Ambulance Billing Audit Template - Excel

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					                                                                                                                                    Appendix 6.1.0
                                                    Financial Reporting Instructions
1. On the certification cover sheet, fill in health plan name, plan number, period ended, preparer's information, and signatures.
2. Each quarter, change "quarter ended" date on Balance Sheet. This will change information on each sheet.
3. Parent Company financial information is an added schedule that should be completed, if applicable.
4. Confirm that audit check figures below match. If they do not match, explain why separately.



                                                               AUDIT CRITERIA

   Program Contractor: (enter name here)
   Quarter Ended: (MMM, DD, YYYY)


                          Amount 1                                                     Amount 2                          Amount 1 Amount 2

   Balance Sheet - Total Assets                               = Balance Sheet - Total Liabilities+Total Equity
   Income Stmnt - Equity/Net Assets at End of Period          = Balance Sheet - Equity/Net Assets


   Supplemental Schedules agree to Statement of Financial Position, Net Assets or Balance Sheet & Statement of Activities or Income Statement:

              Financial Statement information                                   Supplemental Reports

   Other Assets                                               = Report #3
   Other Liabilities                                          = Report #3
   Long Term Debt                                             = Report #3
   Other Revenue                                              = Report #4
   Other Expenses                                             = Report #4


                         For Contractors who provide services in more than one county                                       Yes           No

   Total of Net Income for all counties on Rprt #2A           = Net Income (Loss) on Report #2
                                                                                                                Appendix 6.1.1
Program Contractor Financial Reporting Systems - Report #1 Statement of Financial Position, Net Assets or Balance Sheet
 Program Contractor
      Quarter Ending
   Fiscal Year Ending

     Account #                                           Account Description                                       Balance
Current Assets:
         105              Cash and Cash Equivalents
         110              Short-Term Investments                                                                                 -
         115              Capitation Receivable from AHCCCS
         120              Reinsurance Receivable from AHCCCS:
         125              Investment Income Receivable
         130              Current Due from Affiliates
         135              Other Current Receivables (Report #3)
         140              Other Current Assets (Report #3)                                                                       -
                                                                                       Total Current Assets: $                   -
Other Assets:
         145              General Performance Bond                                                                               -
         150              Restricted Cash and Other Assets                                                                       -
         155              Long-Term Investments
         160              Non-Current Due from Affiliates                                                                        -
         165              Other Non-Current Assets (Report #3)
                                                                                         Total Other Assets $                    -
PROPERTY AND EQUIPMENT:
      170        Land
      175        Buildings
      180        Leasehold Improvements
      185        Furniture & Equipment                                                                                           -
      190        Other Property & Equipment (Report #3)                                                                          -
      195        Accumulated Depreciation & Amortization                                                                         -
                                                                                 Net Property & Equipment: $                     -
                                                                                              Total Assets: $                    -
Current Liabilities:
         205              Accounts Payable
         210              Accrued Administrative Expenses
         215              Capitation Payable
         220              Medical Claims Payable                                                                                 -
         225              Other Current Payables (Report #3)
         230              Current Portion of Long-Term Debt (Report #3)                                                          -
         235              Current Due to Affiliates
         240              Other Current Liabilities (Report #3)                                                                  -
                                                                                    Total Current Liabilities: $                 -
Other Liabilities:
         245              Non-Current Portion of Long-Term Debt (Report #3)                                                      -
         250              Non-Current Due to Affiliates                                                                          -
         255              Other Non-Current Liabilities (Report #3)                                                              -
                                                                                      Total Other Liabilities: $                 -
                                                                                            Total Liabilities: $                 -
Equity/Net Assets (Liabilities):
          505             Preferred Stock                                                                                        -
          510             Common Stock                                                                                           -
          515             Treasury Stock                                                                                         -
          520             Unrestricted Net Assets
          525             Restricted Net Assets
          527             Additional Paid-in Capital                                                                             -
          528             Contributed Capital                                                                                    -
          530             Retained Earnings/Net Assets (Liabilities)                                                             -
                                                                          Net Equity/Net Assets (Liabilities): $                 -
                                                                                     Total Liability & Equity: $                 -
Program Contractor Financial Reporting Systems - Report #2 Statement of Activities/Income Statement
                                       Program Contractor          0
                                            Quarter Ending      01/00/00
                                        Fiscal Year Ending      01/00/00
                                                            CURRENT QUARTER                         YEAR TO DATE

Account #               Account Description                 Total Amount      Total PMPM          Total Amount     Total PMPM


Revenues:
     300    Capitation
     305    PPC Capitation
     310    Reinsurance
     315    PPC - Reconciliation
     320    Share of Cost (SOC) Reconciliation *
     325    HCBS Placement Reconciliation *
     330    HIV-AIDS /Supplement
     335    Other AHCCCS Revenue (Report #4)
                            Subtotal AHCCCS Revenue                    -                -                    -             -

      350   Investment Income *
      360   Third Party Liability Recoveries
      370   Patient Contributions (MSOC)
      380   Other Non-AHCCCS Income (Report #4)
                        Subtotal Non-AHCCCS Revenue                    -                -                    -             -
                                     TOTAL REVENUES                    -                -                    -             -

Institutional Care Expenses:
       400 NF ICF & Bedholds
       402 Level I
       404 Level II
       406 Level III
       408 Institutional Care
       410 PPC Institutional
       412 Other Institutional Care (Report #4)
                         TOTAL INSTITUTIONAL CARE                      -                -                    -             -

Home & Community Bases Services (HCBS)Expenses:
    414 Home Health Nurse
    416 Home Health Aide
    418 Personal Care
    420 Homemaker
    422 Home Delivered Meals
    424 Respite Care
    426 Attendant Care
    428 Assisted Living Home
    429 Assisted Living Center
    430 Adult Day Health
    432 Adult Foster Care
    434 Group Respite
    436 Hospice
    438 Environmental Modifications
    443 PPC HCBS
    444 Other HCBS Costs (Report #4)
                                    TOTAL HCBS                         -                -                    -             -

Acute Care Expenses:
      448 Inpatient Services (Hosp.)
      450 Primary Care Physician Services
      452 Referral Physician Services
      454 Emergency Services
      456 Out Patient Facility
      458 Prescription Drug
      460 Lab/Radiology
      462 Durable Medical Equipment
      464 Dental
      466 Transportation
Program Contractor Financial Reporting Systems - Report #2 Statement of Activities/Income Statement
                                       Program Contractor          0
                                            Quarter Ending      01/00/00
                                        Fiscal Year Ending      01/00/00
                                                            CURRENT QUARTER                         YEAR TO DATE

Account #                Account Description                Total Amount      Total PMPM          Total Amount     Total PMPM

      468   Therapies
      470   Outpatient Behavioral Health
      471   PPC Acute Care
      472   Other Accute Care Costs (Report #4)
                                TOTAL ACUTE CARE                       -                -                    -             -

Other Medical Expenses:
      477 PPC - Other
      479 Other Medical (Report #4)
                          TOTAL OTHER MEDICAL                          -                -                    -             -
      480 Case Management
                    TOTAL MEDICAL EXPENSE:                             -                -                    -             -

Administrative Expenses:*
     484 Compensation
     488 Data Processing
     490 Management Fees
     492 Interest Expense
     493 Occupancy
     494 Marketing
     495 Depreciation
     496 Other Administration (Report #4)
                          TOTAL ADMINISTRATION                         -                -                    -             -
                                  TOTAL EXPENSE                        -                -                    -             -
                     INCOME FROM OPERATIONS                            -                -                    -             -
      497   Non-Operating Income (Loss)

                   INCOME(LOSS) BEFORE TAXES                           -                -                    -             -
      498 Provision for Premium Taxes
      499 Provision for Income Taxes

                  NET INCOME(LOSS) AFTER TAXES                         -                -                    -             -
CHANGES TO EQUITY/NET ASSETS:
    530 Equity/Net Assets at Beginning of Period
      505   Preferred Stock
      510   Common Stock
      515   Treasury Stock
      520   Unrestricted Net Assets
      525   Restricted Net Assets
      527 Increase(Decrease) in Add'l Paid-in Capital
      528 Increase(Decrease) in Contributed Capital
      530 Increase(Decrease) in R/E Fund Balance
             A. Net Income (Loss)
             B. Dividends to Stockholders
             C. Other: specify
      530 Equity/Net Assets at End of Period:
Program Contractor Financial Reporting Systems - Report #2A Statement of Activities/Income Statement ( GSA)
                                       Program Contractor          0
                                           Quarter Ending       01/00/00
                                        Fiscal Year Ending      01/00/00
                                                             CURRENT QUARTER                       YEAR TO DATE

Account #                Account Description                  Total Amount      Total PMPM           Total Amount   Total PMPM


Revenues:
     300    Capitation
     305    PPC Capitation
     310    Reinsurance
     315    PPC - Reconciliation
     320    Share of Cost (SOC) Reconciliation *
     325    HCBS Placement Reconciliation *
     330    HIV-AIDS /Supplement
     335    Other AHCCCS Revenue (Report #4)
                            Subtotal AHCCCS Revenue                      -                 -                  -             -

      350   Investment Income *
      360   Third Party Liability Recoveries
      370   Patient Contributions (MSOC)
      380   Other Non-AHCCCS Income (Report #4)
                        Subtotal Non-AHCCCS Revenue                      -                 -                  -             -
                                     TOTAL REVENUES                      -                 -                  -             -

Institutional Care Expenses:
       400 NF ICF & Bedholds
       402 Level I
       404 Level II
       406 Level III
       408 Institutional Care
       410 PPC Institutional
       412 Other Institutional Care (Report #4)
                         TOTAL INSTITUTIONAL CARE                        -                 -                  -             -

Home & Community Bases Services (HCBS)Expenses:
    414 Home Health Nurse
    416 Home Health Aide
    418 Personal Care
    420 Homemaker
    422 Home Delivered Meals
    424 Respite Care
    426 Attendant Care
    428 Assisted Living Home
    429 Assisted Living Center
    430 Adult Day Health
    432 Adult Foster Care
    434 Group Respite
    436 Hospice
    438 Environmental Modifications
    443 PPC HCBS
    444 Other HCBS Costs (Report #4)
                                    TOTAL HCBS                           -                 -                  -             -

