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Schedule 1 - Riverside County Department of Mental Health - Home

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					                                                          Schedule 1
SCHEDULE 1 - METHODOLOGY                                RIVERSIDE COUNTY DEPARTMENT OF MENTAL HEALTH
NON-HOSPITAL PROVIDER FOR                               MANAGED CARE PROGRAMS
CONTRACTED COUNTY SERVICES                              FINAL Y/E COST REPORT FOR: FY 05/06

SUBMISSION DATE:

REPORTING UNIT/PROVIDER NAME:

FISCAL RU NUMBER/PROVIDER NUMBER:

LEGAL ENTITY NUMBER:


                                         DESCRIPTION/EXPLANATION OF METHODOLOGY

A) Provide an explanation of the methodology used to separate Riverside County contract costs/revenues from
   non-Riverside County contract costs/revenues. Provide sufficient detail, including additional pages and/or
   worksheets, if needed, to fully describe how the segregation(s) are determined.
   If your agency has multiple contracts with the Riverside County Department of Mental Health, provide a separate
   Schedule 1 to explain the methodology used with each contract.




B) Provide an explanation of the methodology used to distribute costs/revenues to the Mode/Sfc within the contract.
   Attached additional pages and/or worksheets, as needed, to fully describe the methodology.




MC Sched 1 - 6/04
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      3/25/2010                                             MANAGED CARE                           Page 1 of 6 Pages
                                                                                                                                                                         Schedule 2
SCHEDULE 2 - EXPENSES BY LINE ITEMS                                        RIVERSIDE COUNTY DEPARTMENT OF MENTAL HEALTH                  MODES               Description      Service Func. Code Units of Measure
NON-HOSPITAL PROVIDER FOR                                                  MANAGED CARE PROGRAMS                                   24 hr. svcs. - 05     Hosp. Inpatient             10-18             Days
CONTRACTED COUNTY SERVICES                                                 FINAL Y/E COST REPORT FOR: FY 05/06                                           Adult Crisis Res.           40-49             Days
                                                                                                                                                         Adult Residential           65-69             Days
                                                                                                                                   Day svcs. - 10        Crisis Stabilization        20-29             Hours
SUBMISSION DATE:                                        0                                                                                                Day Tx 1/2 day              81-84             Hours
                                                                                                                                                         Day Tx full day             85-89             Hours
REPORTING UNIT/PROVIDER NAME:                               0                                                                                            Day Rhab 1/2 day            91-94             Hours
                                                                                                                                                         Day Rhab full day           95-99             Hours
FISCAL RU NUMBER/PROVIDER NUMBER:                           0                                                                      O/P Svcs. - 15        Case Management             01-09            Minutes
                                                                                                                                                         M/H Svcs.               10-19,30-59          Minutes
LEGAL ENTITY NUMBER:                                        0                                                                                            Medication Spt.             60-69            Minutes
                                                                                                                                                         Crisis Intervention         70-79            Minutes
                                                                                                                                   Outreach - 45         MH Promotion                10-19             Hours
                                                                                                                                                         Comm Client Svcs            20-29             Hours

                                                                (A)                 (B)              (C)               (D)               (E)                   (F)                 (G)                (H)                  (I)               (J)              (K)                (L)              (M)               (N)               (O)               (P)               (Q)               (R)               (R)
                                                                           Describe Methodology                    Methodology       Methodology           Methodology         Methodology        Methodology         Methodology       Methodology       Methodology       Methodology       Methodology       Methodology       Methodology       Methodology       Methodology       Methodology       Methodology
                                                                              on Schedule 1a                      on Schedule 1b    on Schedule 1b        on Schedule 1b      on Schedule 1b     on Schedule 1b      on Schedule 1b    on Schedule 1b    on Schedule 1b    on Schedule 1b    on Schedule 1b    on Schedule 1b    on Schedule 1b    on Schedule 1b    on Schedule 1b    on Schedule 1b        Total
                                                                                  LESS:             TOTAL        Mode: 05          Mode:     05          Mode:   05          Mode:   10         Mode:   10          Mode:     10      Mode:     10      Mode:   10        Mode:     15      Mode:   15        Mode:   15        Mode:   15        Mode:   15        Mode:   45        Mode: 45          Mode: ALL
                                                             PROVIDER        UNALLOWABLE          ALLOWABLE      SFC: 10-18        SFC: 40-49            SFC: 65-69          SFC: 20-29         SFC: 81-84          SFC: 85-89        SFC: 91-94        SFC: 95-99        SFC: 01-09        SFC: 10-59        SFC:     58       SFC: 60-69        SFC: 70-79        SFC: 10-19        SFC: 20-29        SFC: ALL
3                 SALARIES & BENEFITS                       TOTAL COSTS           COSTS             COSTS             Costs             Costs                 Costs               Costs              Costs               Costs             Costs             Costs             Costs             Costs             Costs             Costs             Costs             Costs             Costs             Costs
3a                Salaries                                                                                 -                                                                                                                                                                                                                                                                                                        -
 3b                Benefits                                                                                -                                                                                                                                                                                                                                                                                                        -
 3c                Payroll Taxes                                                                           -                                                                                                                                                                                                                                                                                                        -
 3d                Other                                                                                   -                                                                                                                                                                                                                                                                                                        -
3x                TOTAL SALARIES & BENEFITS                           $0                    $0              $0                $0                    $0                  $0                 $0                 $0                 $0                $0                $0                $0                $0                $0                $0                $0                $0                $0   $           -

