Billing Statement Formulas by pje20281

VIEWS: 0 PAGES: 67

More Info
									      Washington State

       Public Hospital
Medicaid Administrative Match
    Interpreter Services

           Manual



          June 2009
-2-
                           Public Hospital
              Medicaid Administrative Match
                      Interpreter Services
                                 Manual

                          Table of Contents
                                                                        Page

Section I     Introduction                                                 5
                   Medicaid Administrative Match and This Program         5
                   Medicaid Administrative Match Program Overview         5
                   Providing LEP Interpreter Services                     6

Section II    Required Interpreter Qualifications                          7
                   DSHS Language Interpreter and Translator Code of       8
                    Professional Conduct
                   Interpreter Certification Requirements                10


Section III   Time Study Process                                          13
                   Introduction to the MAM Time Study                    13

                   Time Study Participant Time Tracking                  13

                   Tracking by Claiming Code                             13

                   Subcontractor Time Tracking                           15

                   Purpose of Parallel Coding                            15

                   Time Study Codes                                      17

                   Detailed Descriptions of Time Study Codes             18

                   24 hour Time Study Form                             20-21

                   Quarterly 24 Hour Time Study Roll-Up Total            22

                   Quarterly Travel Log and Codes                      24-27


Section IV    Claiming/Payment/Administrative Fee                         29
                   Allowable/Matchable Costs                             29

                   Non-Duplication of Payments                           29

                   Offset of Revenues                                    30

                   Billing Forms and the A19-1A Invoice Voucher          31

                   Administrative Fee                                    32

                   Claiming Documentation                                33

                   Agency Information Worksheet                        34-35

                   Medicaid Eligibility Rate (MER) Worksheet and       36-37
                    Certification Form
                   Applying TM and PM Medicaid Related Service Rates     38

                                         -3-
                    Applying the Indirect Rate                                  39

                    Certificate of Indirect Costs                               41

                    Calculating the Billing Quarter FFP Claimable Amount        42

                    PH/PHD’s Calculation of Subcontractor’s Billing Quarter     42
                     FFP Claimable Amount
                    When HRSA Receives Your Claim                               42

                    A19-1A Invoice Voucher                                      43

                    Certifying Your Local Matching Funds                        44

                    Local Match Certification Form                              45

                    Local Match Worksheet and Instructions                    46-47

                    When Your MAM Claim is Approved                             47


Section V      Program Requirements                                              49
                    Applicable Laws and Regulations                             49

                    Claiming Requirements                                       49

                    Insurance Requirements                                      49


Section VI     Required Documentation and Audit File                             51
                    Retention and Access to Records                             51

                    Audit File Preparation                                      51


Section VII    Subcontracting                                                    53
                    Eligible Subcontractors                                     53

                    For Independent Interpreters                                53

                    For Interpreting Agencies                                   54


Section VIII   Program/Contract Management and Monitoring                        55
                    Program Management Requirements                             55

                    Contract Monitoring Plan                                    55


Section IX     Forms, Resources, Calculations, Glossary                          59
                    Listing of all PH/PHD Interpreter Services MAM Program      59
                     Forms
                    Calculations in the Public Hospital A19 and Billing         59
                     Worksheet Workbook – Helpful Information
                    Resources – Links to Helpful Web Sites and “The Guide”      61

                    Glossary                                                    63




                                         -4-
Section I – Introduction

A.   Medicaid Administrative Match and This Program

     The State of Washington Public Hospital Interpreter Services Medicaid
     Administrative Match (MAM) program is administered by the
     Department of Social and Health Services (DSHS), Health and
     Recovery Services Administration (HRSA). Public hospital entities in
     Washington can receive federal matching fund reimbursement through
     the MAM program for providing interpreter services to Limited English
     Proficient (LEP) Clients as they access Medicaid Related Services.
     These LEP Client interpreting services are considered a part of MAM
     outreach activities.

     Public hospitals, public hospital districts (PH/PHDs), and other public
     entities may participate in the MAM program by signing an Interlocal
     Agreement (Contract) with DSHS and complying with the requirements
     and obligations of the program.

     Although not a (PH/PHD), the University of Washington Dentists,
     University of Washington School of Dentistry, and the Pacific Hospital
     Public Development Authority are each eligible to participate in the
     MAM program. These organizations also sign an Interlocal Agreement
     with DSHS and comply with the requirements and obligations of the
     program. Non-governmental entities are not eligible to participate in
     the program.

     This Manual provides information concerning the time tracking,
     claiming processes, and contractual requirements and obligations of
     the PH/PHD MAM program.

B.   Medicaid Administrative Match Program Overview

     The MAM program provides partial federal reimbursement (50%
     matching funds) to qualified governmental entities for performing
     administrative activities that support the goals of the Medicaid State
     Plan. Through participation in the MAM program, PH/PHDs receive
     partial reimbursement for their administrative costs of providing
     interpreter services to LEP Clients.

     HRSA oversees this process and administers the MAM program through
     Interlocal Agreements, training, technical assistance, claims review
     and approval, and monitoring activities with PH/PHDs.




                                     -5-
     Participating PH/PHD’s MAM activities include outreach, assistance with
     Medicaid eligibility application, and coordination of activities for those
     individuals who are potentially eligible for Medicaid or who are current
     Medicaid recipients. An example of a reimbursable MAM activity is:
     “Identifying children and families who are eligible and in need of
     Medicaid Services, and providing them assistance in accessing these
     services.”

     MAM Program Goals:

      Administer an effective, efficient statewide MAM program that
       supports the goals of the Medicaid State Plan and is in compliance
       with federal claiming guidelines.
      Assist children and families in accessing needed Medicaid Services.
      Increase the number of children and adults receiving preventive
       care.
      Increase consumer access to Medicaid providers in Washington
       communities.

C.   Providing LEP Interpreter Services

     An “Interpreter Services Encounter” is an interpreter services
     appointment arranged by the PH/PHD or Subcontractor to run
     concurrent with a Medicaid Related Service or Medicaid Covered
     Service appointment for an LEP Client. The encounter also includes
     time spent providing necessary interpreting services before and/or
     after the LEP Client’s Medicaid Related Service or Medicaid Covered
     Service appointment.




                                     -6-
Section II – Required Interpreter Qualifications
DSHS/HRSA MAM Language Interpreter and Translator
Code of Professional Conduct

All participating PH/PHD and subcontracted interpreters/translators shall
read, agree to, sign, and comply with the DSHS/MAM Language Interpreter
and Translator Code of Professional Conduct presented on the next page.

PH/PHDs and Subcontractors must also comply with the requirements
regarding retention of signed Code of Professional Conduct forms in
accordance with the Interlocal Agreement, Section 4, Statement of Work and
Section 6, Subcontracting.




                                    -7-
              DSHS/HRSA MAM Language Interpreter and Translator
                        Code of Professional Conduct

I agree to comply with this Language Interpreter and Translator Code of Professional
Conduct.

Name: __________________________________ Title: _______________________________

Signature: _______________________________ Date: _______________________________


Accuracy

Interpreters/translators shall always thoroughly and faithfully render the source language message,
omitting or adding nothing, giving consideration to linguistic variations in both source and target
languages, conserving the tone and spirit of the source language message.

Cultural Sensitivity – Courtesy

Interpreters/translators shall be culturally sensitive, and respectful of the individuals they serve.

Confidentiality

Interpreters/translators shall not divulge any information obtained through their assignments, including
but not limited to, information gained through access to documents or other written materials.

Disclosure

Interpreters/translators shall not publicly discuss, report, or offer an opinion concerning matters in which
they are or have been engaged, even when that information is not privileged by law to be confidential.

Proficiency

Interpreters/translators shall meet the minimum proficiency standard set by DSHS.

Compensation

The fee schedule or other payment agreed to between the staff or subcontracted language services
providers and the Contractor, Subcontractor, or DSHS/HRSA shall be the maximum compensation
accepted. Interpreters/translators shall not accept additional money, considerations, or favors for services
reimbursed by the Contractor, Subcontractor, or DSHS/HRSA. Interpreters/translators shall not use for
private or others’ gain or advantage; HRSA’s time or facilities, equipment or supplies, nor shall they use
or attempt to use their position to secure privileges or exemptions.

Non-discrimination

Interpreters/translators shall always be neutral, impartial and unbiased. Interpreters/ translators shall not
discriminate on the basis of gender, disability, race, color, national origin, age, socio-economic or
educational status, or religious, political, or sexual orientation. If interpreters/translators are unable to
ethically perform in a given situation, the interpreters/translators shall refuse or withdraw from the
assignment without threat or retaliation.


                                                      -8-
Self-evaluation

Interpreters/translators, the Contractor and Subcontractors shall accurately and completely represent their
certifications, training, and experience.

Conflict of Interest

Interpreters/translators, the Contractor and Subcontractors shall disclose any real or perceived conflict of
interest. As an example, providing interpreter/translation services for family members or friends may
violate the individual’s right to confidentiality, constitute a conflict of interest, or violate a DSHS/HRSA
contract or subcontract.

Professional Demeanor

Interpreters/translators shall be punctual, prepared, and dressed in a manner appropriate, and not
distracting, for the situation.