Acute Care Expenses:
     448 Inpatient Services (Hosp.)
     450 Primary Care Physician Services
     452 Referral Physician Services
     454 Emergency Services
     456 Out Patient Facility
     458 Prescription Drug
     460 Lab/Radiology
     462 Durable Medical Equipment
     464 Dental
     466 Transportation
     468 Therapies
Program Contractor Financial Reporting Systems - Report #2A Statement of Activities/Income Statement ( GSA)
                                       Program Contractor          0
                                           Quarter Ending       01/00/00
                                        Fiscal Year Ending      01/00/00
                                                             CURRENT QUARTER                       YEAR TO DATE

Account #                 Account Description                 Total Amount      Total PMPM           Total Amount   Total PMPM

      470 Outpatient Behavioral Health
      471 PPC Acute Care
      472 Other Accute Care Costs (Report #4)
                              TOTAL ACUTE CARE                           -                 -                  -             -

Other Medical Expenses:
      477 PPC - Other
      479 Other Medical (Report #4)
                          TOTAL OTHER MEDICAL                            -                 -                  -             -
      480 Case Management
                     TOTAL MEDICAL EXPENSE:                              -                 -                  -             -

Administrative Expenses:*
     484 Compensation
     488 Data Processing
     490 Management Fees
     492 Interest Expense
     493 Occupancy
     494 Marketing
     495 Depreciation
     496 Other Administration (Report #4)
                          TOTAL ADMINISTRATION                           -                 -                  -             -
                                   TOTAL EXPENSE                         -                 -                  -             -
                      INCOME FROM OPERATIONS                             -                 -                  -             -
      497    Non-Operating Income (Loss)

                   INCOME(LOSS) BEFORE TAXES                             -                 -                  -             -
      498 Provision for Premium Taxes
      499 Provision for Income Taxes

                   NET INCOME(LOSS) AFTER TAXES                          -                 -                  -             -
CHANGES TO EQUITY/NET ASSETS:
    530 Equity/Net Assets at Beginning of Period
       505   Preferred Stock
       510   Common Stock
       515   Treasury Stock
       520   Unrestricted Net Assets
       525   Restricted Net Assets
       527 Increase(Decrease) in Add'l Paid-in Capital
       528 Increase(Decrease) in Contributed Capital
       530 Increase(Decrease) in R/E Fund Balance
              A. Net Income (Loss)
              B. Dividends to Stockholders
              C. Other: specify
       530 Equity/Net Assets at End of Period:
Program Contractor Financial Reporting Systems - Report #2A Statement of Activities/Income Statement ( County   Optional)
                                      Program Contractor          0
                                          Quarter Ending       01/00/00
                                       Fiscal Year Ending      01/00/00
                                                            CURRENT QUARTER                       YEAR TO DATE

Account #                Account Description                 Total Amount       Total PMPM          Total Amount      Total PMPM


Revenues:
     300    Capitation
     305    PPC Capitation
     310    Reinsurance
     315    PPC - Reconciliation
     320    Share of Cost (SOC) Reconciliation *
     325    HCBS Placement Reconciliation *
     330    HIV-AIDS /Supplement
     335    Other AHCCCS Revenue (Report #4)
                            Subtotal AHCCCS Revenue                     -                 -                      -            -

      350   Investment Income *
      360   Third Party Liability Recoveries
      370   Patient Contributions (MSOC)
      380   Other Non-AHCCCS Income (Report #4)
                        Subtotal Non-AHCCCS Revenue                     -                 -                      -            -
                                     TOTAL REVENUES                     -                 -                      -            -

Institutional Care Expenses:
       400 NF ICF & Bedholds
       402 Level I
       404 Level II
       406 Level III
       408 Institutional Care
       410 PPC Institutional
       412 Other Institutional Care (Report #4)
                         TOTAL INSTITUTIONAL CARE                       -                 -                      -            -

Home & Community Bases Services (HCBS)Expenses:
    414 Home Health Nurse
    416 Home Health Aide
    418 Personal Care
    420 Homemaker
    422 Home Delivered Meals
    424 Respite Care
    426 Attendant Care
    428 Assisted Living Home
    429 Assisted Living Center
    430 Adult Day Health
    432 Adult Foster Care
    434 Group Respite
    436 Hospice
    438 Environmental Modifications
    443 PPC HCBS
    444 Other HCBS Costs (Report #4)
                                    TOTAL HCBS                          -                 -                      -            -

Acute Care Expenses:
     448 Inpatient Services (Hosp.)
     450 Primary Care Physician Services
     452 Referral Physician Services
     454 Emergency Services
     456 Out Patient Facility
     458 Prescription Drug
     460 Lab/Radiology
     462 Durable Medical Equipment
     464 Dental
     466 Transportation
     468 Therapies
Program Contractor Financial Reporting Systems - Report #2A Statement of Activities/Income Statement ( County   Optional)
                                      Program Contractor          0
                                          Quarter Ending       01/00/00
                                       Fiscal Year Ending      01/00/00
                                                            CURRENT QUARTER                       YEAR TO DATE

Account #                Account Description                 Total Amount       Total PMPM          Total Amount      Total PMPM

      470 Outpatient Behavioral Health
      471 PPC Acute Care
      472 Other Accute Care Costs (Report #4)
                              TOTAL ACUTE CARE                          -                 -                      -            -

Other Medical Expenses:
      477 PPC - Other
      479 Other Medical (Report #4)
                          TOTAL OTHER MEDICAL                           -                 -                      -            -
      480 Case Management
                     TOTAL MEDICAL EXPENSE:                             -                 -                      -            -

Administrative Expenses:*
     484 Compensation
     488 Data Processing
     490 Management Fees
     492 Interest Expense
     493 Occupancy
     494 Marketing
     495 Depreciation
     496 Other Administration (Report #4)
                          TOTAL ADMINISTRATION                          -                 -                      -            -
                                  TOTAL EXPENSE                         -                 -                      -            -
                     INCOME FROM OPERATIONS                             -                 -                      -            -
      497   Non-Operating Income (Loss)

                   INCOME(LOSS) BEFORE TAXES                            -                 -                      -            -
      498 Provision for Premium Taxes
      499 Provision for Income Taxes

                  NET INCOME(LOSS) AFTER TAXES                          -                 -                      -            -
CHANGES TO EQUITY/NET ASSETS:
    530 Equity/Net Assets at Beginning of Period
      505   Preferred Stock
      510   Common Stock
      515   Treasury Stock
      520   Unrestricted Net Assets
      525   Restricted Net Assets
      527 Increase(Decrease) in Add'l Paid-in Capital
      528 Increase(Decrease) in Contributed Capital
      530 Increase(Decrease) in R/E Fund Balance
             A. Net Income (Loss)
             B. Dividends to Stockholders
             C. Other: specify
      530 Equity/Net Assets at End of Period:
                                                                                                               Appendix 6.1.3
Program Contractor Financial Reporting Systems - Report #3 Balance Sheet "Other Account" Details
                         Program Contractor 0
                              Quarter Ending 01/00/00
                          Fiscal Year Ending 01/00/00
                                                            Other Assets
Account: #135 - Other Current Receivables
                                                                                                                         -


                                                                                                   Subtotal:             -
Account: #140 - Other Current Assets
                                                                                                                         -


                                                                                                   Subtotal:             -
Account: #165 - Other Non - Current Assets
                                                                                                                         -


                                                                                                   Subtotal:             -
Account: #190 - Other Property and Equipment
                                                                                                                         -


                                                                                                   Subtotal:             -
                                                                                                     Total :             -

                                                          Other Liabilities
Account: #225 - Other Current Payables
                                                                                                                         -


                                                                                                   Subtotal:             -
Account: #240 - Other Current Liabilities
                                                                                                                         -


                                                                                                   Subtotal:             -
Account: #255 - Other Non - Current Liabilities
                                                                                                                         -


                                                                                                   Subtotal:             -
                                                                                                     Total :             -

                                                          Long Term Debt
Account: #230 - Current Portion of Long Term Debt
                                                                                                                         -


                                                                                                   Subtotal:             -
Account: #245 - Non-Current Portion of Long Term Debt
                                                                                                                         -


                                                                                                   Subtotal:             -
                                                                                                     Total :             -
                                                                                                                  Appendix 6.1.4
Program Contractor Financial Reporting Systems - Report #4 Income Statement "Other Account" Details
                         Program Contractor 0
                              Quarter Ending 01/00/00
                          Fiscal Year Ending 01/00/00
                                                          Other Revenue
Account: #335 - Other AHCCCS Revenue
                                                                                                                            -



                                                                                                      Subtotal:             -
Account: #380 - Other Non-AHCCCS Revenue
                                                                                                                            -



                                                                                                      Subtotal:             -
                                                                                                        Total :             -

                                                          Other Expenses
Account: #412 - Other Institutional Care Expense
                                                                                                                            -



                                                                                                      Subtotal:             -
Account: #444 - Other HCBS Costs
                                                                                                                            -



                                                                                                      Subtotal:             -
Account: #472 - Other Acute Care Costs
                                                                                                                            -



                                                                                                      Subtotal:             -
Account: #479 - Other Medical Expense
                                                                                                                            -



                                                                                                      Subtotal:             -
Account: #496 - Other Administrative Expense
                                                                                                                            -



