on the following day.
4. Certificate of Compliance as to 10-1-98 order transmitted to OAL 1-28-99 and filed 3-15-99 (Register 99, No. 12).