Scope of Practice

Interpreters/translators shall not counsel, refer, give advice, or express personal opinions to individuals for
whom they are interpreting/translating, or engage in any other activities that may be construed to
constitute a service other than interpreting/translating. Interpreters are prohibited from having
unsupervised access to clients, including but not limited to phoning clients directly, other than at the
request of a DSHS/HRSA employee or DSHS-contracted service provider (e.g., medical provider).
Interpreters are also prohibited from marketing their interpreter services to clients, including but not
limited to, arranging services or appointments for clients in order to create business for themselves.
Additionally, interpreters shall not transport LEP* Clients for any DSHS/HRSA related business,
including, but not limited to, Medicaid Administrative Match activities, social services or medical
appointments.

Reporting Obstacles to Practice

Interpreters/translators shall assess at all times their ability to interpret/translate. Should
interpreters/translators have any reservations about their competency, they must immediately notify the
parties and offer to withdraw without threat of retaliation.

Ethical Violations

Interpreters/translators shall immediately withdraw from encounters they perceive as violations of this
Code. Any violation of this Code may result in termination of the contract and/or prohibition from
serving LEP* Clients for any DSHS/HRSA related business, including, but not limited to, Medicaid
Administrative Match activities, social services or medical appointments.

Professional Development

Interpreters/translators are encouraged to develop their skills and knowledge through professional
training, continuing education, and interaction with colleagues, and specialists in related fields.

* LEP Client means a person who has a limited ability or an inability to speak, read, or write the English
language well enough to understand and communicate effectively, or is deaf, deaf-blind, or hearing
impaired.



                                                     -9-
Interpreter Certification Requirements

“Eligible Interpreting Staff” means a PH/PHD employee or a Subcontractor
who is bi-lingual or multi-lingual and deemed qualified to act as an
interpreter because he or she is a DSHS Authorized, Certified, or Qualified
Interpreter, or Certified Sign Language Interpreter, and whose job
description identifies them as staff required to perform interpreting services.

A PH/PHD employee may be part-time Eligible Interpreting Staff and part-
time Eligible Designated Support Staff.

A Subcontractor is an Independent Interpreter or an Independent
Interpreting Agency that has a contract with you to provide interpreting
services, including signing and translating, to LEP Clients.

Requirements and qualifications concerning interpreter services provided by
PH/PHD and Subcontractor interpreters are:

    PH/PHDs, Subcontractor Interpreter Agencies, and Independent
       Interpreters providing interpreter services to LEP Clients must
       maintain current certification and proof of certification as a “DSHS
       Authorized Interpreter”, “DSHS Certified Interpreter”, or “DSHS
       Qualified Interpreter”, for the language for which the interpreter
       services are being provided.
      Copies of current certification documents must be made available to
       DSHS staff or other state or federal personnel upon request.
      “DSHS Authorized Interpreter” means an interpreter who has passed
       the language fluency test of a DSHS recognized interpreter testing
       body such as, but no limited to, the State of Washington Administrator
       of the Courts, or the Federal Courts.
      “DSHS Certified Interpreter” means an interpreter who has passed the
       DSHS language fluency examination in one of the seven (7) DSHS
       certified languages (Spanish, Chinese, Vietnamese, Korean, Russian,
       Cambodian, or Laotian), and is certified as either a medical interpreter
       or social service interpreter.
      “DSHS Qualified Interpreter” means an interpreter who has passed the
       DSHS screening examination in languages other than the seven (7)
       DSHS certified languages or another DSHS recognized qualification
       process.

Requirements and qualifications concerning interpreter services provided by
PH/PHDs and Subcontractors using interpreting software or tele-interpreter
technology are:




                                      - 10 -
 PH/PHDs and Subcontractors using interpreting software or tele-
  interpreter technology must, prior to use to provide interpreter
  services for LEP Clients, obtain certification for the particular software
  or technology from the DSHS Language Testing and Certification (LTC)
  program.




                                  - 11 -
- 12 -
Section III – Time Study Process

Introduction to the Medicaid Administrative Match (MAM)
Time Study

This time study process includes one hundred percent (100%) time tracking
by Eligible Interpreting and Eligible Designated Support Staff, and
completion/retention of time study forms and other documentation by
participating PH/PHDs and Subcontractors to support the claims submitted
for reimbursement.

Your claims and documentation of MAM activities must clearly demonstrate
that the activities/services directly support the administration of the
Medicaid State Plan. The state and participating PH/PHDs and
Subcontractors must maintain/retain these and other adequate source
documentation to support the Medicaid payments for MAM claiming. The
basis for this requirement can be found in federal statute and regulations.1
Administrative claiming records must be made available for review by state
and federal staff upon request during normal working hours.2 It is HRSA’s
responsibility to ensure that policies are applied uniformly throughout the
state, and that claims submitted to CMS are in conformance with such
requirements.

The burden of proof and validation of time study results remains the
responsibility of the state and participating PH/PHDs and Subcontractors. To
meet this requirement, the state currently includes a space on time study
forms for a brief narrative description of the activity, function, or task being
performed. In addition to room for other information, a space for the unique
case number or patient identifier is also provided.

1
 Section 1902(a)(4) of the Social Security Act and 42 CFR 431.17; see also 45 CFR 95 and
42 CFR 433.32(a) (requiring source documentation to support accounting records) and 45
CFR 95 and 42 CFR 433.32(b and c) (retention period for records).
2
Section 1902(a)(4) of the Act, implemented at 42 CFR 431.17.


Time Study Participant Time Tracking

As mentioned above, one hundred percent (100%) time tracking of paid
work time is required for each participating Eligible Designated Support Staff
and Eligible Interpreting Staff providing services to LEP Clients.

Each work day during their work shift, every time study participant must
enter an appropriate time study code, claiming code, patient identification



                                          - 13 -
number, and activity narrative description on the 24-Hour Time Study Form
for each consecutive 15-minute increment of paid work time that day.

Tally the day’s time, by claiming code, at the bottom of the 24-Hour Time
Study Form. The time study participant and supervisor must sign and date
the form certifying its accuracy.

Tracking by Claiming Code

In the Time Study Codes chart found in this section, claiming codes are
shown in conjunction with activity codes. The claiming codes are used to
identify whether an activity is unallowable for Medicaid reimbursement (U),
allowable for proportional Medicaid reimbursement (PM), allowable for
reallocated Medicaid reimbursement (R), or allowable for total Medicaid
reimbursement (TM).

Activities allowable for PM reimbursement are activities represented by Time
Study Codes 5b and 6b in the Time Study Codes chart. The costs identified
by these activities are multiplied by the quarterly Medicaid Eligibility Rate
(MER) to determine costs that can be reimbursed.

Activities allowable for R Medicaid reimbursement are activities represented
by Time Study Code 7, General Administration, as shown in the Detailed
Description of Time Study Codes chart found in this section. MAM-
Reallocated Costs of General Administration Activities is calculated by
multiplying the sum total amount for Total Allowable Staff Salary by Fringe
Benefit Rate in the staff billing worksheet by MAM Reallocated percent of
General Administration Time indicated in that worksheet. This percentage is
calculated by multiplying two ratios. A review of the Billing Worksheet is
suggested to best understand the significance of this percentage and the
following ratios:

    The first ratio is calculated by dividing the total General Administration
      time units by total worked time units reported on the billing document.

    The second ratio is calculated by dividing the total of the total time
      (TM) units and proportional time (PM) units reported in the billing
      document by the total worked units, less the General Administration
      time (R) units.

Proportionate Medicaid costs of reallocated General Administration activities
is calculated by multiplying the MAM-Reallocated Costs of General
Administration activities by the quarterly Medicaid eligibility Rate (MER).




                                      - 14 -
Ratios representative of TM time units divided by total time worked, and PM
time units divided by total time worked, are also used in the calculation of
claimable invoice costs in the Subcontractor Billing Worksheet.

Subcontractor Time Tracking

If you do not employ Eligible Interpreting Staff for interpreter services,
100% of paid work time for Subcontractor Interpreting Staff can be used to
provide a number in the calculation to determine the Medicaid Related
Services Rate for claiming, if/when approved in writing by the HRSA MAM
Program Manager. Note: This methodology applies to PH/PHDs that have
their subcontracted interpreters participate in the 24-Hour Time Study.

Purpose of Parallel Coding

Time Study Codes must capture all of the activities performed by Time Study
participants and distinguish Medicaid activities from similar activities that are
not Medicaid reimbursable. For example, a staff interpreter who provides
interpreter services for clients who may receive both Medicaid Related
Services and/or Medicaid Covered Services covered by the Medicaid State
Plan, and non-Medicaid program services must appropriately allocate his or
her recorded time on the time sheet between the Medicaid and non-Medicaid
services. This is accomplished through the use of “parallel” Time Study
Codes.

In the Time Study Codes chart found in this section, the Time Study Codes
that end with an “a”, e.g., 1a, 2a, 5a, and 6a, are time study codes for
activities other than those related to Medicaid Related Services and/or
Medicaid Covered Services covered by the Medicaid State Plan. These “a”
code activities are parallel in description to those represented by time study
codes ending with a “b”, e.g., 1b, 2b, 5b, and 6b. The “b” codes represent
activities related to Medicaid Related Services and/or Medicaid Covered
Services covered by the Medicaid State Plan.