                                                                                                      Subtotal:             -
                                                                                                        Total :             -
Program Contractor Financial Reporting Systems - Report #6 - Claims Lag Report for Prospective Period Only - IBNR                                           Appendix 6.1.6
                  Program Contractor                    0
                      Quarter Ending                 01/00/00
                   Fiscal Year Ending                01/00/00
  A - INSTITUTIONAL PAYMENTS
  (1)                     (2)                             (3)                  (4)                   (5)            (6)       (7)         (8)         (9)          (10)
            <------------------------------QUARTER IN WHICH SERVICE PROVIDED------------------------------->
                    QUARTER OF
 LINE                 PAYMENT                         CURRENT             1ST PRIOR             2ND PRIOR      3RD PRIOR   4TH PRIOR   5TH PRIOR   6TH PRIOR*     TOTAL
   1     CURRENT
   2     1ST PRIOR
   3     2ND PRIOR
   4     3RD PRIOR
   5     4TH PRIOR
   6     5TH PRIOR
   7     6TH PRIOR
   8     TOTALS
   9     EXP.REPORTED
  10     ADJUSTMENT
  11     REMAINING LIABILITY
B - HCBS PAYMENTS
  (1)                      (2)                 (3)         (4)              (5)                 (6)                           (7)         (8)         (9)          (10)
<------------------------------QUARTER IN WHICH SERVICE PROVIDED------------------------------->
                    QUARTER OF
LINE                 PAYMENT                        CURRENT              1ST PRIOR            2ND PRIOR        3RD PRIOR   4TH PRIOR   5TH PRIOR   6TH PRIOR*     TOTAL
   1     CURRENT
   2     1ST PRIOR
   3     2ND PRIOR
   4     3RD PRIOR
   5     4TH PRIOR
   6     5TH PRIOR
   7     6TH PRIOR
   8     TOTALS
   9     EXP.REPORTED
  10     ADJUSTMENT
  11     REMAINING LIABILITY
C - ACUTE PAYMENTS
  (1)                      (2)                 (3)         (4)              (5)                 (6)                           (7)         (8)         (9)          (10)
<------------------------------QUARTER IN WHICH SERVICE PROVIDED------------------------------->
                    QUARTER OF
LINE                  PAYMENT                       CURRENT              1ST PRIOR            2ND PRIOR        3RD PRIOR   4TH PRIOR   5TH PRIOR   6TH PRIOR*     TOTAL
   1     CURRENT
   2     1ST PRIOR
   3     2ND PRIOR
   4     3RD PRIOR
   5     4TH PRIOR
   6     5TH PRIOR
   7     6TH PRIOR
   8     TOTALS
   9     EXP.REPORTED
  10     ADJUSTMENT
  11     REMAINING LIABILITY
D - OTHER MEDICAL PAYMENTS
  (1)                      (2)                 (3)         (4)              (5)                 (6)                           (7)         (8)         (9)          (10)
<------------------------------QUARTER IN WHICH SERVICE PROVIDED------------------------------->
                    QUARTER OF
LINE                  PAYMENT                       CURRENT              1ST PRIOR            2ND PRIOR        3RD PRIOR   4TH PRIOR   5TH PRIOR   6TH PRIOR*     TOTAL
   1     CURRENT
   2     1ST PRIOR
   3     2ND PRIOR
   4     3RD PRIOR
   5     4TH PRIOR
   6     5TH PRIOR
   7     6TH PRIOR
   8     TOTALS
   9     EXP. REPORTED
  10     ADJUSTMENT
  11     REMAINING LIABILITY

*Amounts in the 6th prior column or row include the amounts for the 6th prior period, and any earlier periods.
Program Contractor Financial Reporting Systems - Report #7 Utilization Data Report (Consolidated)                            Appendix 6.1.7

                                 Program Contractor 0
                                     Quarter Ending 01/00/00
                                  Fiscal Year Ending 01/00/00
      Utilization Data Report for Contractor

                                                                MEDICARE                NON-MEDICARE                        TOTAL
ITEM DESCRIPTION                                        Current                      Current                  Current               Contract
                                                        Period             YTD       Period         YTD       Period                  YTD
A. Enrollees (At End of Period)
B. Member Months (Unduplicated) Prospective Only                -                -             -          -             -                  -
Institutional Member Months Total                               -                -             -          -             -                  -
1. Level 1
2. Level 2
3. Level 3
4. Specialty: Wandering Dementia
5. Specialty: SubAcute Medical
6. Specialty: Behavioral Health
7. Specialty: Respite Care
8. Specialty: Ventilator
9. Home and Community Based Services (HCBS) Total               -                -             -          -             -                  -
  a. Adult Foster Care
  b. Assisted Living Home
  c. Group Home (DD)
  d. Individual Home
  e. Assisted Living Center
  f. Other (Specify) Group Home
10. Acute Care
11. Ventilator
12. PPC
13. Other (Specify)

Admissions
Patient Days
Discharges
Discharge Days
Average Length of Stay
Emergency Room Visits
Program Contractor Financial Reporting Systems - Report #7 Utilization Data Report (GSA)                                Appendix 6.1.7

                                 Program Contractor 0
                                     Quarter Ending 01/00/00
                                  Fiscal Year Ending 01/00/00
      Utilization Data Report by GSA

                                                                MEDICARE                NON-MEDICARE                   TOTAL
ITEM DESCRIPTION                                        Current                      Current                 Current           Contract
                                                        Period             YTD       Period        YTD       Period              YTD
A. Enrollees (At End of Period)
B. Member Months (Unduplicated) Prospective Only                -                -             -         -         -                  -
Institutional Member Months Total                               -                -             -         -         -                  -
1. Level 1
2. Level 2
3. Level 3
4. Specialty: Wandering Dementia
5. Specialty: SubAcute Medical
6. Specialty: Behavioral Health
7. Specialty: Respite Care
8. Specialty: Ventilator
9. Home and Community Based Services (HCBS) Total               -                -             -         -         -                  -
  a. Adult Foster Care
  b. Assisted Living Home
  c. Group Home (DD)
  d. Individual Home
  e. Assisted Living Center
  f. Other (Specify) Group Home
10. Acute Care
11. Ventilator
12. PPC
13. Other (Specify)

Admissions
Patient Days
Discharges
Discharge Days
Average Length of Stay
Emergency Room Visits
Program Contractor Financial Reporting Systems - Report #7 Utilization Data Report (County Optional)                       Appendix 6.1.7A

                                 Program Contractor 0
                                     Quarter Ending 01/00/00
                                  Fiscal Year Ending 01/00/00
      Utilization Data Report by County

                                                                MEDICARE                NON-MEDICARE                       TOTAL
ITEM DESCRIPTION                                        Current                      Current                     Current           Contract
                                                        Period             YTD       Period            YTD       Period              YTD
A. Enrollees (At End of Period)
B. Member Months (Unduplicated) Prospective Only                -                -             -             -         -                  -
Institutional Member Months Total                               -                -             -             -         -                  -
1. Level 1
2. Level 2
3. Level 3
4. Specialty: Wandering Dementia
5. Specialty: SubAcute Medical
6. Specialty: Behavioral Health
7. Specialty: Respite Care
8. Specialty: Ventilator
9. Home and Community Based Services (HCBS) Total               -                -             -             -         -                  -
  a. Adult Foster Care
  b. Assisted Living Home
  c. Group Home (DD)
  d. Individual Home
  e. Assisted Living Center
  f. Other (Specify) Group Home
10. Acute Care
11. Ventilator
12. PPC
13. Other (Specify)

Admissions
Patient Days
Discharges
Discharge Days
Average Length of Stay
Emergency Room Visits
                                                                                                                                                                                                                   Appendix E-9a




Health Plan Name

Quarter Ended: xx/xx/xxxx

                          Paragraph 4.12
                                                                                                     Categorical Linked Federal Non-       Federal Non-   Breast and
                                                                                Categorical                              Categorical        Categorical    Cervical                                       CHIPRA
                                                                                                         Expansion                                                     Freedom    ALTCS       ALTCS
                 FQHC/RHC Member Months                                                                                    Linked             Linked        Cancer                                                     Total
                                                                                                                                                                       to Work     EPD         DD
                                                                            SOBRA/                    SOBRA/             Expansion          Conversion    Treatment
                                                                                           SSI                    SSI                                                                                     KidsCare
                                                                             TANF                      TANF               AC/MED             AC/MED        Program

Chiricahua Community Health Center                                                                                                                                                                                       0
Clinica Adelante, Inc                                                                                                                                                                                                    0
Yavapai Co.Community Health Services (CC of West
Yavapai)                                                                                                                                                                                                                 0
Desert Senita Community Health Center                                                                                                                                                                                    0
El Rio Health Center                                                                                                                                                                                                     0
Lake Powell Community Health Center (Canyonlands)
                                                                                                                                                                                                                         0
Marana Community Health Center                                                                                                                                                                                           0
Mariposa Community Health Center                                                                                                                                                                                         0
Mountain Park Community Health Center                                                                                                                                                                                    0
North Country Community Health Center                                                                                                                                                                                    0
Sun Life Family Health Center                                                                                                                                                                                            0
Sunset Community Health Center                                                                                                                                                                                           0
United Community Health Center                                                                                                                                                                                           0
Maricopa Integrated Health Systems Clinics                                                                                                                                                                               0
Maricopa County for the Homeless                                                                                                                                                                                         0
Native American Community Health Center, Inc.                                                                                                                                                                            0
River Cities Community Clinic, Inc.                                                                                                                                                                                      0
Wesley Health Center                                                                                                                                                                                                     0
                                   Total - FQHC's                                      0         0           0        0                0              0            0          0           0           0            0     0
Community Healthcare of Douglas                                                                                                                                                                                          0
Cobre Valley Community Hospital                                                                                                                                                                                          0
Copper Queen Community Hospital                                                                                                                                                                                          0
La Paz Regional Hospital                                                                                                                                                                                                 0
Northern Cochise Community Hospital                                                                                                                                                                                      0
Wickenburg Community Hospital Clinic                                                                                                                                                                                     0
                                                      Total - RHC's                    0         0           0        0                0              0            0          0           0           0            0     0




Total Member Months                                                              0          0            0        0          0                  0             0           0         0           0            0           0


Instructions:

Please provide quarterly member month information for each FQHC. A member must be assigned to the FQHC on the first day of the month to be counted as one
member month.

Health Plans and Program Contractors will be responsible for maintaining a detailed listing, by month, of members submitted. Listing should include member's name, AHCCCS ID#,
primary care physician, FQHC assignment and rate code. The list may be subject


Any questions related to quarterly member months should be directed to Nancy Neroni at (602) 417-4210 or David Scott at (602) 417-4754.

A current listing of the contracted FQHCs and RHCs can be found on the website at the following link:
http://www.azahcccs.gov/commercial/FQHC-RHC.aspx




12/13/20101:31 PM
D:\Docstoc\Working\pdf\245bfe4d-a8ee-44e3-80d4-284b4c20734a.xls6.1.8 FQHC Mbr Months
SPOUSE AS PAID CAREGIVERS                                                                                                  Appendix 6.2




HEALTH PLAN:

QUARTER ENDING:

CONTRACT YEAR TO DATE:
                                                                                                                        Contract Year To Contract Year To Contract Year To
                                      Current Quarter    Current Quarter       Current Quarter     Current Quarter            Date             Date             Date       Contract Year To Date

                                     Authorized Hours      Paid Hours          Actual Expense      Paid Per Hour        Authorized Hours   Paid Hours     Actual Expense       Paid Per Hour
Paid Caregiver Spouses                            -                 -      $                -         #DIV/0!                        -              -     $           -           #DIV/0!


