This section establishes records and documentation requirements for 'Child Choice Providers' operating under DC Department of Behavioral Health (DBH) regulations. Providers must use the Department's data management system for documenting and billing all services, maintain records in accordance with Chapter 34 standards and applicable privacy laws, and ensure each service entry includes specific details such as service type, date/time, provider credentials, setting, and ICD-10 diagnoses. Claims for reimbursement will be denied if documentation requirements are not met.
View official source3606 RECORDS AND DOCUMENTATION REQUIREMENTS 3606.1 Each Child Choice Provider shall utilize the Department’s data management system for documenting and billing all services provided pursuant to this chapter. 3606.2 Each Child Choice Provider shall maintain all documentation and records in accordance with the Department standards in Chapter 34 of this title, federal and District privacy laws, and the Department’s Privacy Manual. 3606.3 Child Choice Providers shall document each service and activity provided pursuant to this Chapter in the consumer’s record in the Department’s data management system. Any claim for services shall be supported by written documentation which clearly identifies the following: (a) The specific service type rendered; (b) The date, duration, and actual time, a.m. or p.m. (beginning and ending), during which the services were rendered; (c) Name, title, and credentials of the person who provided the services; (d) The setting in which the services were rendered; (e) Identification of any further actions required for the consumer’s well-being raised as a result of the service provided; (f) A description of each encounter or service by the Child Choice Provider which clearly documents how the service was provided in accordance with this chapter; and (g) Dated and authenticated entries, with their authors identified, which are legible and concise, including the printed name and the signature of the person rendering the service, diagnosis, and clinical impression recorded in the terminology of the International Statistical Classification of Diseases and Related Health Problems-10 (ICD-10 CM) or subsequent revisions, and the service provided. 3606.4 No Child Choice Provider shall be reimbursed for a claim for services that does not meet the requirements of this section or is not documented in accordance with this section. 3606.5 Only a Child Choice Provider that has incurred expenses eligible for reimbursement in accordance with its contract with the Department may bill the Department under this regulation. SOURCE: Final Rulemaking published at 63 DCR 16080 (December 30, 2016). District of Columbia Municipal Regulations Mental Health 22-A DCMR § 3606