Time Study Code 5a represents “Interpreting to Assist Provision of Non-
Medicaid Covered Services/Non-Medicaid-Related Services”. Time Study
Code 5b represents “Interpreting to Assist Provision of Medicaid Covered
Services/Medicaid-Related Services”. Codes 5a and 5b parallel each other,
but contrast in that Code 5a is representative of a non-Medicaid activity
where as Code 5b represents Medicaid Related Services and/or Medicaid
Covered Services covered by the Medicaid State Plan.

Using a parallel coding structure ensures that the Time Study captures 100
percent of the participant’s time spent and allocates it to the appropriate
program.


                                      - 15 -
All Time Study participants must be trained on proper coding procedures,
including reporting activities using the parallel codes, before participating in
the Time Study.




                                       - 16 -
        Time Study Codes – The Time Study Codes and detailed
        descriptions that follow are located in the Public Hospital Time
        Study document.


  Public Hospital/Public Hospital District (PH/PHD) Medicaid Administrative Match
                                 Time Study Codes
 Time
 Study      Claiming
 Code        Code                             Time Study Code Description

   1a           U        Interpreting to Assist Provision of Non-Medicaid Outreach
   1b          TM        Interpreting to Assist Provision of Medicaid Outreach
   2a           U        Interpreting to Facilitate Application for Non-Medicaid Programs
                         Interpreting to Facilitate Application for Medicaid Eligibility
   2b          TM        Determination
                         Paid Time - Activities other than Interpreting Services, Direct Medical
                         Services, Training or General Administration (General Administration is
    3           U        Code 7)
                         Direct Medical Services - Medicaid Covered Services/Medicaid-Related
    4           U        Services
                         Interpreting to Assist Provision of Non-Medicaid Covered Services/Non-
   5a           U        Medicaid-Related Services
                         Interpreting to Assist Provision of Medicaid Covered Services/Medicaid-
   5b          PM        Related Services
   6a           U        General Training Related to Non-Medicaid Activities
                         Training Related to Medicaid Administrative Activities and/or Access to
                         Medicaid Covered Services/Medicaid-Related Services (Note: Time
                         providing or receiving MAM training or MAM refresher training/briefing is
   6b          PM        recorded as Code 7)
    7           R        General Administration

Claiming Code Description:
PM = Proportional Medicaid Reimbursement
 R = Reallocated Medicaid Reimbursement
TM = Total Medicaid Reimbursement
 U = Unallowable for Medicaid Reimbursement

Medicaid-Related Services = Medical, Dental, Mental Health, Substance Abuse Prevention or
Treatment, or Family Planning Services




                                             - 17 -
Detailed Descriptions of Time Study Codes

Code                          Time Study Code Description

 1a    Interpreting to Assist Provision of Non-Medicaid Outreach – U
       Interpreting provided by a certified or qualified interpreter, either face-to-face or
       telephone interpreting, while providing Non-Medicaid related outreach. Below are
       typical examples of these activities, but they are not all inclusive:
          Informing potentially eligible individuals about general health education,
           wellness and prevention programs other than Medicaid and Medicaid managed
           care.
          Informing potentially eligible individuals about Public Cash Assistance, Food
           Assistance, Housing Assistance, and other Non-Medicaid healthcare services
           programs.

 1b    Interpreting to Assist Provision of Medicaid Outreach – TM
       Interpreting provided by a certified or qualified interpreter, either face-to-face or
       telephone interpreting, while providing Medicaid related outreach. Below are
       typical examples of these activities, but they are not all inclusive:
          Informing potentially eligible individuals about Medicaid Programs and
           encouraging access to these programs.
          Providing information to families/individuals, agencies, and community groups
           about Medicaid managed care plans and about the Medicaid covered services
           they offer, for the purpose of bringing Medicaid eligible individuals into
           Medicaid services.

 2a    Interpreting to Facilitate Application for Non-Medicaid Programs – U
       Interpreting provided by a certified or qualified interpreter, either face-to-face or
       telephone interpreting, while providing Non-Medicaid related outreach. Below are
       typical examples of these activities, but they are not all inclusive:
          Interpreting for WIC application; facilitate application assistance for non-
           Medicaid program.

 2b    Interpreting to Facilitate Application for Medicaid Eligibility
       Determination – TM
       Interpreting provided by a certified or qualified interpreter, either face-to-face or
       telephone interpreting, while providing Medicaid related outreach. Below are
       typical examples of these activities, but they are not all inclusive:
          Interpreting between patient and Financial Services about arranging for
           payment (getting Medicaid authorization) for upcoming care; facilitating
           application assistance for Medicaid eligibility determination.

 3     Paid Time – Activities other than Interpreting Services, Direct Medical
       Services, Training or General Administration (General Administration is
       Code 7) – U
       All activities for which the employee is paid that are not applicable to the other
       time study codes.
          Time traveling or walking to an interpreting appointment and interpreter is not
           accompanying the LEP Client.
          Time waiting for an interpreting appointment, LEP Client has not shown up
           yet.
          Technical work on communication infrastructure for direct patient service.


                                           - 18 -
4    Direct Medical Services – Medicaid Covered Services/Medicaid-Related
     Services – U
     Providing direct clinical/treatment services, scheduling, collecting medical history,
     performing assessment/medical exams, charting, and/or patient education that is
     part of care provided to a patient for Medicaid Covered Services/Medicaid-Related
     Services.
       Providing speech and occupational therapy to LEP Client.
       Providing personal aide services for LEP Client.
       Providing medical care to LEP Client.

5a   Interpreting to Assist Provision of Non-Medicaid Covered Services/Non-
     Medicaid-Related Services – U
     Interpreting provided by a certified or qualified interpreter, either face-to-face or
     telephone interpreting, while providing Non-Medicaid services. Below are typical
     examples of these activities, but they are not all inclusive:
        Translating a specific patient letter, at the request of a care team, to help LEP
         Client access and understand social and vocational services.
        Arranging for or providing translation services that assist the LEP Client to
         access and understand general health education campaign materials.
        Phone interpreting when LEP Client and service professional are on the line to
         discuss housing assistance.

5b   Interpreting to Assist Provision of Medicaid Covered Services/Medicaid-
     Related Services – PM
     Interpreting services provided by a certified or qualified interpreter, either face-
     to-face or telephone interpreting, while providing direct clinical/treatment services
     which also includes scheduling care, collecting medical history, performing
     assessment/medical exams, charting, patient education and/or making referrals,
     and following up on care provided to a patient for Medicaid Covered
     Services/Medicaid-Related Services that are covered by the Medicaid State Plan.
     Below are examples of these activities, but they are not all inclusive:
        Speaking with LEP Client to make sure Client knows the time for a medical
         appointment, how to get there and what to bring.
        Interpreting between LEP Client and Financial Services concerning a bill and
         making payment to Financial services for a service covered by the Medicaid
         State Plan.
        Interpreting between LEP inpatient Client and nurse to patients in inpatient
         care unit to make sure LEP Client has Admit packet with tools for language
         support and an interpreter phone at bedside while receiving a service covered
         by the Medicaid State Plan.
        Birth certificate preparation, interpreting (baby just born at the hospital).
        Paternity affidavit preparation, interpreting (baby just born at the hospital).

6a   General Training Related to Non-Medicaid Activities – U
     Training provided or received to improve understanding, delivery and/or referral
     to Non-Medicaid services, such as Public Cash Assistance, Food Assistance,
     Housing Assistance, other healthcare-related programs or services, or other non-
     healthcare programs or services.
        Participating in or coordinating training that improves the delivery of non-
         Medicaid services to LEP Clients.
        Attending training on how to assist LEP Client families to access US citizenship
         educational program.



                                        - 19 -
  6b   Training Related to Medicaid Administrative Activities and/or Access to
       Medicaid Covered Services/Medicaid-Related Services (Note: Time
       providing or receiving MAM training or MAM refresher training/briefing is
       recorded as Code 7) – PM
       Training provided or received to improve understanding, delivery and/or referral
       to Medicaid Covered Services/Medicaid-Related Services.
          Teaching care teams and administrative managers and staff about language
           support rules for interpreting as LEP Client receives care.
          Interpreter teaches medical students how to conduct an interpreted interview
           during LEP Client Medicaid-covered medical appointment.

  7    General Administration – R
       Use this code when performing administrative activities that are not related to
       program activities. Include related paperwork, clerical activities, or staff travel
       required to perform these general administrative activities.

       Note: Public Hospital/Public Hospital District (PH/PHD) administrative staff
       expenses that are included in the indirect costs as defined in the MAM Interlocal
       Agreement (usually including accounting, payroll, executive direction, etc.), are
       only allowable through the application of the PH/PHD approved indirect cost rate.
       Below are typical examples of general administrative activities, but they are not
       all inclusive:
         Taking paid lunch time, breaks, vacation and sick leave, or other paid time
            while not at work.
         Reviewing PH/PHD procedures and rules.
         Attending or facilitating staff meetings.
         Performing administrative or clerical activities related to general interpreting
            services, provided these are not included in the PH/PHD indirect cost rate.
         Providing general supervision of staff, including evaluation of employee
            performance.
         Reviewing technical literature and research articles.
         Performing other general administrative activities of a similar nature as listed
            above that cannot be specifically identified under other activity codes.
         On a time study day – performing managerial, administrative, or clerical
            activities related specifically implementation of the MAM Interlocal Agreement,
            including conducting the MAM time study, compiling time study results,
            preparing the billing statement, invoicing, and coordinating with HRSA with
            specific reference to the MAM program.
         Participating in or coordinating MAM program training such as code definitions,
            time sheet completion, and time study requirements, etc.
         Coordinating/assigning interpreting services encounter visits.
         Financial oversight of contracts with interpreting agencies.