                                                   -                  -    $                -          #DIV/0!                      -                -    $           -           #DIV/0!




Program Contractors are required to provide quarterly financial statements that include separate authorized hours and
expenditures information for Paid Caregiver Spouses.
Code S5125: Attendant Care.
Modifier U3: Provided by spouse
                     Sub-Capitated Expenses Report
Health Plan Name
Quarter Ended:
Contract Year To Date:


                             Account
                            Description                                Amount
Sub-Capitated Hospitalization Expenses:
Hospital Inpatient                                                $             -
PPC-Hospital Inpatient                                            $             -
                     Total Sub-Capitated Hospitalization Expense: $             -
Sub-Capitated Medical Compensation Expenses:                       $            -
Primary Care Physician Services                                    $            -
Referral Physician Services                                        $            -
Other Professional                                                 $            -
PPC-Physician Services                                             $            -
            Total Sub-Capitated Medical Compensation Expenses:     $            -
Sub-Capitated Other Medical Expenses:                              $            -
Emergency Facility Services                                        $            -
Pharmacy                                                           $            -
Lab, X-ray, & med image                                            $            -
Outpatient Facility                                                $            -
Durable Med Equip                                                  $            -
Dental                                                             $            -
Transportation                                                     $            -
NF, Home HC                                                        $            -
Physical Therapy                                                   $            -
Miscellaneous Med Exp                                              $            -
PPC-Other                                                          $            -
                     Total Sub-Capitated Other Medical Expenses:   $            -
                                 Total Sub-Capitated Expenses: $                -
     Appendix 6.3




     YTD
    Amount

$            -
$            -
$            -
$            -
$            -
$            -
$            -
$            -
$            -
$            -
$            -
$            -
$            -
$            -
$            -
$            -
$            -
$            -
$            -
$            -
$            -
$            -
$            -
                                                                                           Appendix 6.4
                       QUARTERLY CERTIFICATION STATEMENT FROM

                               (Name of Program Contractor)

                                              TO THE

                         Arizona Health Care Cost Containment System

                                     FOR THE PERIOD ENDED

                                          (Time Period)

                                   Prepared by: (Type name here)

                                       Title: (Type title here)

                              Phone Number: (Type phone number here)




I hereby attest that the information submitted in the reports herein is current, complete, and
accurate to the best of my knowledge. I understand that whoever knowingly and willfully
makes or causes to be made a false statement or representation on the reports may be
prosecuted under the applicable state laws. In addition, knowingly and willfully failing to
fully and accurately disclose the information requested may result in denial of a request to
participate, or where the entity already participates, a termination of a Plan's agreement or
contract with the Arizona Health Care Cost Containment System. Failure to sign a
Certification Statement will result in AHCCCS' non acceptance of the attached reports.




      (Preparers Signature)                                                      (Date Signed)



      (Approvers Signature)                                                      (Date Signed)



      (Approvers Signature)                                                      (Date Signed)
Program Contractor
    Quarter Ending
 Fiscal Year Ending
                                                                                 Amount Related
                                                                                    to Prior
                                                                                 Contract year(s)
                      BALANCE SHEET
                      ASSETS
                      Current Assets
    105               Cash and Cash Equivalents                                                 -
    110               Short-Term Investments                                                    -
    115               Capitation Receivable from AHCCCS                                         -
    120               Reinsurance Receivable from AHCCCS:                                       -
    125               Investment Income Receivable                                              -
    130               Current Due from Affiliates                                               -
    135               Other Current Receivables (Report #3)                                     -
    140               Other Current Assets (Report #3)                                          -
                                                        Total Current Assets                    -
                      Other Assets
    145               General Performance Bond                                                  -
    150               Restricted Cash and Other Assets                                          -
    155               Long-Term Investments                                                     -
    160               Non-Current Due from Affiliates                                           -
    165               Other Non-Current Assets (Report #3)                                      -
                                                          Total Other Assets                    -
                      Property and Equipment
    170               Land                                                                      -
    175               Buildings                                                                 -
    180               Leasehold Improvements                                                    -
    185               Furniture & Equipment                                                     -
    190               Other Property & Equipment (Report #3)                                    -
    195               Accumulated Depreciation & Amortization                                   -
                                               Net Property and Equipment                       -

                                                              TOTAL ASSETS                      -
                      LIABILITIES
                      Current Liabilities
    205               Accounts Payable                                                          -
    210               Accrued Administrative Expenses                                           -
    215               Capitation Payable                                                        -
    220               Medical Claims Payable                                                    -
    225               Other Current Payables (Report #3)                                        -
    230               Current Portion of Long-Term Debt (Report #3)                             -
    235               Current Due to Affiliates                                                 -
    240               Other Current Liabilities (Report #3)                                     -
                                                    Total Current Liabilities                   -
                      Other Liabilities
    245               Non-Current Portion of Long-Term Debt (Report #3)                         -
    250               Non-Current Due to Affiliates                                             -
    255               Other Non-Current Liabilities (Report #3)                                 -
                                                       Total Other Liabilities                  -
      TOTAL LIABILITIES                                         -
      EQUITY/NET ASSETS (Liabilities)
505   Preferred Stock                                           -
510   Common Stock                                              -
515   Treasury Stock                                            -
520   Unrestricted Net Assets                                   -
525   Restricted Net Assets                                     -
527   Additional Paid-in Capital                                -
528   Contributed Capital                                       -
530   Retained Earnings/Net Assets (Liabilities)                -

                         Net Equity/Net Assets (Liabilities):   -
                                    Total Liability & Equity:   -
Amount Related      Total
  to Current     Adjustment
 Contract year




             -          -
             -          -
             -          -
             -          -
             -          -
             -          -
             -          -
             -          -
             -          -

             -          -
             -          -
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             -          -
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             -          -


             -          -
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             -          -
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             -          -
-   -

-   -
-   -
-   -
-   -
-   -
-   -
-   -
-   -

-   -
-   -
Program Contractor
    Quarter Ending
 Fiscal Year Ending




                      REVENUES
              300     Capitation
              305     PPC Capitation
              310     Reinsurance
              315     PPC - Reconciliation
              320     Share of Cost (SOC) Reconciliation *
              325     HCBS Placement Reconciliation *
              330     HIV-AIDS /Supplement
              335     Other AHCCCS Revenue (Report #4)
                                                              Subtotal AHCCCS Revenue
              350     Investment Income *
              360     Third Party Liability Recoveries
              370     Patient Contributions (MSOC)
              380     Other Non-AHCCCS Income (Report #4)
                                                           Subtotal Non-AHCCCS Revenue
                      TOTAL REVENUES
                      EXPENSES
                      Institutional Care Expenses:
              400     NF ICF & Bedholds
              402     Level I
              404     Level II
              406     Level III
              408     Institutional Care
              410     PPC Institutional
              412     Other Institutional Care (Report #4)
                                                            TOTAL INSTITUTIONAL CARE
                      Home & Community Bases Services (HCBS)Expenses:
              414     Home Health Nurse
              416     Home Health Aide
              418     Personal Care
              420     Homemaker
              422     Home Delivered Meals
              424     Respite Care
              426     Attendant Care
              428     Assisted Living Home
              429     Assisted Living Center
              430     Adult Day Health
              432     Adult Foster Care
              434     Group Respite
              436     Hospice
              438     Environmental Modifications
              443     PPC HCBS
              444     Other HCBS Costs (Report #4)
                                                                           TOTAL HCBS
                      Acute Care Expenses:
              448     Inpatient Services (Hosp.)
450   Primary Care Physician Services
452   Referral Physician Services
454   Emergency Services
456   Out Patient Facility
458   Prescription Drug
460   Lab/Radiology
462   Durable Medical Equipment
464   Dental
466   Transportation
468   Therapies
470   Outpatient Behavioral Health
471   PPC Acute Care
472   Other Accute Care Costs (Report #4)
                                                 TOTAL ACUTE CARE
    Other Medical Expenses:
477 PPC - Other
479 Other Medical (Report #4)
                                              TOTAL OTHER MEDICAL
480 Case Management
                                            TOTAL MEDICAL EXPENSE:
      Administrative Expenses:*
484   Compensation
488   Data Processing
490   Management Fees
492   Interest Expense
493   Occupancy
494   Marketing
495   Depreciation
496   Other Administration (Report #4)
                                             TOTAL ADMINISTRATION
                                                    TOTAL EXPENSE
    INCOME FROM OPERATIONS
497 Non-Operating Income (Loss)
    INCOME(LOSS) BEFORE TAXES
498 Provision for Premium Taxes
499 Provision for Income Taxes
    NET INCOME(LOSS) AFTER TAXES
Amount Related     Amount Related      Total
   to Prior          to Current     Adjustment
Contract year(s)    Contract year

              -                 -          -
              -                 -          -
              -                 -          -
              -                 -          -
              -                 -          -
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              -                 -          -
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              -                 -          -
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-   -   -
-   -   -
-   -   -
-   -   -
                                                                            Appendix 6.6
      Quarterly Premium Tax Information and Web site address

In lieu of including a copy of this form, the Arizona Department of Insurance has made the
form available on the World Wide Web at: http://www.id.state.az.us/ once filed, submit a
copy to the ALTCS office.
                                                                                     Appendix 6.7
Program Contractor Financial Reporting Systems -Statement of Cash Flows
  Program Contractor 0
       Quarter Ending 01/00/00
   Fiscal Year Ending 01/00/00


                                 Category                           Current Period      YTD
Cash From Operating Activities
Net Income
 Add: Current assets if current assets have decreased
 Less: Current assets if current assets have increased
 Add: Current Liabilities if current liabilities have increased
 Less: Current Liabilities if current liabilities have decreased
 Receivables:
 Expenses:
  Net Cash Inflow from Operating Activities                                      0             0
Cash Flows from Investing Activities
 Purchase of Investments
 Sale of Investments
 Purchase of Plant assets
  Net Cash Flow from Investing Activities                                        0             0
Cash Flows from Financing Activities
 Repayment of Bonds
 Issue of Common Stock
 Dividends Paid
Net Cash Flows from Financing Activities                                         0             0