4                 OPERATING EXPENSES
4a                Professional Svcs/Contracts                                                              -                                                                                                                                                                                                                                                                                                       -
4b                Office Supplies/Expense                                                                  -                                                                                                                                                                                                                                                                                                       -
4c                Utilities/Telephone                                                                      -                                                                                                                                                                                                                                                                                                       -
4d                Vehicle Maint./Transportation                                                            -                                                                                                                                                                                                                                                                                                       -
4e                Rent/Occupancy                                                                           -                                                                                                                                                                                                                                                                                                       -
4f                Insurance                                                                                -                                                                                                                                                                                                                                                                                                       -
4g                Other Operating Expense                                                                  -                                                                                                                                                                                                                                                                                                       -
4x                TOTAL OPERATING EXPENSES                            $0                    $0              $0                $0                    $0                  $0                 $0                 $0                 $0                $0                $0                $0                $0                $0                $0                $0                $0                $0   $          -

5                 OTHER EXPENSE
5a                Depreciation                                                                             -                                                                                                                                                                                                                                                                                                       -
5b                Amortization                                                                             -                                                                                                                                                                                                                                                                                                       -
5c                Other                                                                                    -                                                                                                                                                                                                                                                                                                       -
5x                TOTAL OTHER                                         $0                    $0              $0                $0                    $0                  $0                 $0                 $0                 $0                $0                $0                $0                $0                $0                $0                $0                $0                $0   $          -

6x                GROSS COST                                          $0                    $0              $0                $0                    $0                  $0                 $0                 $0                 $0                $0                $0                $0                $0                $0                $0                $0                $0                $0   $          -


6-May
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                        3/25/2010                                                                                                                                                                 MANAGED CARE                                                                                                                                                                            Page 2 of 6 Pages
                                                                                                                                                                                   Schedule 3
SCHEDULE 3 - REVENUES BY SOURCE                                               RIVERSIDE COUNTY DEPARTMENT OF MENTAL HEALTH
NON-HOSPITAL PROVIDER FOR                                                     MANAGED CARE PROGRAMS                                          MODES              Description        Service Func. Code Units of Measure
CONTRACTED COUNTY SERVICES                                                    FINAL Y/E COST REPORT FOR: FY 05/06                      24 hr. svcs. - 05    Hosp. Inpatient        10-18                    Days
                                                                                                                                                            Adult Crisis Res.      40-49                    Days
                                                                                                                                                            Adult Residential      65-69                    Days
SUBMISSION DATE:                                        0                                                                              Day svcs. - 10       Crisis Stabilization   20-29                    Hours
                                                                                                                                                            Day Tx 1/2 day         81-84                    Hours
REPORTING UNIT/PROVIDER NAME:                               0                                                                                               Day Tx full day        85-89                    Hours
                                                                                                                                                            Day Rhab 1/2 day       91-94                    Hours
FISCAL RU NUMBER/PROVIDER NUMBER:                           0                                                                                               Day Rhab full day      95-99                    Hours
                                                                                                                                       O/P Svcs. - 15       Case Management        01-09                   Minutes
LEGAL ENTITY NUMBER:                                        0                                                                                               M/H Svcs.              10-19,30-59             Minutes
                                                                                                                                                            Medication Spt.        60-69                   Minutes
                                                                                                                                                            Crisis Intervention    70-79                   Minutes
                                                                                                                                       Outreach - 45        MH Promotion           10-19                    Hours
                                                                                                                                                            Comm Client Svcs       20-29                    Hours