Time Study Form

The Time Study Form is in consecutive 15-minute increments for a 24-hour
period beginning at midnight and spanning through the remainder of each
day. (See sample on next page)




                                           - 20 -
         Below is a sample portion of a completed 24 Hour Time Study Form.



                                Public Hospital/Public Hospital District (PH/PHD)
                         Medicaid Administrative Match "24 Hour" Time Study Form

                       For Eligible Interpreting Staff And/Or Designated Support Staff
            Public Hospital/PHD:     Summit Valley General

                      Staff Name:    Susan Doe

                        Job Title:   Receptionist (Eligible Designated Support Staff)

        Date (month / day / year):   05/20/2009
Complete the time study form by recording your entire paid work day for each activity performed in 15-minute time increments.
Put the time study code and a written narrative that best describes the activity performed. Note: The written narrative should
contain enough clarifying information to reflect the activity performed.
After completing the time study form for your entire paid work day, sign and date the form and forward it to your
supervisor or time study manager for their signature.
Electronic Copy: Time Study Code, use the drop down boxes. (Do NOT copy from one box to another.)
Paper Copy: Write in INK, not pencil, and do not use correction fluid (White Out, etc). If you make a mistake, cross it out and
write the correction.

                    Time                                                         Written Narrative
   Time                         Claiming        Unique
                    Study         Code        Patient ID #
                                                              (Describe actual activity performed related to the time
Increments
                    Code                                      study code)
12:00-12:15 am         3              U                        Reviewing email/voice mail. Not related to interpreting.
12:15-12:30 am         7              R                        Reviewing email/voice mail related to interpreting.
12:30-12:45 am        5b             PM          789ghi        Physician and LEP patient to assist in provision of medical care.
12:45-1:00 am         5b             PM          234jkl        Same as above.
 1:00-1:15 am         3               U                        Document filing. Not related to interpreting and not part of indirect costs.
 1:15-1:30 am         1b             TM         890pqr         Inform LEP patient on Medicaid programs and access.
 1:30-1:45 am         2b             TM         321stu         Explain Medicaid eligibility & application process to LEP patient.
 1:45-2:00 am         3a              U         654wxy         Explain public housing eligibility & application process to LEP patient.
 2:00-2:15 am          7              R                        Attending staff meeting.
 2:15-2:30 am         7               R                        Same as above.
 2:30-2:45 am         7               R                        Paid break.
 2:45-3:00 am         1a              U           098lkj       Inform LEP patient on public assistance & public housing programs.
                                                                 Total
                                                                                    Proportional
                                                               Medicaid                                        General              Total Units
                                                                                     Medicaid
                                                                (100%)                                        Admin (R)              Worked
                                                                                       (PM)
                                                                 (TM)
  Totals for the "Quarterly Time Study Roll-Up" Report                2                       2                       4                   12
I certify this is a true and accurate record of my activities for the time reported above.
                    Signature:                                                                                       Date:
     Supervisor Signature:                                                                                           Date:



                                                             - 21 -
Quarterly “24 Hour” Time Study Roll-Up Total

Interpreting supervisors/managers use the Quarterly Roll-up Total worksheet to
record daily time, by claiming code, for each time study participant for the
respective claiming quarter. Below is a sample portion of one worksheet.



                  Public Hospital/Public Hospital District (PH/PHD)
                   Quarterly "24 Hour" Time Study Roll-Up Total

Staff Name:

          Year:

                  Total Medicaid   Proportional      General        Total Units
   DATE
                   (100%) (TM)     Medicaid (PM)    Admin (R)        Worked
 January 01
 January 02
 January 03
 January 04
 January 05
 January 06
 January 07
 January 08
 January 09
 January 10
 January 11
 January 12
 January 13
 January 14
 January 15
 January 16



                              Totals for PH/PHD Billing Worksheet
Used for Travel Log Calculation
TM + PM
TM %
PM %




                                           - 22 -
Note Concerning Subcontractors:

If a PH/PHD does not employ Eligible Interpreting Staff for interpreter services,
100% of paid work time for Subcontractor Interpreting Staff can be used to
provide a number in the calculation to determine the Medicaid Related Services
Rate for claiming, if/when approved in writing by the HRSA MAM Program
Manager. Note: This methodology applies to PH/PHDs that have their
subcontracted interpreters participate in the 24-Hour Time Study.

A PH/PHD that does not employ Eligible Designated Support Staff and/or
Eligible Interpreting Staff and who subcontracts for interpreter services, can
use a proxy Medicaid Related Service Rate to complete the Subcontractor Billing
Worksheet, if/when approved in writing by the HRSA MAM Program Manager.
Note: We have obtained CMS approval to allow these PH/PHDs to use the
University of Washington Medical Center’s Medicaid Related Services Rate as a
proxy rate.




                                       - 23 -
Tracking Travel Information for PH/PHD Interpreter Staff

PH/PHD staff Time Study participants use the Quarterly Travel Log worksheet to
record daily travel log statistics for claiming. This form must be signed and
dated by the time study participant and his or her supervisor.

Quarterly Travel Log

The next 2 pages reflect a sample portion of the Travel Log.




                                      - 24 -
  Public Hospital/Public Hospital District (PH/PHD) Medicaid Administrative
                                    Match
                            Quarterly Travel Log
          This log is required for claiming expenses related to travel associated with MAM-claimable activities.
     ONLY travel for activities that would be MAM-Claimable ("1b, 2b, 5b, 6b" Time Study Codes) should be recorded.

              Staff Name:                                                                        Quarter:
                Job Title:                                                                           Year:
                             THIS SECTION COMPLETED BY STAFF TRAVELING
                                                                                                                        Other
                            BRIEF DESCRIPTION of ACTIVITY                                    Mileage $   Per Diem $
MONTH                                                                              Number                             Expense     Total
          LOCATION/                      /ACTIVITIES                                         Amount       Amount
 and                                                                               of Auto                             $ Amts    Travel $
         DESTINATION     (purpose of travel, mode(s) of transportation,                       Paid by     Paid by
 DAY                                                                                Miles                             Paid by    Amount
                                  other kinds of expenses)                                   Hospital     Hospital
                                                                                                                      Hospital

Jan 01
Jan 02
Jan 03
Jan 04
Jan 05
Jan 06
Jan 07
Jan 08
Jan 09
Jan 10
Jan 11
Jan 12
Jan 13
Jan 14
Jan 15
Feb 26
Feb 27
Feb 28
Feb 29

                                                                          - 25 -
Mar 01
Mar 02
Mar 03
Mar 04
Mar 05
Mar 06
Mar 07
Mar 08
Mar 09
Mar 20
Mar 21
Mar 22
Mar 23
Mar 24
Mar 25
Mar 26
Mar 27
Mar 28
Mar 29
Mar 30
Mar 31

                                                                  Total
                                                                  Allowable
                                                                  Travel
                                                                  Expense
                                                                  Total Medicaid (TM) Travel Expense

                                                                  Total Proportional Medicaid (PM) Travel Expense

I certify this is a true and accurate record of my activities for the travel and related expenses reported above.
                Signature:                                                                                  Date:


   Supervisor Signature:                                                                                    Date:


                                                               - 26 -
Quarterly Travel Log Codes

Below are the Travel Log Codes used to record Contractor staff travel statistics.



            Public Hospital/Public Hospital District (PH/PHD)
                        Medicaid Administrative Match

                             Quarterly Travel Log Codes



 Activity    Claiming
  Code        Code                           Activity Code Description


   1b          TM       Interpreting to Assist Provision of Medicaid Outreach
                        Interpreting to Facilitate Application for Medicaid Eligibility
   2b          TM       Determination
                        Interpreting to Assist Provision of Medicaid Covered
   5b          PM       Services/Medicaid-Related Services
                        Training Related to Medicaid Administrative Activities and/or
                        Access to Medicaid Covered Services/Medicaid-Related Services
                        (Note: Time providing or receiving MAM training or MAM refresher
   6b          PM       training/briefing is recorded as Code 7)




                                             - 27 -
- 28 -
Section IV – Claiming/Payment/Administrative Fee
Completing the Claiming Process

In accordance with the Interlocal Agreement for the MAM Program, the PH/PHD
agrees to comply with the billing and claiming guidelines provided in this
section of the Manual. If you have questions regarding the process or need
assistance, please contact the MAM Program Manager at 360-725-1970.

1. Allowable/Matchable Costs

  Allowable costs are direct or indirect costs reimbursable in accordance with
  the Interlocal Agreement. They are incurred by the PH/PHD to provide
  interpreting service activities for LEP Clients.

  A direct cost activity is performed by the PH/PHD’s Eligible Interpreting Staff
  or Eligible Designated Support Staff or an Independent Interpreter or
  Independent Interpreting Agency and meets the definition of a Medicaid
  reimbursable activity as described in Section III -- Time Study Process of
  this Manual.