Net Increase (Decrease) in Cash                                                  0             0
  Cash at the Beginning of the Year
   Cash at End of the Year                                                       0             0
                                                               AZ Local to HIPAA Code                                                 APPENDIX 6.5
                                                           Crosswalk to Financial Statement


                                                                                                                                       Appendix 6.8
Current Code          Current Description       New Code           Modifier(s)      Place of Service            Provider Type         COA
               MILEAGE-ALTCS PROVIDERS OF
               HCBS SERVICES TO NATIVE
W0100          AMERICANS ON RE                   A0160                                      99                      24, 40            466
W2100          NURSING SERVICES                  T1002                                11, 12, 33, 99                77, A6            414
W2101                                            H2010                HG            11, 50, 53, 72, 99          08, 18, 19, 31        470
                OPIOID AGONIST                                                    11, 22, 23, 50, 53, 71,
W2102          ADMINISTRATION-TAKE HOME          H0020                HG                  72, 99                08, 18, 19, 31        470
                HOME BASED INDIVIDUAL
               THERAPY/COUNSELING (1MBR
W2151          TEAM,      15 MI                  H0004                               12,31,32,33,99              77,85,86,87          470
                FAMILY COUNSELING, OUT-OF-
W2152          OFFICE                            H0004             HR or HS               12, 99                 77,85,86,87          470
                OFFICE/CLINIC INDIVIDUAL
               THERAPY/COUNSELING (OTHER
W2300          MENTAL HLTH                       H0004                            03, 11, 22, 50, 53, 72      77,85,86,87,88,89       470
                OFFICE/CLINIC FAMILY
               THERAPY/COUNSELING (OTHER
W2350          MENTAL HEALTHPRACT                H0004             HR or HS       03, 11, 22, 50, 53, 72      77,85,86,87,88,89       470
                OFFICE/CLINIC GRP
               THERAPY/COUNSELING (OTHER                                          11, 22, 31, 32, 33, 50,
W2351          MENTAL HEALTH PRACT               H0004                HQ              53, 54, 72, 99          77,85,86,87,88,89       470
                HOME RESPIRATORY THERAPY
W2404          NON-MEDICARE CERTIFIED HHA        S5180                                      12                        95              468
                              #N/A               S5181                                      12                        95              468
                HOME RESPIRATORY THERAPY
               MEDICARE CERTIFIED HOME HLTH
W2405          AGENCY                            S5180                                      12                        23              468
                              #N/A               S5181                                      12                        23              468
                HOME RESPIRATORY THERAPY,
W2406          RESPIRATORY THERAPIST (IND)       S5180                                      12                        20              468
                              #N/A               S5181                                      12                        20              468
                INITIAL NUTRITIONAL
W2600          ASSESSMENT (ALTCS)                S9470                                      12                      23, 47
                PRENATAL & POSTPARTUM CARE
W3001          BY LICENSED MIDWIFE               99212                                      12                        84
                LABOR & DELIVERY (VAGINAL) BY
W3002          LICENSED MIDWIFE                  59400                                      12                        84
                                                                                  04, 11, 12, 20, 22, 23,
                                                                                  34, 50, 53, 54, 71, 72,   72, 77, 85, 86, 87, 88,
W4001          ASSESSMENT GENERAL                H0031                                      99                      89, A6            470
               ASSESSMENT REHABILITATIVE                                          04, 11, 12, 20, 22, 50,
W4002          EMPLOYMENT SUPPORT                H0031                 HB           53, 54, 71, 72, 99      72, 77, 85, 86, 87, A3    470
                                                                                  11, 12, 22, 23, 34, 50,
W4003          SCREENING                         H0002                                53, 54, 71, 72        72, 77, 85, 86, 87, A6    470
                                                                                  03, 11, 12, 22, 23, 34,   72, 77, 85, 86, 87, 88,
W4005           ASSESSMENT COMPREHENSIVE         H2000                            50, 53, 54, 71, 72, 99            89, A6            470
                LIVING SKILLS TRAINING-                                           11, 12, 50, 53, 54, 71,   39, 72, 77, 85, 86, 87,
W4006          INDIVIDUAL                        H2014                                    72, 99                    A3, A6            470
                LIVING SKILLS TRAINING GROUP                                      11, 12, 50, 53, 54, 71,   39, 72, 77, 85, 86, 87,
W4015          (PER PERSON)                      H2014                HQ                  72, 99                    A3, A6            470
                LIVING SKILLS TRAINING                                            11, 12, 50, 53, 54, 71,   39, 72, 77, 85, 86, 87,
W4016          3>HOURS EXTENDED                  H2017                                    72, 99                    A3, A6            470
                HEALTH PROMOTION (PER                                             11, 12, 50, 53, 54, 71,   72, 77, 85, 86, 87, A3,
W4020          PERSON)                           H0025                                    72, 99                      A6              470
                                                                                  11, 12, 50, 53, 54, 71,   72, 77, 85, 86, 87, A3,
                           #N/A                  H0034                                    72, 99                      A6              470
               PRE-JOB TRAINING EDUCAION                                          11, 12, 50, 53, 54, 71,
W4030          AND DEVELOPMENT                   H2027                                    72, 99            72,77,85,86,87,A3,A6      470
               JOB COACHING AND                                                   11, 12, 50, 53, 54, 71,
W4031          EMPLOYMENT SUPPORT                H2025                                    72, 99            72,77,85,86,87,A3,A6      470
                                                                                  11, 12, 50, 53, 54, 71,
                            #N/A                 H2026                                    72, 99            72,77,85,86,87,A3,A6      470

               CASE MANAGEMENT - BEH
W4040          HEALTH PROFESSIONAL - OFFICE      T1016                HO          11, 50, 53, 71, 72, 99      72, 77, 85, 86, 87      470
               CASE MANAGEMENT-BEH
               HEALTH PROFESSIONAL - OUT-OF-
W4041          OFFICE                            T1016                HO          12, 22, 23, 34, 54,99       72, 77, 85, 86, 87      470
               CASE MANAGEMENT - BEH
W4042          HEALTH TECHNICIAN-OFFICE          T1016                HN          11, 50, 53, 71, 72, 99            72, 77            470
               CASE MANAGEMENT - OUT-OF-
W4043          OFFICE                            T1016                HN           12, 22, 23, 34, 54,99            72, 77            470
                                                                                  11, 12, 50, 53, 71, 72,
W4044          PERSONAL ASSISTANCE               T1019                                       99               39, 72, 77, A3, A6      418
               PERSONAL ASSISTANCE-                                               11, 12, 50, 53, 71, 72,
W4045          EXTENDED                          T1020                                       99               39, 72, 77, A3, A6      418
                                                                                  11, 12, 50, 53, 71, 72,   39, 72, 77, 85, 86, 87,
W4046          FAMILY SUPPORT                    S5110                                       99                     A3, A6            470
                                                                                  11, 12, 23, 50, 53, 54,
W4047          PEER SUPPORT                      H0038                                  71, 72, 99              72, 77, A3, A6        470
                                                                                  11, 12, 50, 53, 54, 71,
W4048          PEER SUPPORT-EXTENDED             H2016                                     72, 99               72, 77, A3, A6        470
               PEER SUPPORT GROUP (PER                                            11, 12, 23, 50, 53, 54,
W4049          PERSON)                           H0038                HQ                71, 72, 99              72, 77, A3, A6        470
W4050          THERAPEUTIC FOSTER CARE           S5140                                    12, 99                      A5              432
                          #N/A                   S5145                                    12, 99                      A5              432
                                                               AZ Local to HIPAA Code                                                APPENDIX 6.5
                                                           Crosswalk to Financial Statement


