1. (A) Payment for any service listed in 130 CMR 464.000 is conditioned upon its full and complete documentation in the member's medical record. The PACT provider must maintain an electronic or hard copy record of all PACT provider 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 12 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 PACT provider;
   6. (6) the relevant medical, psychosocial, educational, and vocational history;
   7. (7) a comprehensive assessment of the member at intake and semi-annually thereafter;
   8. (8) the clinical impression of the member, including a specific diagnosis using standard nomenclature;
   9. (9) a list of measurable, realistic short and long-range goals, and a time frame for their achievement;
   10. (10) a list of short-term objectives, which must be established in such a way as to lead toward accomplishment of the long-range goals;

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4. Program Regulations

4-16

Provider Manual Series (130 CMR 464.000)

Transmittal Letter Date

Program of Assertive Community

Treatment Manual

PACT-1 11/1/2025

1. (11) the proposed schedule of therapeutic activities necessary to achieve such goals and objectives and the responsibilities of each individual member of the treatment team;
2. (12) a schedule of dates for utilization review to determine the member's progress in accomplishing goals and objectives;
3. (13) the name, qualifications, and discipline of the PACT provider staff responsible for the activity documented;
4. (14) all information and correspondence regarding the member, including appropriately signed and dated consent forms;
5. (15) a medication-use profile; and
6. (16) 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. This must be shared with the member, LAR, and all involved ongoing services, with permission, as appropriate.

1. (B) The PACT provider must document compliance with the requirements of 130 CMR 464.000.
2. (C) All records must be made available to the MassHealth agency upon request.