  The participating PH/PHD and its Subcontractors must accept full
  responsibility for all Independent Interpreter Agency and Independent
  Interpreter FFP Claimable Amounts which were later disallowed, and
  recoupment of funds is necessary.

2. Non-Duplication of Payments

  Federal, state and local government resources should be expended in the
  most cost-effective manner possible. In determining the administrative costs
  that are reimbursable under Medicaid, duplicate payments are not allowable.
  PH/PHDs may not claim FFP for the costs of allowable administrative
  activities that have been or should have been reimbursed through an
  alternative mechanism or funding source.

  This is because the state provides assurances to CMS of non-duplication
  through its administrative claims and the claiming process. PH/PHDs should
  not be reimbursed more than the actual cost of providing services under the
  PH/PHD Interpreter Services Medicaid Administrative Match Program,
  including state, local, and federal funds.




                                      - 29 -
  A listing of examples of activities, that is not all-inclusive, for which costs
  may not be claimable as Medicaid administration due to the potential for
  duplicate payments follows:

     Activities that are integral parts or extensions of direct medical services,
      such as patient follow-up, patient assessment, patient education, or
      counseling. In addition, the cost of any consultations between medical
      professionals that may occur is already reflected in the payment rate for
      medical assistance services and may not be claimed separately as an
      administrative cost.

     An activity that has been, or will be, paid for as a medical assistance
      service (or as a service of another (non-Medicaid) program).

     An activity that has been, or will be, paid for as a Medicaid administrative
      cost through another MAM program.

     An activity that is included as part of a managed care rate and is
      reimbursed by the managed care organization.

  It is important to distinguish between duplicate payments for the same
  activity and an inefficient use of resources, which may result in the
  unnecessary repeated performance of an activity.

  Duplicate performance of services or administrative activities must be
  mitigated through coordination of activities.

3. Offset of Revenues

  Certain revenues must offset allocation costs in order to reduce the total
  amount of costs in which the federal government will participate. To the
  extent the funding sources have paid or would pay for the costs at issue,
  federal Medicaid funding is not available and the costs must be removed
  from total costs (See OMB Circular A-87, Attachment A, Part C., Item 4.a.).

  The following include some of the revenue offset categories which must be
  applied in developing the net costs:

     All federal funds.

     All state expenditures which have been previously matched by the federal
      government (includes Medicaid funds for medical assistance (such as the
      payment rate for services under fee-for-service)).




                                        - 30 -
     Insurance and other fees collected from non-governmental sources must
      be offset against claims for Medicaid funds.

     All applicable credits must be offset against claims for Medicaid funds.
      Applicable credits refer to those receipts or reduction of expenditure type
      transactions that offset or reduce expense items allocable to federal
      awards as direct or indirect costs.

  You may not claim any federal match for administrative activities if its total
  cost has already been paid by the revenue sources above. A government
  program may not be reimbursed in excess of its actual costs, i.e., make a
  profit.

4. Billing Forms and the A19-1A Invoice Voucher

  Note on Billing Worksheets: Although many sample forms have been
  presented in this Manual, the PH/PHD Billing Worksheet “With Fringe”, the
  PH/PHD Billing Worksheet that calculates benefits and salary “Without
  Fringe”, and the Subcontractor Billing Worksheet are not included. They are
  voluminous and in a legal-size format that would not be legible if shrunk-to-
  fit. Find them and other billing forms in your Public Hospital A-19 and Billing
  Worksheet workbook.

  At that Web site, navigate to the Billing Documents link to find your own
  billing forms.

  Each Billing Quarter:

  a. Use the A19-1A Invoice Voucher to submit the billing for the FFP
     Claimable Amount for that quarter, to the MAM Program Manager.

  b. Include with each A19-1A Invoice Voucher the following completed
     documents that are in your Billing Worksheet Excel workbook at the web
     site referenced in 2. above:

         The Agency Information Worksheet
         The   Medicaid Eligibility Rate (MER) Worksheet and Certification Form
         The   Billing Worksheet with Fringe % Form, when applicable
         The   Billing Worksheet No Fringe % Form, when applicable
         The   Subcontractor Billing Worksheet Form, when applicable

  c. Submit the completed A19-1A Invoice Voucher and the supporting
     documents indicated in 2.b. above, no later than three (3) months
     following the end of the quarter for which an FFP Claimable Amount is




                                             - 31 -
     being requested to:

                 MAM Program Manager
                 Health and Recovery Services Administration
                 Department of Social and Health Services
                 PO Box 45530
                 Olympia, Washington 98504-5530

     If you need to overnight your claim, send it to the MAM Program Manager
     at the following physical address.

                 MAM Program Manager
                 DSHS/HRSA – Division of Healthcare Services
                 Medicaid Outreach Section
                 626 – 8th Avenue SE
                 Olympia, Washington 98504-5530

     If a telephone number is needed, use 360-725-1726.

     As a public entity, the hospitals must submit claims within the two year
     time limit identified in 45 CFR 95.7, however, as stated above the DSHS
     claim submission requirement is no later than three (3) months following
     the end of the quarter for which an FFP Claimable Amount is being
     requested.

5. Administrative Fee

  Each billing quarter, HRSA will send your PH/PHD an invoice for an
  administrative fee that will not exceed its actual costs to administer your
  MAM Interpreter Program and the Interlocal Agreement. Administrative Fees
  you pay HRSA will only be used to offset HRSA’s cost incurred in
  administering the Program and Agreement.

  The PH/PHD pays that billing quarter’s Administrative Fee with non-federal
  dollars, within forty-five (45) days of the date on the Administrative Fee
  invoice. Mail administrative fee payments to the following address:

                 DSHS / Health and Recovery Services Administration
                 Medical Assistance / Division of Rates and Finance
                 Office of Finance / Accounting Unit
                 PO Box 45500
                 Olympia, Washington 98504-5500




                                     - 32 -
6. Claiming Documentation

  You must maintain time tracking, billing, and related personnel records and
  be able to support claims submitted for MAM Program reimbursement. Also
  ensure that any Subcontractors also maintain interpreting encounter
  documentation and billing invoices sufficient to support claims submitted.

  You must make administrative claiming records available for review by state
  and federal staff upon request. Documentation for administrative activities
  must be sufficiently detailed and clearly demonstrate that the activities are
  necessary for the proper and efficient administration of the Medicaid State
  Plan. For most activities, the activity is self-evident in the detailed coding
  used on the Time Tracking Sheet.

  Please see additional guidance below regarding documentation for
  compensation of salary and wages, as excerpted from the OMB Circular A-
  87, Attachment B, Section 11.h (5):

  Personnel activity reports or equivalent documentation for participating staff
  must meet the following standards:

  a. They must reflect an after-the-fact distribution (i.e., distribution following
     completion of the activity) of the actual activity of each employee;

  b. They must account for the total activity for which each employee is
     compensated;

  c. They must be prepared at least monthly and must coincide with one or
     more pay periods;

  d. They must be signed by the employee as being a true statement of
     activities; and

  d. The Contractor must retain documentation to support the report.

  Note: The requirement to document costs at least monthly does not mean that a
  Time Study must be conducted monthly. OMB Circular A-87 makes a distinction
  between documentation of costs and the methods/mechanisms for allocating costs.
  While costs must be documented at least monthly, time studies, conducted for the
  purpose of allocating costs, can occur on a quarterly basis, or some other
  statistically valid time frame.

  As provided for in the Interlocal Agreement, Contractors will complete a 100% Time
  Study each quarter, unless otherwise approved and specified in writing by the MAM




                                       - 33 -
  Program Manager.

  Principles related to documentation and documentation requirements are:

  a. Documentation related to salaries and wages, including personnel activity
     reports is required;

  b. Accounting records are supported by source documentation such as
     canceled checks, paid bills, payrolls, contract and sub-grant award
     documents;

  c. Documentation related to administrative costs is required.

7. Completing the Agency Information Worksheet

  Complete and submit your Agency Information Worksheet each quarter.
  This information will, in turn, be transferred as needed to the Billing
  Worksheets, and the A19-1A Invoice Voucher.

  The next page reflects a sample Agency Information Worksheet.




                                     - 34 -
                         Public Hospital/Public Hospital District (PH/PHD) Agency Information
Contractor is to complete the yellow sections.
Claiming Entity:
Address 1 (DBA)                                                                                                  Vendor Number
Address 2                                                                                                       Assigned by HRSA
                                                                                                                on Agency A19-1A
Address 3
Quarter:
Prepared by Contact Name:
Prepared by Telephone #:
Prepared by Email Address:
                                                                                                PROJ                                PROJ
PH/PHD Contract Number                                                                          PREFIX   PROJ       SUB PROJ       PHASE

                               Project Prefix "8IN" for Public Hospital Interpreting             8IN      0           18            58

Completing the "Agency         1. Claiming entity (the name and address that appears above has been completed by DSHS. If there is
Information" Tab               a discrepancy with the name and address, please contact Ralph Faulder. (See DSHS Contact
                               Information below)
                               2. Complete the Quarter. Use this format: January-March 2009, April-June 2009, etc.
                               3. Complete the Prepared by name, telephone number and email address of the Hospital billing
                               contact.
                               4. The vendor number has been completed by DSHS.