 Current Code            Current Description    New Code           Modifier(s)       Place of Service           Provider Type        COA
                 LEVEL II BEHAVIORAL HEALTH
W4051           RESIDENTIAL                      H0018                                      99                       74              444
                 LEVEL III BEHAVIORAL HEALTH
W4052           RESIDENTIAL                      H0019                                      99                       A2              444
                 CRISIS INTERVENTION-
W4060           URGENT(UP TO 5 HOURS)            S9484                                  21, 51, 99           02, 71, B5, B6, B7      470
                 CRISIS INTERVENTION-URGENT(5
W4061           THROUGH 23 HOURS)                S9485                                  21, 51, 99           02, 71, B5, B6, B7      470
                 CRISIS INTERVENTION MOBIL 1                                      11, 12, 23, 50, 53, 54,
W4062           PERSON                           H2011                                  71, 72, 99          02, 71, 77, B5, B6, B7   470
                 CRISIS INTERVENTION MOBIL                                        11, 12, 23, 50, 53, 54,
W4063           TEAM 2 PERSON                    H2011                 HT                71, 72,99          02, 71, 77, B5, B6, B7   470
                 BEHAVIORAL HEALTH DAY
                PROGRAM-SUPERVISED(MIN OF 3
W4071           HRS < THAN6 HOU                  H2012                                53, 71, 72, 99             72, 77, A3          470
                 BEHAVIORAL HEALTH DAY
                PROGRAM SUPERVISED (6 HOURS
W4072           OR MORE)                         H2015                                53, 71, 72, 99             72, 77, A3          470
                 BEHAVIORAL HEALTH DAY
W4073           PROGRAM-THERAPEUTIC              H2019                                53, 71, 72, 99                 77              470
                 BEHAVIORAL HEALTH DAY
                PROGRAM-THERAPEUTIC (MIN 3
W4074           HRS AND LESS                     H2019                 TF             53, 71, 72, 99                 77              470
                 BEHAVIORAL HEALTH DAY
                PROGRAM-THERAPEUTIC (6
W4075           HOURS OR MORE)                   H2020                                53, 71, 72, 99                 77              470
                 BEHAVIORAL HEALTH DAY
                PROGRAM-THERAPEUTIC (MIN 3
W4077           HRS LESS THAN                    H2019                 TF                   12                       77              470
                 BEHAVIORAL HEALTH DAY
                PROGRAM-THERAPEUTIC (6
W4078           HOURS OR MORE)                   H2020                                      12                       77              470
                 BEHAVIORAL HEALTH DAY
W4079           PROGRAM-MEDICAL                  H0036                                  53, 72, 99                   77              470
                 BEHAVIORAL HEALTH DAY
                PROGRAM-MEDICAL (MIN 3 HRS <
W4080           6 HRS                            H0036                 TF               53, 72, 99                   77              470
                 BEHAVIORAL HEALTH DAY
                PROGRAM-MEDICAL (6 HOURS OR
W4081           MORE)                            H0037                                  53, 72, 99                   77              470
                 BEHAVIORAL HEALTH DAY
W4082           PROGRAM-MEDICAL                  H0036                                      12                       77              470
                 BEHAVIORAL HEALTH DAY
                PROGRAM-MEDICAL (MIN 3 HRS
W4083           LESS THAN 6)                     H0036                 TF                   12                       77              470
                 BEHAVIORAL HEALTH DAY
                PROGRAM-MEDICAL (6 HOURS OR
W4084           MORE)                            H0037                                      12                       77              470
Y4550            HOME UTERINE MONITORING         S9208                RR                    12                       30              462
                 EMERGENCY ALERT SYSTEM:
Y4552           EQUIPMENT                        S5160                RR                    12                       30              444
                 EMERGENCY ALERT SYSTEM:
Y4553           SERVICE/MAINTENANCE FEE          S5161                RR                    12                        30             444
Z2999            SPECIAL TRANSPORT               A0999                                  41, 42, 99            6, 28, 72, 77, A3      466
                 ADULT DAY HEALTH SERVICES;
Z3000           PER HOUR                         S5100                                      99                      27, 81           430
                                #N/A             S5101                                      99                      27, 81           430
                                #N/A             S5102                                      99                      27, 81           430
Z3001            ADULT CARE HOME (ACH 1)         T2031                                      12                       36              428
Z3002            ADULT CARE HOME (ACH2)          T2031                 TF                   12                       36              428
                                #N/A             T2031                 TG                   12                       36              428
Z3003            ADULT FOSTER CARE 1             S5140                                      12                       50              432
Z3004            ADULT FOSTER CARE (2)           S5140                 TF                   12                       50              432
Z3005            ADULT FOSTER CARE (3)           S5140                 TG                   12                       50              432
                 HOME DELIVERED MEAL; PER
Z3010           MEAL                             S5170                                      12                     70, 81            422
Z3020            HOME HEALTH AIDE; PER VISIT     T1021                                      12                     02, 23            416
                 RN & LPN (CERT HHA)
Z3030           INTERMITTENT VISIT; PER HOUR     S9123                                      12                     02, 23            414
                                #N/A             S9124                                      12                     02, 23            414
                 RN (NON CERT HHA)
Z3031           INTERMITTENT VISIT; PER HOUR     S9123                                      12                    39, 81, 95         414
                 RN (NON-CERT) CONTINUOUS
Z3032           VISIT; PER HOUR                  S9123                 TG                   12                    39, 81, 95         414
                 RN (HH NURSE/INDEPENDENT)
Z3033           INTERMITTENT VISIT; PER HOUR     S9123                                      12                     19, 46            414
                 RN (HH NURSE/INDEPENDENT)
Z3034           CONTINUOUS VISIT; PER HOUR       S9123                 TG                   12                     19, 46            414
                 LPN (HH NURSE/INDEPENDENT)
Z3035           INTERMITTENT VISIT; PER HOUR     S9124                                      12                     19, 46            414
                 LPN (HH NURSE/INDEPENDENT)
Z3036           CONTINUOUS VISIT; PER HOUR       S9124                 TG                   12                     19, 46            414
                 LPN (NON-CERT HHA)
Z3037           INTERMITTENT VISIT; PER HOUR     S9124                                      12                    39, 81, 95         414
                 LPN (NON-CERT HHA)
Z3038           CONTINUOUS VISIT; PER HOUR       S9124                 TG                   12                    39, 81, 95         414
                 RN & LPN (CERT HHA)
Z3039           CONTINUOUS CARE PER HOUR         S9123                 TG                   12                     02, 23            414
                                                                AZ Local to HIPAA Code                                             APPENDIX 6.5
                                                            Crosswalk to Financial Statement


 Current Code          Current Description       New Code           Modifier(s)      Place of Service        Provider Type         COA
                              #N/A                S9124                TG                   12                   02, 23            414
                                                                                                         23, 24, 37, 39, 40, 81,
Z3040           HOMEMAKER; PER HOUR               S5130                                    12                      95              420
                                                                                                         02, 23, 24, 39, 40, 72,
Z3050           PERSONAL CARE; PER HOUR           T1019                                  12, 99                77, 81, 95          418
                SHORT TERM IN-HOME RESPITE                                                               02, 23, 24, 37, 39, 40,
Z3060           CARE; PER HOUR                    S5150                                  12, 99              72, 77, 81, A3        424
                GROUP RESPITE CARE; PER
Z3061           HOUR                              S5150                HQ                12, 99          02, 23, 38, 39, 40, 81    434
                CONTINUOUS IN-HOME RESPITE                                                               02, 23, 24, 37, 39, 40,
Z3070           CARE; PER 24 HRS                  S5151                                  12, 99              72, 77, 81, A3        436
                NON-FAMILY ATTENDANT CARE;
Z3080           PER HOUR                          S5125                                    12                02, 23, 24, 40        426
Z3082           HOME MAINTENANCE SERVICE          S5165                                    12                      44              438
                SUPPORTIVE EMPLOYMENT
Z3084           SERVICE                           T2019                                   99                       39              444
                             #N/A                 T2018                                   99                       39              444
Z3125           ALZHEIMER PROJ-LEVEL 1            T2033                 U1               12, 99                    57              429
Z3132           DAY TREATMENT AND TRAINING        T2021                                  12, 99                    39              444
                HABILITATION GROUP OF
Z3133           SERVICES-(DES)                    T2016                                  12, 99                  25, 39            444
                HABILITATION GROUP OF
                SERVICES - DES, UNIT EQUALS
Z3134           ONE HOUR                          T2017                                  12, 99                  25, 39            444
                LEVEL II BEHAVIORAL HEALTH (1
Z3138           OR "M")                           H0018                 TF                 99                      74              444

Z3139           LEVEL II BEHAVIORAL HEALTH (2)    H0018                 TG                 99                       74             444
Z3144           DDD GROUP HOMES (1 OR "M")        T2016                                    12                    25, 39            444
Z3145           DDD GROUP HOME (2)                T2016                TF                  12                    25, 39            444
Z3146           DDD GROUP HOME (3)                T2016                TG                  12                    25, 39            444
Z3470           IV ANTIBIOTIC THERAPY             S9379                NU                  12                   02, 03, 23         414
                                                                                                        24,28,36,37,39,40,46,49
                                                                                                        ,50,71,72,77,78,A3,B1,B
Z3610           PRIVATE VEHICLE                   A0090                                    99                2,B3,B5,B6,B7         466
                                                                                                        02,06,28,39,71,72,77,78
                URBAN NON-EMERGENCY                                                                       ,81,A3,A6,B1,B2,B3,
Z3620           TRANSPORT COACH VAN               S0215                                    99                   B5,B6,B7           466
                                                                                                        02,06,28,39,71,72,77,78
                AMBULATORY VAN, URBAN BASE                                                              ,81,A3,A6,B1,B2,B3, B5,
Z3621           RATE                              A0120                                    99                     B6,B7            466
                                                                                                        02,06,28,39,71,72,77,78
                RURAL, NON-EMERGENCY                                                                      ,81,A3,A6,B1,B2,B3,
Z3643           TRANSP. COACH VAN                 S0215                 TN                 99                   B5,B6,B7           466
                RURAL, WHEELCHAIR VAN, BASE                                                             02,06,28,39,71,72,77,81
Z3644           RATE                              A0130                 TN                 99               ,A3,A6,B1,B2,B3        466
                RURAL, WHEELCHAIR VAN, PER                                                              02,06,28,39,71,72,77,81
Z3645           MILE                              S0209                 TN                 99               ,A3,A6, B1,B2,B3       466
                RURAL, STRETCHER VAN, BASE                                                              02,06,,28,71,72,77,81,A
Z3646           RATE                              T2005                 TN                 99                3,A6,B1, B2,B3        466
                RURAL, STRETCHER VAN, PER                                                                    02,06,28,71,72,
Z3647           MILE                              S0209                 TN                 99            77,81,A3,A6,B1, B2,B3     466
                                                                                                             02,06,28,71,72,
                 AMBULATORY VAN, RURAL BASE                                                                   77,81,A3,A6,
Z3648           RATE                              A0120                 TN                 99             B1,B2,B3,B5, B6,B7       466
                 NONCOVERED GROUND
                AMBULANCE MILEAGE, PER MILE
Z3655           (E.G., FOR MLSTRAVE               A0888                                  41, 42                     6              466
                                                  A0888                                  41, 42                    97              466
                 MATERNAL/NEONATE TRANS
Z3660           TEAM - GROUND AMB/TRIP            A0225                                    41                      97              466
                 HELICOPTER TAXI - NON
Z3715           EMERGENCY                         T2003                                    99                      28              466
                 NON-AMBULANCE/NON-
                EMERGENCY AIR TRANSPORT
Z3716           PER MILE                          A0435                                  42, 99                    6               466
                 NON-AMBULANCE WAITING TIME                                                             06,28,39,71,72,77,81,A3
Z3717           (PER HALF HOUR)                   T2007                                    99                ,A6,B1,B2,B3          466
                 ASSISTED LIVING CENTER LEVEL
Z3718           1                                 T2033                                    12                      49              429
                 ASSISTED LIVING CENTER LEVEL
Z3719           2                                 T2033                 TF                 12                      49              429
                 ASSISTED LIVING CENTER LEVEL
Z3720           3                                 T2033                 TG                 12                      49              429
                                                                                                        02,06,28,71,72,77,78,81
Z3721           URBAN STRETCHER VAN-BASE          T2005                                    99              ,A3,A6, B1,B2,B3        466
                                                                                                             02,06,28,71,72,
                URBAN STRETCHER VAN-                                                                        77,78,81,A3,A6,
Z3722           MILEAGE/PER MILE                  S0209                                    99                   B1,B2,B3           466
                                                                                                             02,06,28,71,72,
                URBAN WHEELCHAIR VAN,                                                                       77,78,81,A3,A7,
Z3723           MILEAGE                           S0209                                    99                   B1,B2,B3           466
                                                                                                         28, 72, 77, A3, A6, B1,
Z3724           TAXI - MILEAGE/PER MILE           S0215                                    99                    B2, B3            466
                FAMILY ATTENDANT CARE; PER
Z3725           HOUR                              S5125                                  12, 99                  24, 40            426
Z3800           MEDICAL FOODS                     S9435                                   12                      30               444
                                                                             AZ Local to HIPAA Code                                                 APPENDIX 6.5
                                                                         Crosswalk to Financial Statement


