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Texas Department of Human Services by 4mD4ar

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									Texas Department of Aging                                                                                                                         Form 3058
and Disability Services                           Day Activity and Health Services (DAHS)                                                     December 2004
                                                     Financial Errors Standard
Client Name                                                        Medicaid No.                 Date of Review                       Review Month
                                                                                                (MM/DD/YY)                           (MM/YY)
Review Type                                        Service Code                          Vendor No.                                  Region
    Formal        Administrative        Other
Agency Name                                                              Monitor


                                                    FINANCIAL ERRORS STANDARD
                                             A.                         B. Unit Rate                                C. Total Reimbursement (A X B)
A. Number of Units Reimbursed
   (COGNOS)                                                              X                                          =
                                             D.

D. Number of Accurate Units Provided
                                          
                                             E.                         F. Unit Rate                                G. Total Recoupment (E X F)
E. Number of Units in Error
   (A minus D)                                                           X                                          =

                      EXPLANATION OF FINANCIAL ERRORS STANDARD                                                      SERVICE DELIVERY PERIOD
                              Reference: 40 TAC §98.210(b)                                                              & UNITS IN ERROR

 1. The facility is reimbursed for services, but the daily attendance and daily transportation record
    form is missing for the period for which services are reimbursed. The department applies the
    error to the total number of units reimbursed for the billing period.
 2. The facility is reimbursed for units that exceed the units recorded on the daily attendance and
    daily transportation record. The department applies the error to the total number of units
    reimbursed in excess of the units recorded.
 3. The facility is reimbursed for units of service and the client did not receive services. The
    department applies the error to the total number of units reimbursed for the days the client did
    not receive services.
 4. The facility is reimbursed for units of service and the client was Medicaid ineligible. The
    department applies the error to the total number of units reimbursed for the days the client was
    Medicaid ineligible. (Not applicable to Title XX clients).

                                                                  TOTAL NUMBER OF UNITS IN ERROR:
                                                                                       (If Any, Units in Item E.)
                                                                                                                    Unit(s) X Rate
                                                                  TOTAL AMOUNT FOR RECOUPMENT:


Comments: Enter any under billing or other information not captured above. Attach additional pages, if needed.

								
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