Printing the Original A19-1A   Print the A-19. Sign the A19-1A in blue ink. Include copies of the backup documents: MER Certification
and backup                     Form, Billing Worksheet With Fringe %, Billing Worksheet No Fringe % & Subcontractor Billing
                               Worksheet.

Mailing the A19-1A &           Mail the original signed A-19 and the required backup to:
backup to DSHS                 DSHS-Health and Recovery Services Administration
                               Division of Healthcare Services
                               Medicaid Outreach Section
                               PO Box 45530
                               Olympia, WA 98504-5530.
                               If overnighting send it to Larry Linn at:
                               DSHS-HRSA-Division of Healthcare Services
                               Medicaid Outreach Section
                               Cherry Street Plaza, 3rd Floor
                               626 8th Ave SE
                               Olympia, WA 98504-5530
                               If a telephone number is needed use 360-725-1726

DSHS Contact Information       If you have fiscal questions, call Ralph Faulder at 360-725-1872 or email him at Fauldr@dshs.wa.gov
                               If you have program questions, call Larry Linn at 360-725-1970 or email him at Linnld@dshs.wa.gov

                                                                            - 35 -
8. The Medicaid Eligibility Rate (Not to be confused with the Medicaid Related
   Services Rates discussed on page 38)

  The Medicaid Eligibility Rate (MER) refers to the proportion of unduplicated
  LEP Medicaid Clients served in the quarter for which a claim is made, to the
  total unduplicated number of LEP patients served in that quarter. The MER
  must be calculated separately by each contracting PH/PHD as follows:

  The total unduplicated number of LEP Medicaid Clients served during the
  quarter (numerator), divided by the total unduplicated number of LEP
  individuals served during that same quarter (denominator).

  (See sample MER Worksheet and Certification Form on next page.)

  To determine these numbers, you may use your databases and other
  resources, such as IHS RPMS (Resource & Patient Management System),
  ENVOY, etc.

  You must verify and document each LEP Patient’s/Client’s Medicaid eligibility
  and maintain that documentation for state or federal review as requested.
  Medicaid eligibility can be verified free of charge through the Washington
  State Medicaid (WAMED) web site.


  Obtaining a copy of an LEP Client’s medical identification card (or Medicaid
  Services Card) and keeping it on file for review is also an acceptable
  method.

  You must complete, sign, and keep on file the Medicaid Eligibility Rate (MER)
  Worksheet and Certification Form for each quarter. In accordance with 2. b.
  above, a copy of each MER Worksheet and Certification Form must
  accompany every quarterly A19-1A Invoice Voucher that is submitted for
  reimbursement.

  The MER is used as a factor to determine Total MAM Claimable Cost on the
  PH/PHD’s Billing Worksheets.

  On the next page you can see a sample MER Worksheet and Certification
  Form.




                                      - 36 -
                     Public Hospital/Public Hospital District (PH-PHD)
                               Medicaid Eligibility Rate (MER)
                              Worksheet and Certification Form

PH/PHD:

DBA:

Contract #:

Quarter:

MER:                 0.00%

Provide Medicaid Eligibility Formula:

Insert numbers applied in the formula to determine the MER rate for the Quarter:

Numerator                          0
                                                         =           0.00%
Denominator                        0

Numerator: The total unduplicated number of LEP Medicaid Clients served by the
Contractor during the Quarter.

Denominator: The total unduplicated number of LEP individuals served by the Contractor
during the Quarter.

Supporting documentation of the MER must be kept on file for review/audit purposes as
needed, including databases utilized.

I certify that the information provided above is true, and that documentation is available
for review upon request.

Signature:

Job Title:

Date:




                                                - 37 -
9. The Total Medicaid (TM) Time and Proportional Medicaid (PM) Time
   Medicaid Related Service Rates (Not to be confused with the Medicaid
   Eligibility Rate discussed on page 36)

  Total Medicaid (TM) Time is reimbursed in this Interpreter Services MAM
  program using a one hundred percent (100%) MER.

  TM time is representative of Medicaid Outreach (Code 1b) and Medicaid
  Application Assistance (Code 2b) activities in this MAM program. These
  activities are reimbursed at a higher MER because CMS and the state
  consider the goals of providing interpreter services for Medicaid Outreach
  and Medicaid Application Assistance to be core goals which are paramount.

  Other goals of the program include interpreter services to assist in provision
  of care for LEP Clients (Code 5b) and training on Medicaid related topics and
  processes (Code 6b). These goals, while important, are representative of
  Proportional Medicaid (PM) Time which is reimbursed using a reduced MER in
  the calculation, as explained on the previous two pages.

  Because Independent Interpreter Subcontractors and staff from
  Subcontracted Interpreter Agencies do not participate in the one hundred
  percent (100%) time tracking process, an alternative process is used to
  reduce Subcontractor Total LEP Invoice Costs to represent costs in line with
  TM and PM Time recorded in the Time Study.

  For those Contractors who do not use staff interpreters, the TM and PM
  Medicaid Related Service Rates established each quarter by the University of
  Washington Medical Center are used as proxy to reduce Subcontractor Total
  LEP Invoice Costs.

  The process to reduce the Subcontractor invoice costs involves use of the TM
  and PM Medicaid Related Service Rates. The TM and PM Medicaid Related
  Service Rates are used to derive Total TM Cost and Total PM Cost from Total
  LEP Invoice Costs reported on the Subcontractor Billing Worksheet.

  The TM Medicaid Related Service Rate is calculated by dividing the TM time
  units reported on the PH/PHD Billing Worksheet by Total Time (TT) units
  reported on the worksheet.

  The PM Medicaid Related Service Rate is calculated by dividing the PM time
  units reported on the PH/PHD Billing Worksheet by Total Time (TT) units
  reported on the worksheet.




                                      38
  Note on Billing Worksheets: The PH/PHD Billing Worksheet “With
  Fringe”, the PH/PHD Billing Worksheet that calculates benefits and salary
  “Without Fringe”, and the Subcontractor Billing Worksheet are not presented
  in this Manual. The forms are voluminous and in a legal-size format that
  would not be legible if shrunk-to-fit. They are in your “Public Hospital A-19
  and Billing Worksheet” workbook.


10.   Applying the Indirect Rate

  Allowable Eligible Interpreting Staff and Eligible Designated Support Staff
  personnel costs and travel costs are Direct Claimable Costs.

  In addition, you may claim Indirect Costs for these staff in accordance with
  OMB Circular A-87. Indirect Costs are calculated by multiplying the Direct
  Claimable Costs for MAM activities by the Indirect Rate negotiated or
  approved by the PH/PHD and its Cognizant Agency (as documented by the
  applicable signed Indirect Cost Rate Certificate).

  You must assure that costs claimed as Direct Claimable Costs (through the
  Time Study process) do not duplicate costs claimed through the application
  of the Indirect Rate.

  Apply the Indirect Rate (stated as a percentage) to the sub-total amount
  claimed after the Allowable Eligible Interpreting Staff and Eligible Designated
  Support Staff costs are complete. For PH/PHDs without an approved
  Indirect Cost Rate Certificate, no Indirect Rate can be applied.

  Apply the approved Indirect Rate to each quarterly claim within the
  applicable state fiscal year. If your PH/PHD does not have an approved
  Indirect Rate for the current state fiscal year, you may use the most recently
  approved Indirect Rate if authorized by the Cognizant Agency.

  When you intend to claim Indirect Costs as part of your FFP Claimable
  Amount, you need to submit:

         A copy of your approved Indirect Cost Rate Certificate for the
          applicable state fiscal year, that complies with OMB Circular A-87, from
          your Cognizant Agency; or
         If you do not have, or do not know who the Cognizant Agency is, an
          Indirect Cost Rate Certificate that complies with OMB Circular A-87,
          and related documentation, to: HRSA Accounting
                                             PO Box 45500
                                             Olympia, WA 98504-5500




                                       - 39 -
You must make a copy of the applicable Indirect Cost Rate Certificate
available for review by state and federal staff upon request. Note: Indirect
Rates vary by PH/PHD and are renegotiated or reapproved periodically as
directed by the Cognizant Agency.

(See the next page for a sample of the Indirect Cost Rate Certificate.)




                                    - 40 -
                                         Certificate of Indirect Costs

                                                   NAME OF LOCAL GOVERNMENT
CONTACT’S NAME



CONTACT’S TELEPHONE NUMBER (INCLUDE AREA CODE)      CONTACT’S EMAIL ADDRESS



INDIRECT COST PROPOSAL RATE                         TIME PERIOD THE RATE COVERS

                                                    FROM                      TO


This is to certify that I have reviewed the indirect cost rate submitted with this contract
and to the best of my knowledge and belief:
1. All costs included in this rate proposal (date)                      to establish billing
   or final indirect costs rates for (period covered by rate)              are
   allowable in accordance with the requirements of the Federal award(s) to which they
   apply and OMB Circular A-87, “Cost Principles for State, Local, and Indian Tribal
   Governments.” Unallowable costs have been adjusted for in allocating costs as
   indicated in the cost allocation plan.
2. All costs included in this proposal are properly allocated to Federal awards on the
   basis of a beneficial or causal relationship between the expenses incurred and the
   agreements to which they are allocated in accordance with applicable requirements.
   Further, the same costs that have been treated as indirect costs have not been
   claimed as direct costs. Similar types of costs have been accounted for consistently
   and the Federal Government will be notified of any accounting changes that would
   affect the predetermined rate.
I declare that the foregoing is true and correct.
SIGNATURE                                           DATE OF EXECUTION



PRINTED NAME OF OFFICIAL                            TITLE




                                          - 41 -
11.   Calculating the Billing Quarter FFP Claimable Amount

  Calculate your FFP Claimable Amount for each Billing Quarter by entering the
  required information and data in the Billing Worksheets.