                                                                (A)                    (B)              (C)                (D)               (E)                  (F)                    (G)                (H)                 (I)               (J)              (K)                (L)              (M)               (N)               (O)               (P)               (Q)               (R)
                                                                              Describe Methodology                     Methodology       Methodology          Methodology            Methodology        Methodology        Methodology       Methodology       Methodology       Methodology       Methodology       Methodology       Methodology       Methodology       Methodology       Methodology      Methodology
                                                                                on Schedule 1a                        on Schedule 1b    on Schedule 1b       on Schedule 1b         on Schedule 1b     on Schedule 1b     on Schedule 1b    on Schedule 1b    on Schedule 1b    on Schedule 1b    on Schedule 1b    on Schedule 1b    on Schedule 1b    on Schedule 1b    on Schedule 1b    on Schedule 1b        Total
                                                            PROVIDER                 LESS:             TOTAL         Mode: 05          Mode:     05         Mode:   05             Mode:   10         Mode:   10         Mode:     10      Mode:     10      Mode:   10        Mode:    15       Mode:   15        Mode:   15        Mode:   15        Mode:   15        Mode:   45        Mode: 45          Mode: ALL
                                                              TOTAL            NON-CONTRACT          CONTRACT        SFC: 10-18        SFC: 40-49           SFC: 65-69             SFC: 20-29         SFC: 81-84         SFC: 85-89        SFC: 91-94        SFC: 95-99        SFC: 01-09        SFC: 10-59        SFC:     58       SFC: 60-69        SFC: 70-79        SFC: 10-19        SFC: 20-29        SFC: ALL
                    REVENUE TYPES                           REVENUES              REVENUES           REVENUES           Revenues          Revenues             Revenues               Revenues             Costs              Costs             Costs             Costs             Costs             Costs             Costs             Costs             Costs             Costs             Costs            Costs
9                   County Contract Income                                                                    0.00                                                                                                                                                                                                                                                                                                      -
10                  Grants Income                                                                             0.00                                                                                                                                                                                                                                                                                                      -
11                  Donations Income                                                                          0.00                                                                                                                                                                                                                                                                                                      -
12                  Program Fees                                                                              0.00                                                                                                                                                                                                                                                                                                      -
13                  Food Stamps                                                                               0.00                                                                                                                                                                                                                                                                                                      -
14                  Rental Income                                                                             0.00                                                                                                                                                                                                                                                                                                      -
15                  Other Income                                                                              0.00                                                                                                                                                                                                                                                                                                      -
16                  TOTAL REVENUE                                     $0.00                 $0.00            $0.00             $0.00                $0.00                $0.00                $0.00                -                 -                 -                 -                 -                 -                 -                 -                 -                 -                 -                -




MC Sched 3 - Revised 5/06
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                    3/25/2010                                                                                                                                                                               MANAGED CARE                                                                                                                                                                          Page 3 of 6 Pages
                                                                                     Schedule 4
SCHEDULE 4 - UNITS                                                                                                 RIVERSIDE COUNTY DEPARTMENT OF MENTAL HEALTH
NON-HOSPITAL PROVIDER FOR                                                                                          MANAGED CARE PROGRAMS
CONTRACTED COUNTY SERVICES                                                                                         FINAL Y/E COST REPORT FOR: FY 05/06


SUBMISSION DATE:                                                 0

REPORTING UNIT/PROVIDER NAME:                                                               0

FISCAL RU NUMBER/PROVIDER NUMBER:                                                           0

LEGAL ENTITY NUMBER:                                                                        0


                       MODES             Description                   Service Func. Code       Units of Measure
                   24 hr. svcs. - 05 Hosp. Inpatient                  10-18                           Days
                                     Adult Crisis Res.                40-49                           Days
                                     Adult Residential                65-69                           Days
                   Day svcs. - 10 Crisis Stabilization                20-29                           Hours
                                     Day Tx 1/2 day                   81-84                           Hours
                                     Day Tx full day                  85-89                           Hours
                                     Day Rhab 1/2 day                 91-94                           Hours
                                     Day Rhab full day                95-99                           Hours
                   O/P Svcs. - 15 Case Management                     01-09                         Minutes
                                     M/H Svcs.                        10-19,30-59                   Minutes
                                     Medication Spt.                  60-69                         Minutes
                                     Crisis Intervention              70-79                         Minutes
                   Outreach - 45 MH Promotion                         10-19                           Hours
                                     Comm Client Svcs                 20-29                           Hours


                                                                                                      (A)                 (B)               (C)


