30:4D-12. Unnecessary use of care and services; methods and procedures; maintenance of records required for reimbursement

Subject to the limitations provided in sections 7, 8 and 9 of this act, the department shall (a) develop and employ such methods and procedures relating to the utilization of and the payment for medical care and services available under the plan as may be necessary to safeguard against unnecessary utilization of such care and services;

(b) Assure that payments (including payments for any drugs provided under the plan) are not in excess of reasonable charges (reasonable costs in the instance of inpatient hospital services) consistent with efficiency, economy and quality of care;

(c) Prescribe standards that providers must meet;

(d) Require that any provider who renders health care services authorized under this act shall keep and maintain such individual records as are necessary to fully disclose the name of the recipient to whom the service was rendered, the date of the service rendered, the nature and extent of each such service rendered, and any additional information, as the department may require by regulation. Records herein required to be kept and maintained shall be retained by the provider for a period of at least 5 years from the date the service was rendered;

(e) Require that providers who render health care services authorized under this act shall not be entitled to reimbursement for the services rendered unless said services are documented pursuant to subsection (d) of this section. Any evidence other than the documentation required pursuant to subsection (d) of this section shall be inadmissible in any proceeding conducted pursuant to this act for the purpose of proving that said services were rendered; unless the evidence is found to be clear and convincing by the finder of fact; and

(f) Examine and make copies of any books and records of a provider if they relate in any way to services rendered to any recipient under this act, and visit and inspect the premises or facilities of any provider it may deem necessary to carry out the provisions of this act and regulations adopted pursuant thereto.

L.1968, c. 413, s. 12. Amended by L.1979, c. 365, s. 14, eff. Feb. 4, 1980.