  Note: To support the calculations, these worksheets consist of locked and unlocked
  cells. Enter your information and data in the unlocked cells. There are formulas
  embedded in the locked cells to calculate the Total MAM Claimable Cost and the FFP
  Claimed at Match Rate 50% (A19 Dollar Amount) located in the upper right portion
  of the worksheet.

12. PH/PHD’s Calculation of Subcontractor’s Billing Quarter FFP Claimable
   Amount

  Calculate the total Subcontractor’s FFP Claimable Amount for each Billing
  Quarter by entering the required information and data in the Subcontractor
  Billing Worksheet. This worksheet also contains locked and unlocked cells.
  Enter the information and data in the unlocked cells. The embedded
  formulas will calculate the Total Subcontractor MAM Claimable Cost and FFP
  Claimed at Match Rate 50% (A19 Dollar Amount) located near the bottom of
  the Subcontractor Billing Worksheet.

13.   When HRSA Receives Your Claim

  The MAM Program Manager will review the completed and signed original
  A19-1A Invoice Voucher and its accompanying Billing Forms for
  appropriateness, accuracy, and trends. If a claim is considered incorrect,
  incomplete, unsubstantiated or inaccurate, you will be contacted for
  additional documentation or asked to resubmit a corrected claim.

  The next page reflects a sample A19-1A Invoice Voucher. The working Excel
  version is located in your PH/PHD A-19 and Billing Worksheet workbook.




                                       - 42 -
           FORM
                                                                                                                                                                AGENCY USE ONLY
                                                             STATE OF WASHINGTON
    A19-1A                                                INVOICE VOUCHER
                                                                                                                                           AGENCY NO.                  LOCATION CODE                 P.R. OR AUTH NO.
         (REV. 6/95)



                                           AGENCY NAME                                                                                       3000
     DSHS-Health and Recovery Services Administration
                                                                                                                                    INSTRUCTIONS TO VENDOR OR CLAIMANT: Submit this form to claim
     Division of Healthcare Services                                                                                                payment for materials, merchandise or services. Show comlete detail for
     Medicaid Outreach Section                                                                                                      each item.
     PO Box 45530                                                                                                                     Vendor's certificate: I hereby certify under penalty of perjury
     Olympia WA 98504-5530                                                                                                            that the items and totals listed herin are proper charges for
                                      VENDOR OR CLAIMANT                                                                              materials, merchandise or services furnished to the State of
                                                                                                                                      Washington, and that all goods furnished and/or services
                                                                                                                                      rendered have been provided without discrimination because of
                                                                                                                                      age, sex, marital status, race, creed, color, national origin,
                                                                                                                                      handicap, religion, or Vietnam era or disabled veterans Status



                                                                                                                                    BY
                                                                                                                                                             (SIGN IN INK)



                                                                                                                                                        (TITLE)                                        (DATE)

FEDERAL I.D. NO. OR SOCIAL SECURITY NO. (For Reporting Personal Services Contract Payments to I.R.S.)                   RECEIVED BY                                                        DATE RECEIVED




      DATE                                               DESCRIPTION                                      QUANTITY          UNIT      UNIT PRICE                  AMOUNT                      FOR AGENCY USE

                          For services rendered in performance under
                          Contract #
                          Quarter:

                          Total PH/PHD MAM Claimable Cost                                                                                                                      $0.00
                             FFP Claimed at Match Rate 50%                                                                                                                     $0.00

                          Total Subcontractor MAM Claimable Cost                                                                                                               $0.00
                             FFP Claimed at Match Rate 50%                                                                                                                     $0.00

                                                                                                                             Total Claimable                                   $0.00
                                                                                                                                   Total FFP                                   $0.00
I certify that these expenses were incurred following the requirements
of the Centers for Medicare and Medicaid Services (CMS) and that the
funds are not already being used to match federal funds of other federal
programs, or being reimbursed by other federal grants.
PEREPARED BY                                                      TELEPHONE NUMBER                 DATE                         AGENCY APPROVAL                                                  DATE



EMAIL ADDRESS

DOC. DATE              PMT DUE DATE       CURRENT DOC. NO.              REF. DOC. NO.              VENDOR NUMBER                                                                  USE   UBI NUMBER
                                                                                                                                                                                  TAX


                                         H3
ACCOUNT NUMBER 30 CHARS                                                                            VENDOR MESSAGE 25 CHARS

                                                                                                   Interpreter Services
                               MASTER INDEX                 SUB
                                                                                                                             PHAS
                                                                                                                     PROJ




                                                                                                                             PROJ




 TRANS                                             SUB                 ORG                                                                                         INVOICE
                                                                                                                     SUB




                FUND                                        SUB                 ALLOC        MOS          PROJ                              AMOUNT                                           INVOICE # 30 CHARS
 CODE                       APPN
                                   PROGRAM INDEX
                                                   OBJ                INDEX                                                                                          DATE
                           INDEX                            OBJ

            001                    H1994           ER 9772          H710 5EAA                           8IN                                           0.00                        Contract #




ACCOUNTING APPROVAL FOR PAYMENT                                                                    DATE                               WARRANT TOTAL                          WARRANT NUMBER


                                                                                                                                                $0.00




                                                                                                              - 43 -
14. Certifying Your Local Matching Funds

  The Federal Financial Participation (FFP) amount for the Interpreter Service
  Activities provided is 50% of the Total MAM Claimable Cost.

  Your   monetary share of costs for MAM are:
        non-federal monies;
        eligible federal monies; or
        funds allowable as state match by regulation.

  These local matching funds cannot be used by the PH/PHD as match for
  other federal money. Accordingly, each A19-1A Invoice Voucher submitted
  for reimbursement includes the following statement:

         “I certify that these expenses were incurred following the
         requirements of the Centers for Medicare and Medicaid Services
         (CMS) and that the funds are not already being used to match
         federal funds of other federal programs, or being reimbursed by
         other federal grants.”

  When you claim under the MAM program, you are using a certified public
  expenditure process as a means to satisfy state match requirements.

  In accordance with DSHS Policy No. 19.50.02, Accounting for Local Match
  and Cost Sharing Agreements, Contractors must track and record the source
  of Local Matching Funds for each quarter.

  Submit each year a completed and signed DSHS form 06-155 Local match
  Certification and its accompanying Local Match Worksheet, along with the
  signed original April – June A19-1A Invoice Voucher within three (3) months
  following the end of the state fiscal year. These submitted forms indicate
  the Local Matching Fund totals for the state fiscal year being certified and
  must be received and approved for acceptance by the MAM Program
  Manager and the HRSA fiscal office.

  Note: HRSA will not approve nor reimburse your April – June A19-1A
  Invoice each year, and any subsequent invoices, until the Local Matching
  Funds have been certified for that year.

  See the next 2 pages for a sample of the Local Match Certification and
  accompanying Worksheet.




                                        - 44 -
                                               Local Match Certification
                                      (This form must be submitted with final contract billing.)



    I,                                                         certify that local funds and/or in-kind items
         PRINT NAME

                                                                                          were provided in the amount of
    TYPE AND SOURCE OF FUNDS/ITEMS


    $                                    and were used to match federal funds paid during the time period

    of                                   through                                   for

                                                                                                                           .
    TYPE OF SERVICE/CONTRACT


5




NAME OF ENTITY


NAME OF AUTHORIZED AGENT                                                                           CONTRACT/VENDOR NUMBER


AUTHORIZED REPRESENTATIVE’S SIGNATURE              DATE               TITLE OR POSITION


PRINTED NAME OF AUTHORIZED REPRESENTATIVE                             TELEPHONE NUMBER




                                                           Instructions
                                        Name: Printed name of the local entity’s agent authorized to complete certification
                                              form.
                  Type and source of funds: The type and source of local funds used. In-kind sources need specific
                                            identification showing who donated the item(s) (e.g., volunteers, building use,
                                            etc.).
                               Dollar amount: Dollars that were used to match federal funds paid during the time period.
                                              Dollars reported must agree with amount on the final billing.
                                  Time frame: Period of time the services were provided.
                      Type of service/contract: Services eligible for FFP.
                               Name of entity: Name of local entity that is providing the local funding match.
                 Name of authorized agent: Name of local entity that is authorized to act in behalf of local entity.
                      Contract/vendor number: The contract or vendor number of the local entity.
    Authorized representative’s signature: The signature of the local entity authorized representative.
                                         Date: Date when form was completed.
                              Title or position: Title or position of local entity authorized representative
                                Printed name: Printed name of authorized representative.
                           Telephone number: Telephone number of authorized representative. Include the area code.