 Current Code            Current Description             New Code                Modifier(s)      Place of Service            Provider Type         COA
VA                              #N/A                                                SL
T1                              #N/A                    Not trimester
T2                              #N/A                    Not trimester
T3                              #N/A                    Not trimester
2X                              #N/A                                                 X

MIPS CODES
                OFFICE/CLINIC INDIVIDUAL
                THERAPY/COUNSELING (OTHER
W2300           MENTAL HLTH                                H0004                                03, 11, 22, 50, 53, 72          77, 88, 89          470
                OFFICE/CLINIC FAMILY
                THERAPY/COUNSELING (OTHER
W2350           MENTAL HEALTHPRACT                         H0004                 HR or HS       03, 11, 22, 50, 53, 72          77, 88, 89          470
                OFFICE/CLINIC GRP
                THERAPY/COUNSELING (OTHER                                                       11, 22, 31, 32, 33, 50,
W2351           MENTAL HEALTH PRACT                        H0004                    HQ              53, 54, 72, 99              77, 88, 89          470
W4001           ASSESSMENT GENERAL                         H0031                                          3                      88, 89             470

W4005           ASSESSMENT COMPREHENSIVE                   H2000                                          3                       88, 89            470
                NON-FAMILY ATTENDANT CARE 1
Z3330           HOUR PER DAY MIPS                          S5125                                        03, 99                      93              426
                NON FAMILY ATTENDANT CARE 3
Z3331           HOURS PER DAY MIPS                         S5125                                        03, 99                      93              426
                NON-FAMILY ATTENDANT CARE 6
Z3332           HOURS PER DAY MIPS                         S5125                                        03, 99                      93              426
                DAILY TRANSPORTATION < 10
Z3340           MILES AMBULATORY VEHICLE                   A0120                                          99                        92              460
                                                           S0215                                          99                        92              460
                                                           A0120                     TN                   99                        92              460
                                                           S0215                     TN                   99                        92              460
                DAILY TRANSPORTATION < 10
Z3344           MILES WHEELCHAIR VEHICLE                   A0130                                          99                        92              466
                                                           S0209                                          99                        92              466
                                                           A0130                     TN                   99                        92              466
                                                           S0209                     TN                   99                        92              466
                RN: 15 MIN, 1 OR MORE
                ENCOUNTERS WITH SINGLE
Z3350           STUDENT IN 1 WK                            T1002                                        03, 99                      94              414
                LPN: 15 MIN, 1 OR MORE
                ENCOUNTERS WITH SINGLE
Z3360           STUDENT IN 1 WK                            T1003                                        03, 99                      94              414

IHS CODES
                IHS AMBULATORY SURGERY
00090           CENTER I                               UB revenue code
                IHS AMBULATORY SURGERY
00091           CENTER II                              UB revenue code
                IHS AMBULATORY SURGERY
00092           CENTER III                             UB revenue code
                IHS AMBULATORY SURGERY
00093           CENTER IV                              UB revenue code
                IHS AMBULATORY SURGERY
00094           CENTER V                               UB revenue code
                IHS AMBULATORY SURGERY
00095           CENTER VI                              UB revenue code
                IHS AMBULATORY SURGERY
00096           CENTER VII                             UB revenue code
                IHS AMBULATORY SURGERY
00097           CENTER VIII                            UB revenue code
                IHS AMBULATORY SURGERY
00098           CENTER IX                              UB revenue code
                IHS-OUTPATIENT
00099           REIMBURSEMENT RATE                     UB revenue code

NEW CODES
E1399           DME Miscellaneous                          S9209                                          12                       23,30            462
E1399           DME Miscellaneous                          S9211                                          12                       23,30            462
E1399           DME Miscellaneous                          S9214                                          12                       23,30            462
E1399           DME Miscellaneous                          S9212                                          12                       23,30            462
E1399           DME Miscellaneous                          S9213                                          12                       23,30            462
                                                                                                                          22, 24, 36, 39, 40, 49,
NA                                                         S5135                                        12, 99                    50, 57            444
                                                                                                                          22, 24, 36, 39, 40, 49,
NA                                                         S5136                                        12, 99                    50, 57            444
NA                                                         T2020                                        12, 99                      39              444

MODIFIERS
GT              Telecommunication
HB              Adult program, non geriatric
HG              Opiod addiction treatment program
HN              Bachelors degree level
HO              Masters degree level
HQ              Goup setting
HR              Family/couple with client present
HS              Family/couple without client present
HT              Multi-disciplinary team
SL              State supplied vaccine
TF              Intermediate level of care
                                                                    AZ Local to HIPAA Code                                  APPENDIX 6.5
                                                                Crosswalk to Financial Statement


 Current Code           Current Description          New Code           Modifier(s)      Place of Service   Provider Type   COA
TG              Complex/high level of care
TN              Rural
U1              Pilot

SUMMARY
                Codes changed
                Codes added
                Codes deleted
                Total number of code modifications
                                   AZ Local to HIPAA Code         APPENDIX 6.5
                               Crosswalk to Financial Statement



     Account Description


Transportation
Home Health Nurse
Outpatient Behavioral Health

Outpatient Behavioral Health


Outpatient Behavioral Health

Outpatient Behavioral Health


Outpatient Behavioral Health


Outpatient Behavioral Health


Outpatient Behavioral Health

Therapies
Therapies


Therapies
Therapies

Therapies
Therapies




Outpatient Behavioral Health

Outpatient Behavioral Health

Outpatient Behavioral Health

Outpatient Behavioral Health

Outpatient Behavioral Health

Outpatient Behavioral Health

Outpatient Behavioral Health

Outpatient Behavioral Health

Outpatient Behavioral Health

Outpatient Behavioral Health

Outpatient Behavioral Health

Outpatient Behavioral Health


Outpatient Behavioral Health


Outpatient Behavioral Health

Outpatient Behavioral Health

Outpatient Behavioral Health

Personal Care

Personal Care

Outpatient Behavioral Health

Outpatient Behavioral Health

Outpatient Behavioral Health

Outpatient Behavioral Health
Adult Foster Care
Adult Foster Care
                                   AZ Local to HIPAA Code         APPENDIX 6.5
                               Crosswalk to Financial Statement


     Account Description

Other HCBS Costs

Other HCBS Costs

Outpatient Behavioral Health

Outpatient Behavioral Health

Outpatient Behavioral Health

Outpatient Behavioral Health


Outpatient Behavioral Health


Outpatient Behavioral Health

Outpatient Behavioral Health


Outpatient Behavioral Health


Outpatient Behavioral Health


Outpatient Behavioral Health


Outpatient Behavioral Health

Outpatient Behavioral Health


Outpatient Behavioral Health


Outpatient Behavioral Health

Outpatient Behavioral Health


Outpatient Behavioral Health


Outpatient Behavioral Health
Durable Medical Equipment

Other HCBS Costs

Other HCBS Costs
Transportation

Adult Day Health
Adult Day Health
Adult Day Health
Assisted Living Home
Assisted Living Home
Assisted Living Home
Adult Foster Care
Adult Foster Care
Adult Foster Care

Home Delivered Meals
Home Health Aide

Home Health Nurse
Home Health Nurse

Home Health Nurse

Home Health Nurse

Home Health Nurse

Home Health Nurse

Home Health Nurse

Home Health Nurse

Home Health Nurse

Home Health Nurse

Home Health Nurse
                                  AZ Local to HIPAA Code         APPENDIX 6.5
                              Crosswalk to Financial Statement


   Account Description
Home Health Nurse

Homemaker

Personal Care

Respite Care

Group Respite

Hospice

Attendant Care
Environmental Modifications

Other HCBS Costs
Other HCBS Costs
Assisted Living Center
Other HCBS Costs

Other HCBS Costs


Other HCBS Costs

Other HCBS Costs

Other HCBS Costs
Other HCBS Costs
Other HCBS Costs
Other HCBS Costs
Home Health Nurse


Transportation


Transportation


Transportation


Transportation

Transportation

Transportation

Transportation

Transportation


Transportation


Transportation
Transportation

Transportation

Transportation


Transportation

Transportation

Assisted Living Center

Assisted Living Center

Assisted Living Center

Transportation


Transportation


Transportation

Transportation

Attendant Care
Other HCBS Costs
                                   AZ Local to HIPAA Code         APPENDIX 6.5
                               Crosswalk to Financial Statement


     Account Description




Outpatient Behavioral Health


Outpatient Behavioral Health


Outpatient Behavioral Health
Outpatient Behavioral Health

Outpatient Behavioral Health

Attendant Care

Attendant Care

Attendant Care

Lab/Radiology
Lab/Radiology
Lab/Radiology
Lab/Radiology

Transportation
Transportation
Transportation
Transportation


Home Health Nurse


Home Health Nurse




Durable Medical Equipment
Durable Medical Equipment
Durable Medical Equipment
Durable Medical Equipment
Durable Medical Equipment

Other HCBS Costs

Other HCBS Costs
Other HCBS Costs
                          AZ Local to HIPAA Code         APPENDIX 6.5
                      Crosswalk to Financial Statement


Account Description
Nursing Facility Contracted Rates Template / Weighted Average Rate                                                       Appendix 6.8               Amended
Conceptual Model                                                                                                                                     9/15/2010
Information is hypothetical and presented for illustration purposes only

                                                                                            # of Members                Member as        CY10        CY11
                                                            CY10           CY11                placed                       %           Weighted    Weighted
                                           County           Rate           Rate         as of 8/1, 9/1 or 10/1**         of total        Rate        Rate
Nursing Facility #1
Provider ID# ____________

