Sample Documentation

Why do we need documentation?

All Medicaid waiver providers are required to keep documentation to support Medicaid reimbursement. Documentation of services provides the evidence that services were delivered and delivered in accordance with the individual’s needs. Completing service documentation is an essential first step in the Medicaid billing process. Below you will find the document requirements needed and examples for some of the most commonly requested supports.

Ohio Administrative Code requirements:

Ohio Administrative Code (OAC) mandates documentation requirements in OAC 5123:2-9-06, and establishes the general standards for waiver service documentation. Service-specific rules in section 5123 of the OAC specify documentation standards for specific services.

  • If you are paid for services that are not supported by proper service documentation, you may be required to repay those funds. It’s important to remember that failure to keep and maintain proper service documentation could also result in the termination of your provider waiver certification.
  • Providers are responsible to document services at the time of or shortly after service delivery. Service documentation records are to be maintained for a period of six (6) years. This retention period may be extended if the provider is in the process of being audited.
  • Providers are required to submit documentation records at any time they are requested by the County Board, Ohio Department of Developmental Disabilities, Ohio Department of Medicaid, Centers for Medicaid and Medicare Services, and/or the Ohio Auditor’s office.
  • It is the provider’s responsibility to develop documentation forms that contain all of the required elements identified in the Ohio Administrative Code. Service documentation must also be reflective of the specific services and supports provided.

Support for providers:

To assist and support providers in developing documentation forms, Summit DD has created and made available a few form templates for the most common waiver services that can be individualized for your use. These templates include all of the OAC required elements, however, it is the responsibility of the provider to individualize these forms to reflect the person they are serving and that person’s identified services and supports. Below are samples of completed forms as well as blank templates to be downloaded for individualization.

Please note, if you are providing a service not identified in the samples, please reference OAC section 5123 for service specific requirements. If after familiarizing yourself with the specific rule requirements you would like some additional assistance with your documentation forms, please contact us.

**Note: Summit DD requires that providers of locally funded services maintain documentation records in accordance with the standards outlined in the rule for waiver funded services. **

Homemaker Personal Care (HPC)

List of required elements

Adult Foster Care (AFC)

Adult Family Living (AFL)

  • AFL – unit rate
    • Template
  • AFL – daily rate

Non-Medical Transportation (NMT) – per trip/per mile

List of required elements.

Additional information, examples and resources can be found on DODD’s website.

*Please note: these forms are examples and providers can tweak them or use other forms that best suit the needs of who and what they are supporting

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