The speech and hearing center must maintain a health-care service record for each member for a period of at least four years following the date of service. The record must contain all pertinent information about the services provided, including the date of service and the dates on which materials were ordered and dispensed. The record must include the following:

1. (A) a licensed physician's or licensed nurse practitioner’s written and dated referral for evaluation

and referral for treatment, if applicable;

1. (B) the written comprehensive evaluation report (see 130 CMR 413.416(A));
2. (C) the name, address, and telephone number of the member’s primary care physician; and

3. (D) at least weekly documentation of the following:

   1. (1) the date or dates of which speech therapy or aural rehabilitation was provided;
   2. (2) the specific therapeutic procedures and methods used;
   3. (3) the member’s response to treatment;
   4. (4) any changes in the member’s condition;
   5. (5) the problems encountered or changes in the treatment plan or goals, if any;
   6. (6) the location where the service was provided, if different from that in the evaluation report;
   7. (7) the amount of time spent in treatment; and
   8. (8) the speech therapist's signature.

REGULATORY AUTHORITY

130 CMR 413.000: M.G.L. c. 118E, §§ 7 and 12.

Commonwealth of Massachusetts SUBCHAPTER NUMBER AND TITLE PAGE Division of Medical Assistance 4 PROGRAM REGULATIONS

4-8

Provider Manual Series (130 CMR 413.000)

SPEECH AND HEARING CENTER TRANSMITTAL LETTER DATE

MANUAL

SHC-16 07/01/05

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