                                                                                                  PROVIDER              LESS:       TOTAL CONTRACT
                                                                                                 TOTAL UNITS        NON-CONTRACT           UNITS
7                  UNIT TYPES                                                                                         UNITS/ADJ     (including Medi-Cal)
7a                  24 hr svcs 05              Hosp Inpt.                    10-18                                                                   -
7b                  24 hr svcs 05              Adult Crisis Res              40-49                                                                   -
7c                  24 hr svcs 05              Adult Res                     65-69                                                                   -
7d                 Day svcs 10                 Crisis Stabilization          20-29                                                                   -
7e                 Day svcs 10                 Day Tx 1/2 day                81-84                                                                   -
7f                 Day svcs 10                 Day Tx full day               85-89                                                                   -
7g                 Day svcs 10                 Day Rehab 1/2 day             91-94                                                                   -
7h                 Day svcs 10                 Day Rehab full day            95-99                                                                   -
7i                 O/P Svcs 15                 Case Management               01-09                                                                   -
7j                 O/P Svcs 15                 M/H Svcs                      10-59                                                                   -
7k                 O/P Svcs 15                 M/H Svcs-TBS                   58                                                                     -
7l                 O/P Svcs 15                 Medication Spt.               60-69                                                                   -
7m                 O/P Svcs 15                 Crisis Intervention           70-79                                                                   -
7n                 Outreach 45                 MH Promotion                  10-19                                                                   -
7o                 Outreach 45                 Comm Client Svcs              20-29                                                                   -



MC Sched 4 - Revised 5/06
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                                                                                                                                                           Page 4 of 6 Pages
        3/25/2010                                                                           MANAGED CARE
                                                                                                                                                                                 Schedule 5
SCHEDULE 5 - SUMMARY REPORT OF                                                           RIVERSIDE COUNTY DEPARTMENT OF MENTAL HEALTH
EXPENDITURES/REVENUES BY MODE/SFC                                                        MANAGED CARE PROGRAMS
NON-HOSPITAL PROVIDER FOR                                                                FINAL Y/E COST REPORT FOR: FY 05/06
CONTRACTED COUNTY SERVICES

SUBMISSION DATE:                                        0                                                       TYPE OF CONTRACT:                        TYPE OF ORGANIZATION:                          ACCOUNTING METHOD:
                                                                                                                ACTUAL COST _____________                PROFIT     ______________                      CASH                                      _______________
REPORTING UNIT/PROVIDER NAME:                                     0                                             IMD________________________              NON-PROFIT ______________                      MODIFIED ACCRUAL                          _______________
                                                                                                                NET NEG. RATE ____________                                                              ACCRUAL                                   _______________
FISCAL RU NUMBER/PROVIDER NUMBER:                                 0                                             NET NEG. AMT. _____________

LEGAL ENTITY NUMBER:                                              0

                                                                       (1)                    (2)                     (3)                (4)                   (5)                    (6)                    (7)                (8)                     (9)                (10)              (11)               (12)               (13)                   (14)               (15)                                   Check Figure
1               MODE OF SERVICE CODE                                   05                     05                      05                 10                    10                     10                     10                 10                      15                  15                15                 15                 15                     45                 45               TOTAL                Mode: ALL
2               SERVICE FUNCTION CODE                                 10-18                  40-49                   65-69              20-29                 81-84                  85-89                  91-94              95-99                   01-09              10-59               58               60-69              70-79                  10-19              20-29                                   Svc Fun. ALL

                EXPENSES
 3x              Salaries & Benefits                                            -                      -                       -                -                       -                      -                      -                  -                       -                  -                 -                  -                  -                      -                  -                    -                  -
 4x              Operating Expenses                                             -                      -                       -                -                       -                      -                      -                  -                       -                  -                 -                  -                  -                      -                  -                    -                  -
 5x              Other                                                          -                      -                       -                -                       -                      -                      -                  -                       -                  -                 -                  -                  -                      -                  -                    -                  -
6x              GROSS COST                                                          $0                     $0                      $0               $0                      $0                     $0                     $0                 $0                      $0                 $0                $0                 $0                 $0                     $0                 $0                   $0             -



 7               Total Units of Service                                         -                      -                       -              -                         -                      -                      -                  -                       -                  -                 -                  -                  -                      -                  -                                       -
8               Cost per Unit of Service                                      $0.00                  $0.00                   $0.00          $0.00                     $0.00                  $0.00                  $0.00              $0.00                   $0.00              $0.00             $0.00              $0.00              $0.00                  $0.00              $0.00
8a              Published Charge per Unit                                     $0.00                  $0.00                   $0.00          $0.00                     $0.00                  $0.00                  $0.00              $0.00                   $0.00              $0.00             $0.00              $0.00              $0.00                  $0.00              $0.00
8b              SB 900 Rate