   Class 1                                                      99.33         105.67                               20         33.33%        33.11        35.22
   Class 2                                                     115.85         123.24                                5          8.33%         9.65        10.27
   Class 3                                                     135.41         144.05                                3          5.00%         6.77         7.20
   Wandering                                                   144.81         154.05                                2          3.33%         4.83         5.14
   BH                                                          177.62         188.96                                1          1.67%         2.96         3.15
   Medical Sub-acute
   Other (use as many lines as needed)

Nursing Facility #2
Provider ID# ____________

   Class 1                                                     105.38         112.11                               15         25.00%        26.35        28.03
   Class 2                                                     118.89         126.48                                2          3.33%         3.96         4.22
   Class 3                                                     150.50         160.11                                4          6.67%        10.03        10.67
   Wandering                                                   164.61         175.12                                2          3.33%         5.49         5.84
   BH                                                          184.37         196.14                                3          5.00%         9.22         9.81
   Medical Sub-acute                                             0.00
   Other                                                       170.37         181.24                               3           5.00%         8.52         9.06

Total Members                                                                                                      60       100.00%
Total Weighted Rate                                                                                                                        120.89       128.60


Instructions:
Provide Facility Name and AHCCCS Provider Identification Number and County. Provider Identification Number should be six digits.
* List is to include as many nursing facilities for which the Program Contractor has contracts.
** Contractor can choose date of member placement as of 8/1/2010, 9/1/2010 or 10/1/2010. Please disclose date
chosen.
Identify any facilities no longer under contract.
Identify any facilities currently under contract negotiation.
Program Contractor may add to descriptions to coincide with payment methodology for facility type.
Disclose any projected significant changes in overall placement for the coming contract year.
                  Program Contractor HCBS Rate Information                                                                                                                  Appendix 6.8
                                                                                                                                                                              9/15/2010

                                                                                                                                CY10 Avg. Rate in     CY11 Avg. Rate in
                                                                                                                                Place as of Oct. 1,   Place as of Oct. 1,
                                                                                                                                       2009                  2010
ALTCS Provider Contractor Services                                                                               Code

Adult Day Health Care Facility/Group Respite
                                                                                             15 Minutes          S5100
                                                                                               Half Day          S5101
                                                                                               Per Diem          S5102
Attendant Care
                                                                                             15 Minutes          S5125
                                                                                    Provided by spouse      S5125/U3 Modifier
                                               Provided by family member not residing in member's home      S5125/U4 Modifier
                                      Provided by family member, non-spouse, residing in member's home      S5125/U5 Modifier


Attendant care provided through the SDAC service
                                                                         15 minutes
           Code and modifier are utilized for all ACW provided in the SDAC service. S5125 / U2
 Code and modifier are utilized for ACW providing attendant care when the ACW is a
                               family member who is not residing in member’s home. S5125 / U2, U4 *
 Code and modifier are utilized for ACW providing attendant care when the ACW is a
                                    family member who is residing in member’s home. S5125 / U2, U5 *
     Note: SDAC services may not be provided by a spouse of member or parent of
                                                    member who is their minor child.
 * When ACW is a family member, second modifier must be utilized. If ACW is not a
                  family member one modifier is sufficient. Effective Date: 04/01/08

Training provided through the SDAC service to the Member
                                                                                     15 minutes
                          Code is utilized for training to the member as needed about SDAC.                      S5108
                        Code is utilized for training to ACW who is not related to the member.                  S5115
                           Code is utilized for training to ACW who is related to the member.                    S5110


FEA Services

                                     Initiation of FEA – Service per member, Per event
Code and modifier are utilized for a one-time fee to initiate a case for a consumer that
                    elects SDAC program. Initial service includes first month service.
                                                                                                               T2040/ UA


                                                            FEA– Service Ongoing, Per event
                         Code and modifier are utilized to designate monthly billing thereafter               T2040/ UB

         Initiation of FEA Service per ACW including a background check, Per event
  Code and modifier are utilized to designate a one-time fee to open a caregiver case,
                                                        includes a background check.                          T1023 / UC

               Initiation of FEA Service per ACW without a background check, Per event
                     A one-time fee to open a caregiver case without a background check                          T1023


Home Delivered Meals                                                                                             S5170
Home Health Aid                                                                                                  T1021


Homemaker
                                                                                             15 Minutes          S5130
                                                                               Per Diem (Pest Control)           S5131
Personal Care                                                                                                    T1019
Respite Care
                                                                                   In Home-Short Term            S5150
                                                                                   Continuous In-Home            S5151
                                                                                         Group Respite      S5150/HQ Modifier


Habilitation
                                                                  Day Treatment & Training 15 Minutes            T2021
                                                         Day Treatment & Training Per Diem (21+ units)           T2020
                                                                     Supported Employment 15 Minutes             T2019
                                                           Supported Employment Per Diem (24+ Units)             T2018


Home Health - Medicare Agency
RN & LPN Intermittent Visit                                                                                      G0154
RN Continuous Care                                                                                               S9123
LPN Continuous Care                                                                                              S9124


Home Health - State Licensed Only Agency
RN Intermittent Visit                                                                                            G0154
RN Continuous Care                                                                                               S9123
LPN Continuous Care                                                                                              S9124


Independent
RN Intermittent Visit                                                                                            G0154
RN Continuous Care                                                                                               S9123
LPN Continuous Care                                                                                              S9124




Home Modification                                                                                                S5165


Emergency Alert System
                                                                          1 Unit per Service Installation   S5160/RR Modifier
                                                                        1 Unit per Service Maintenance      S5161/RR Modifier
Hospice
                                                                                   Routine Home Care              651
                                                                                Continuous Home Care              652
                                                                                 Inpatient Respite Care           655
                                                                                General Inpatient Care            656




*If rates vary by provider, Contractors should submit average rates based on
weighting of their own utilization.
Alternative Residential Settings Rates Template                                                                                    Appendix 6.8               Amended
Conceptual Model                                                                                                                                               9/15/2010
Information is hypothetical and presented for illustration purposes only

         Assisted Living Homes                                                                         # of Members                Member as       CY10         CY11
                                                                    CY10               CY11               placed                       %          Weighted     Weighted
                                                County          Per Diem Rate      Per Diem Rate   as of 8/1, 9/1 or 10/1**         of total       Rate         Rate
Assisted Living Home #1
Provider ID# ____________

   Class 1 -                                                                                                                  20        33.33%         0.00         0.00
   Class 2 -                                                                                                                   5         8.33%         0.00         0.00
   Class 3 -                                                                                                                   3         5.00%         0.00         0.00
   Wandering                                                                                                                   2         3.33%         0.00         0.00
   BH                                                                                                                          1         1.67%         0.00         0.00
   Other (use as many lines as needed)

Assisted Living Home #2
Provider ID# ____________

   Class 1                                                                                                                    15        25.00%         0.00         0.00
   Class 2                                                                                                                     2         3.33%         0.00         0.00
   Class 3                                                                                                                     4         6.67%         0.00         0.00
   Wandering                                                                                                                   2         3.33%         0.00         0.00
   BH                                                                                                                          3         5.00%         0.00         0.00
   Other                                                                                                                       3         5.00%         0.00         0.00

Total ALH Placements                                                                                                          60      100.00%          0.00         0.00


         Assisted Living Centers

Assisted Living Center #1
Provider ID# ____________
   Class 1                                                                                                                     5        19.23%         0.00         0.00
   Class 2                                                                                                                     2         7.69%         0.00         0.00
   Class 3                                                                                                                     5        19.23%         0.00         0.00
   Wandering                                                                                                                   1         3.85%         0.00         0.00
   BH                                                                                                                          0         0.00%         0.00         0.00
   Youth                                                                                                                       0         0.00%         0.00         0.00
   Other                                                                                                                       0         0.00%         0.00         0.00

Assisted Living Center #2
Provider ID# ____________
   Class 1                                                                                                                     5        19.23%         0.00         0.00
   Class 2                                                                                                                     2         7.69%         0.00         0.00
   Class 3                                                                                                                     5        19.23%         0.00         0.00
   Wandering                                                                                                                   1         3.85%         0.00         0.00
   BH                                                                                                                          0         0.00%         0.00         0.00
   Youth                                                                                                                       0         0.00%         0.00         0.00
   Other                                                                                                                       0         0.00%         0.00         0.00

Total Assisted Living Center Placements                                                                                       26      100.00%          0.00         0.00

        Adult Foster Care Homes

Adult Foster Care Home #1
Provider ID# ____________
   Class 1                                                                                                                     6        17.65%         0.00         0.00
   Class 2                                                                                                                     5        14.71%         0.00         0.00
   Class 3                                                                                                                     4        11.76%         0.00         0.00
   Wandering                                                                                                                   1         2.94%         0.00         0.00
   BH                                                                                                                          0         0.00%         0.00         0.00
   Other                                                                                                                       0         0.00%         0.00         0.00


Adult Foster Care Home #2
Provider ID# ____________
   Class 1                                                                                                                     6        17.65%         0.00         0.00
   Class 2                                                                                                                     5        14.71%         0.00         0.00
   Class 3                                                                                                                     4        11.76%         0.00         0.00
   Wandering                                                                                                                   1         2.94%         0.00         0.00
   BH                                                                                                                          1         2.94%         0.00         0.00
   Other                                                                                                                       1         2.94%         0.00         0.00

Total AFC Home Placements                                                                                                     34      100.00%          0.00         0.00


            Other Placements

Level II Behavioral Health Residential                                                                                         1

Habilitation Services/DD Group Home                                                                                            1

Therapeutic Behavioral Health Services                                                                                         1

Other                                                                                                                          1

Total Placements                                                                                                              64


Instructions:
Provide Facility Name and AHCCCS Provider Identification Number and County. Provider Identification Number should be six digits.
* List is to include as many Alternative Residential Settings for which the Program Contractor has contracts
** Contractor can choose date of member placement as of 8/1/2009, 9/1/2009 or 10/1/2009. Please disclose date
chosen.
Identify any facilities no longer under contract.
Identify any facilities currently under contract negotiation.

List any projected significant changes in overall placement for the coming contract year.

				
DOCUMENT INFO
Description: Ambulance Billing Audit Template document sample