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PDFWAC 182-537-0700

School district documentation requirements.

(1) Providers must document all school-based health care services as required in this section and the medicaid agency's school-based health care services (SBHS) billing guide.
(2) Documentation to justify billed claims must be maintained for at least six years from the date of service.
(3) Records for each student must include, but are not limited to:
(a) A referral or prescription for services by a physician or other licensed health care provider within their scope of practice;
(b) Assessment reports;
(c) Evaluation and reevaluation reports;
(d) Individualized education program (IEP) or individualized family service plan (IFSP);
(e) Attendance records; and
(f) Treatment notes. Treatment notes must include the:
(i) Child's name;
(ii) Child's ProviderOne client ID;
(iii) Child's date of birth;
(iv) Date of service, and for each date of service:
(A) Time-in;
(B) Time-out;
(C) A procedure code for and description of each service provided;
(D) The child's progress related to each service;
(E) Whether the occupational therapy, speech-language therapy, physical therapy or counseling service described in the note was individual or group therapy;
(F) The licensed provider's printed name, handwritten or electronic signature, and title; and
(G) Assistants and nonlicensed people, as defined in WAC 182-537-0350, who provide early intervention or health care-related services under supervision, must have a licensed provider review and cosign all treatment notes.
(4) The agency accepts electronic records and signatures. Maintaining the records in an electronic format is acceptable only if the original records are available to the agency for program integrity activities for up to six years after the date of service. Each school district is responsible for determining what standards are consistent with state and federal electronic record and signature requirements.
(5) For a signature to be valid, it must be handwritten or electronic. Signature by stamp is acceptable only if the provider is unable to sign by hand due to a physical disability.
(6) School districts must maintain a signature log to support the provider's signature identity.
(7) The signature log must include the provider's:
(a) Printed name;
(b) Handwritten signature;
(c) Initials;
(d) Credentials;
(e) License number; and
(f) National provider identifier (NPI).
(8) Each school district must establish policies and procedures to ensure complete, accurate, and authentic records. These policies and procedures must include:
(a) Security provisions to prevent the use of an electronic signature by anyone other than the licensed provider to whom the electronic signature belongs;
(b) Procedures that correspond to recognized standards and laws and protect against modifications;
(c) Protection of the privacy and integrity of the documentation;
(d) A list of which documents will be maintained and signed electronically; and
(e) Verification of the signer's identity at the time the signature was generated.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-14-062, § 182-537-0700, filed 6/26/20, effective 7/27/20; WSR 19-04-095, § 182-537-0700, filed 2/5/19, effective 3/8/19; WSR 16-07-141, § 182-537-0700, filed 3/23/16, effective 4/23/16; WSR 14-20-090, § 182-537-0700, filed 9/29/14, effective 10/30/14. Statutory Authority: RCW 41.05.021. WSR 13-05-017, § 182-537-0700, filed 2/7/13, effective 3/10/13. WSR 11-14-075, recodified as § 182-537-0700, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, and 42 C.F.R. 440.110. WSR 09-07-004, § 388-537-0700, filed 3/4/09, effective 4/4/09.]
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