                REVENUES
 10              Grants Income                                                  -                      -                       -                -                       -                      -                      -                  -                       -                  -                 -                  -                  -                      -                  -                    -                  -
 11              Donation Income                                                -                      -                       -                -                       -                      -                      -                  -                       -                  -                 -                  -                  -                      -                  -                    -                  -
 12              Program Fees                                                   -                      -                       -                -                       -                      -                      -                  -                       -                  -                 -                  -                  -                      -                  -                    -                  -
 13              Food Stamps                                                    -                      -                       -                -                       -                      -                      -                  -                       -                  -                 -                  -                  -                      -                  -                    -                  -
 14              Rental Income                                                  -                      -                       -                -                       -                      -                      -                  -                       -                  -                 -                  -                  -                      -                  -                    -                  -
 15              Other Income                                                   -                      -                       -                -                       -                      -                      -                  -                       -                  -                 -                  -                  -                      -                  -                    -                  -
16x             TOTAL REVENUES                                                      $0                     $0                      $0               $0                      $0                     $0                     $0                 $0                      $0                 $0                $0                 $0                 $0                     $0                 $0                   $0             -

17              NET COST                                                            $0                     $0                      $0               $0                      $0                     $0                     $0                 $0                      $0                 $0                $0                 $0                 $0                     $0                 $0                   $0             -

18              Maximum Contract Amount                                        0.00                   0.00                    0.00              0.00                   0.00                   0.00                   0.00               0.00                    0.00               0.00              0.00               0.00               0.00                   0.00               0.00              0.00
19              NEG. NET RATE CONTRACTS ONLY:
                Maximum Cost for Reimbursement           (rate)
                Reimbursement Calculation:                                      -                      -                       -                -                       -                      -                      -                  -                       -                  -                 -                  -                  -                      -                  -                    -
20              LESS:Payment received from County
21a             Balance Due to County (if 20>Reimbursement)                                                                                                                                                                                                                                                                                                                                            -
21b             Balance Due to Provider (if 20<Reimbursement)                                                                                                                                                                                                                                                                                                                                          -

MC Sched 4 - Revised 5/06
K:\CONT_CR\FY0405\BLANK K FORMS\MC Combined Schedules



I certify under penalty of perjury that the information
contained on these documents is true and accurate.

_________________________________________________                                        ____________________________________________                                            __________________________                                                                                                                          _
                                                                                                                                                                                                                                                  ___________________________________________________________________________________________________________
Signature                             Date                                               Prepared By                                                                             Telephone No.                                                    Contact Person to Answer Questions about information contained in this Cost Report Telephone No.

_________________________________________________                                        __________________________                                                              __________________________                                       __________________________                                                                         __________________________
Title                                                                                    Email Address                                                                           Fax No.                                                          Email Address                                                                                      Fax No.




                  3/25/2010                                                                                                                                                                                MANAGED CARE                                                                                                                                                                          Page 5 of 6 Pages
                                                                                     Schedule 6
SCHEDULE 6 - NOMINAL FEE PROVIDER DETERMINATION                                                      RIVERSIDE COUNTY DEPARTMENT OF MENTAL HEALTH
NON-HOSPITAL PROVIDER FOR                                                                            MANAGED CARE PROGRAMS
CONTRACTED COUNTY SERVICES                                                                           FINAL Y/E COST REPORT FOR: FY 05/06

SUBMISSION DATE:                                             ############

REPORTING UNIT/PROVIDER NAME:                                       0

FISCAL RU NUMBER/PROVIDER NUMBER:                                   0

LEGAL ENTITY NUMBER:                                                0

Nominal Fee Provider Determination
Please answer the following questions:
    Yes            No
                                                        1.   Does your legal entity have a published schedule of its full (non-discounted) charges?
                                                             Are your legal entity's revenues for patient care based on application of published
                                                        2.
                                                             charge schedule?
                                                             Does your legal entity maintain written policies for its process of making patient
                                                        3.
                                                             indigence determinations?
                                                             Does your legal entity maintain sufficient documentation to support the amount of
                                                        4.
                                                             “indigence allowances” written off in accordance with the above procedures?


COMPLETED BY:

TITLE OR POSITION:




MH Sched 6 - Revised 5/06
K:\CONT_CR\FY0405\BLANK K FORMS\MC Combined Schedules




3/25/2010                                                                                          MANAGED CARE                                       Page 6 of 6 Pages

				
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