Each provider shall keep, maintain, and have readily retrievable, such records as are necessary to fully disclose the type and extent of services provided to a Medi-Cal beneficiary. Required records shall be made at or near the time at which the service is rendered. Such records shall include, but not be limited to the following:

• Billings.
• Treatment authorization requests.
• All medical records, service reports, and orders prescribing treatment plans.
• Records of medications, drugs, assistive devices, or appliances prescribed, ordered for, or furnished to beneficiaries.
• Copies of original purchase invoices for medication, appliances, assistive devices, written requests for laboratory testing and all reports of test results, and drugs ordered for or supplied to beneficiaries.
• Copies of all remittance advices which accompany reimbursement to providers for services or supplies provided to beneficiaries.
• Identification of the person rendering services. Records of each service rendered by non-physician medical practitioners shall include the signature of the non-physician medical practitioner and the countersignature of the supervising physician to the extent required by the applicable professional licensing statutes and regulations.

Records of institutional providers shall include, in addition, the following:

• Records of receipts and disbursements of personal funds of beneficiaries being held in trust by the provider.
• Employment records including shifts, schedules and payroll records of employees.
• Book records of receipts and disbursements by the provider.
• Individual ledger accounts reflecting credit and debit balances for each beneficiary to whom services are provided.

Every practitioner who issues prescriptions for Medi-Cal beneficiaries shall maintain, as part of the patient's chart, records which contain the following for each prescription:

• Name of the patient.
• Date prescribed.
• Name, strength and quantity of the item prescribed.
• Directions for use.

A provider shall make available, during regular business hours, all pertinent financial books and all records concerning the provision of health care services to a Medi-Cal beneficiary, and all records required to be made and retained by this section, to any duly authorized representative of the Department acting in the scope and course of employment including, but not limited to, employees of the Attorney General, Medi-Cal Fraud Unit duly authorized and acting within the scope and course of their employment. Failure to produce records may result in sanctions, audit adjustments, or recovery of overpayments.

Reference

22 CCR § 51476