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Ensure timely signing of your medical records and entering amendments

Magellan’s Special Investigation Unit (SIU) has reported recent cases in which providers’ medical records and/or amendments to medical records were not entered or signed in a timely manner.

This is a reminder that you should adhere to medical record signature and amendment requirements set forth by state, license and/or plan regulations to ensure accuracy and proper reimbursement.

Medical record signature best practices

• Records should include the signature of the rendering provider and supervising provider (if applicable), listing licensure/credentials. Magellan’s Treatment Record Review tool (PDF) includes a standard requirement that “Entries are dated and signed by appropriately credentialed provider.”
• You should not bill for services unless and until you meet the documentation signature requirements.
• Sign and date records at the time of service or shortly thereafter. This ensures a fresh recollection of the details and facilitates a faster and more accurate note-writing process. Delays can make remembering essential details and events more difficult, which may result in incomplete or inaccurate notes. We encourage timely notetaking and recommend finishing the notes within 24 to 48 hours of the session if feasible.

Amended medical records 

These include...

• A late entry which supplies additional information omitted from the original entry should list the current date of the entry and be signed by the person making the entry as soon as possible.
• A correction to a medical record should never be written over or deleted when an entry error occurs. Corrections should be crossed out, yet still legible, signed, or initialed and dated stating the reason for the correction. Information added to the record should be signed or initialed and dated, referencing the original entry.

Amended records best practices 

• Sign and date medical records and amendments in a timely manner according to state, license and/or plan regulations.
• Create an internal medical record documentation policy for your practice specifying a timeframe in which records are expected to be signed and dated.
• Conduct regular self-audits on medical records to ensure you have appropriately signed and dated amendments and medical records.

What not to do

• Do not back date or post-date entries.
  • Magellan will only accept corrections to medical records if they include a valid amendment to the record listing the date of the correction and the signature of the person making the correction.
• Do not create new records if you receive a request for certain records.
  • We cannot accept creation of new records, back dating, post-dating entries, writing over, and/or adding to existing documentation without a valid amendment.

Resources with helpful tips on timely medical record entry and amendments

• Medical record entry timeliness: What is reasonable (AAPC)
• Documentation guidelines for amended medical records (Noridian)
• Authenticate services with proper physicians’ signatures (AAPC)

Remember that lack of compliance with documentation standards may result in investigations, retraction of provider payment, reporting to customer oversight agencies, pre-payment review of a provider’s claims, and termination from the Magellan network.

For more information

• Review Magellan's policy on audits and investigations in Section 4, page 86, of Magellan's National Provider Network Handbook (PDF).
• Contact your Network representative with questions about your contractual obligations to supply medical records for review.
• If you have additional questions regarding our audit/investigation processes, contact the SIU via email (SIU@MagellanHealth.com) or via our hotline, 1-800-755-0850 (you may remain anonymous).