1. (A) Payment for any service listed in 130 CMR 462.000 is conditioned upon its full and complete documentation in the member's medical record. The licensed independent behavioral health clinician must maintain an electronic or hard copy record of all licensed independent behavioral health clinician services provided to a member for a period of at least six years following the date of service subject to any applicable federal or state standard requiring a longer retention period. For all services, the record must contain the following information:

   1. (1) the member's name and case number, MassHealth identification number, address, telephone number, sex, age, date of birth, marital status, next of kin, school or employment status (or both), and date or dates of service including date of initial contact;
   2. (2) a report of a physical examination performed within six months of the date of intake or documentation that the member did not want to be examined and any stated reason for that preference;
   3. (3) the name and address of the member's primary care physician or, if not available, another physician who has treated the member;
   4. (4) the member's description of the problem, and any additional information from other sources, including the referral source, if any;
   5. (5) the events precipitating contact with the licensed independent behavioral health clinician;
   6. (6) the relevant medical, psychosocial, educational, and vocational history;
   7. (7) a comprehensive diagnostic services evaluation of the member at intake and semi- annually thereafter;
   8. (8) the clinical impression of the member and a diagnostic formulation, including a specific diagnosis using standard nomenclature;
   9. (9) a listing of realistic long-range goals, and a time frame for their achievement;
   10. (10) a listing of short-term objectives, which must be established in such a way as to lead toward accomplishment of the long-range goals;
   11. (11) the proposed schedule of therapeutic activities necessary to achieve such goals and objectives and the responsibilities of each individual member of the interdisciplinary team;
   12. (12) a schedule of dates for utilization review to determine the member's progress in accomplishing goals and objectives;
   13. (13) the name, qualifications, and discipline of the licensed independent behavioral health clinician responsible for the member;
   14. (14) a written record of annual treatment plan reviews by the licensed independent behavioral health clinician, which relate to the short- and long-range goals;
   15. (15) all information and correspondence regarding the member, including appropriately signed and dated consent forms;
   16. (16) a medication-use profile;
   17. (17) when the member is discharged, a discharge summary, including a recapitulation of the member's treatment and recommendations for appropriate services concerning follow-up as well as a brief summary of the member's condition and functional performance on discharge; and

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth Table of Contents

4-6

Provider Manual Series (130 CMR 462.000)

Transmittal Letter Date

Licensed Independent Behavioral Health

Clinician Manual

LICSW-2 04/01/25

1. (18) for members younger than 21 years of age, a CANS completed during the initial behavioral health assessment and updated at least every 180 days thereafter.

2. (B) Release of information in the record is limited to the following:

   1. (1) those instances required by federal or state statute or regulation in accordance with the confidentiality provisions of the profession; and
   2. (2) qualified personnel or consultants of the MassHealth agency or the US Department of Health and Human Services for the purpose of monitoring the provision of services in accordance with 130 CMR 462.000.