                                                                 45
                                               LOCAL MATCH WORKSHEET

                                                Type and Source of Funds
                             Local Match for Hospitals Medicaid Administrative Match Invoices


Claiming Entity:



        Quarter               For the Period              FFP            Local Match     Total Computable
          1                                                                                        $0.00
          2                                                                                        $0.00
          3                                                                                        $0.00
          4                                                                                        $0.00
                              Grand Total                       $0.00              $0.00           $0.00


Type and Source of Funds used as Local Match
List only the funds that are funds available for local match.
                         Name of Local Match                                Type               Source              Amount




Total Local Match                                                                                                       $0.00
Administrative Policy No: 19.50.02                                                         Check Point: Net Zero            $0.00




                                                                - 46 -
                            GENERAL INSTRUCTIONS

CLAIMING ENTITY               Type the name of your Claiming Entity as it appears in the Vendor or
                              Claimant Box on the Medicaid Administrative Match A19 Invoice Voucher
                              .

FOR THE PERIOD                Type the quarter as it appears on the A19 Invoice Voucher "for the period
                              of" (Ex: Apr-Jun 08)

FFP DOLLAR AMOUNT             Federal Financial Participation (FFP) Dollar Amount

LOCAL MATCH DOLLAR AMOUNT     Local Match Dollar Amount

NAME OF LOCAL MATCH           List the name of the Local Match fund. If the name is in shorthand or a
                              nickname, please also list the official name. For example, if the official
                              name of the fund is "Local Capacity Development Fund", and you listed
                              "CON/CON State", please write the na

TYPE OF FUND                  Please list the type of fund as "Cash".

SOURCE OF FUND                Please list the source of the fund i.e., City, County, State ….


15. When Your MAM Claim is Approved

  When the MAM Program Manager has reviewed your billing and claiming
  information, and if no changes are needed, the A19-1A Invoice Voucher will
  be approved and sent to the HRSA fiscal office for payment processing.
  HRSA will send the reimbursement within thirty (30) days of receiving and
  approving a properly executed claim.




                                       - 47 -
- 48 -
Section V – Program Requirements

Applicable Laws and Regulations

Activities shall be in accordance with the following rules and regulations, and all
updates, revisions, or replacements:

    Titles 42 and 45, Code of Federal Regulations
    Executive Office of the President of the United States, Office of
     Management and Budget, Circular A-87 Cost Principles for State, Local,
     and Indian Tribal Governments
    Centers for Medicare and Medicaid Services, Medicaid School-Based
     Administrative Claiming Guide, dated May 2003
    This Manual

Claiming Requirements

Your PH/PHD must:

    Claim only activities that are necessary and directly support the
       administration of the Medicaid State Plan.
      Track 100% of the actual work activities performed by all eligible staff
       participating in the Time Study. Another Time Study Methodology may
       be used if/when authorized in writing by the MAM Program Manager.
      Not submit any claims for payment in connection with services and
       activities provided to all clients (both Medicaid and non-Medicaid) as free
       care, unless expressly authorized by federal law, Washington State law,
       the Interlocal Agreement or this Manual.
      Not claim for activities that are normally covered by other means, such as
       collateral or related activities.
      Not claim for activities that are normally performed for the same
       individuals under another program.

Insurance Requirements

You and all Subcontractors must be self-insured or insured through a risk pool
and shall pay for any losses for which you/they are found liable, or must
maintain the types and amounts of insurance identified below:

Commercial General Liability Insurance (CGL) – to include coverage for bodily
injury, property damage, and contractual liability, with the following minimum




                                        - 49 -
limits: Each Occurrence - $1,000,000; General Aggregate - $2,000,000. The
policy shall include liability arising out of premises, operations, independent
contractors, products-completed operations, personal injury, advertising injury,
and liability assumed under an insured contract. The State of Washington,
DSHS, its elected and appointed officials, agents, and employees shall be
named as additional insureds.




                                      - 50 -
Section VI – Required Documentation and Audit File

Retention and Access to Records

You must maintain records and documentation identified in this Section on-site
for a minimum of 6 years following the quarter for which a claim was
submitted. You must store these records and documentation in a centrally
located Audit File and make them readily accessible to the MAM Program
Manager and state or federal auditors upon request. Also, it is required that if
any litigation, claim, or audit is started before the expiration of the 6 year
period, the records must be kept until all litigation, claims, or audit findings
involving those records has been resolved.

Audit File Preparation – Monitoring, Technical Assistance, and Auditing

Having and maintaining a current Audit File is the best way to be prepared for
on-site monitoring visits and receiving any technical assistance from your MAM
Program Manager that may be needed. Although Time Study Forms and
supporting documentation related to training, time tracking, certifications,
billing and claiming need to be maintained on-site, due to their bulk, we don’t
recommend that you physically keep them in your Audit File. Just indicate in
the file where those documents can be accessed.

It is recommended that your Audit File include the following current records and
documents:

      All MAM Training Documentation, including:

            Training rosters with date, staff names, and signatures
            For each training event, a list of trainers and all materials used to train
             Time Study participants

      Completed Local Match Certification Form DSHS 06-155 and the
      accompanying Local Match Worksheet

             This is necessary to validate the Local Match Certification. Be sure to
             keep a copy of the form and worksheet you submit each year.

      Completed Indirect Cost Rate Certification Form

             This is necessary to validate the Indirect Cost Rate calculation. Keep a
             copy of each one.




                                           - 51 -
Billing Documentation, including:

      24 Hour Time Study Forms for all participants
      Quarterly 24 Hour Time Study Roll-Up Total Forms
      Agency Information Worksheets
      PH/PHD Billing Worksheets (Fringe and/or No Fringe)
      Subcontractor Billing Worksheets
      Copies of all submitted A19-1A Invoice Vouchers
      Original MAM Interlocal Agreement (executed)
      Medicaid Eligibility Rate Worksheet and Certification Form
      Indirect Cost Rate Certificate (and back-up documentation)

       These records, whether required to be originals or copies, must be signed.
       They are all necessary to validate the way you conduct your Time Studies,
       and the accuracy of your claims.

Interpreter Service Encounter Documentation

       An Interpreter Service Encounter is an appointment arranged by the
       PH/PHD or Subcontractor that is concurrent with a Medicaid related
       Service or Medicaid Covered Service appointment for an LEP Client. It
       also includes time spent providing necessary Interpreter Services before
       and/or after the LEP Client’s appointment.

       You and all Subcontractor(s) conducting Interpreter Service Encounters
       must maintain complete documentation concerning the encounter and
       related billings/claims.

MAM Time Study Desk Review Results

       Only PH/PHDs that have been asked to submit Time Study Forms for
       review will receive a copy of this spreadsheet. It must be retained.

Copies of All Audit Reports, including:

      MAM Audit Report(s)/Corrective Action Documents
      State or Federal Audit Report(s)/Corrective Action Documents

Originals of any Contracts/Agreements with:

      Medicaid Administrative Match (DSHS/HRSA)
      Interpreter Services Subcontractors – Note: Subcontractors should also
       maintain an Audit File of training materials, time tracking documents,
       certifications, and billing/claiming documents (in accordance with your
       Interlocal Agreement with HRSA) sufficient to justify all invoiced billings.

       If original contracts/agreements cannot be maintained within the Audit
       File, add a document indicating where they can be accessed.




                                     - 52 -
Section VII – Subcontracting

Eligible Subcontractors

You may obtain interpreting services through written subcontracts with self-
employed Independent Interpreters or Interpreting Agencies that provide
interpreters who are:

      DSHS Authorized, Certified, Qualified Interpreters; and/or
      Certified Sign Language Interpreters.

See Section II; Required Interpreter Qualifications or the Glossary in Section
VIII; Forms, Resources, Glossary of this Manual for additional information on
these certifications.

When you choose to provide interpreting services either in whole or in part,
through Subcontractors, the subcontracts must include the following
requirements:

For Independent Interpreters:

      Identity of the parties to the subcontract (e.g.; name, address, type of
       organization) and their legal basis to do business
      Description of the payment methodology and applicable rates
      Terms and conditions for providing interpreter services
      Subcontractor’s signed copy of the DSHS Language Interpreter and
       Translator Code of Professional Conduct
      Subcontractor’s proof of Authorization, Certification, or Qualification; per
       Section II; Required Interpreter Qualifications of this Manual
      Subcontractor’s signed statement that he/she will not seek payment
       separate from DSHS, or from LEP Clients or other contract service
       providers for interpreting services performed under the subcontract
      Requirement to retain all invoices and documentation used to calculate
       the invoices for interpreting services billed to HRSA for six (6) years.

Subcontracted Independent Interpreters must:

      Verify, prior to billing, that the Medicaid Service or Medicaid Related
       Service being provided is within the scope of care of the LEP Client’s
       health care program at the time the care and interpreting was provided,
       by:

          1. Obtaining a photocopy of the LEP Client’s Medicaid ID (MAID) Card,




                                         - 53 -
            Client Services Card, or successor card; or

         2. Verifying the LEP Medicaid Client’s eligibility free of charge through
            the Washington State Medicaid (WAMED) web site

     Accept full fiscal responsibility for their billings. In the event of a state or
      federal audit, the Independent Interpreter will be responsible for any
      repayments.

For Interpreting Agencies:

     Identity of the parties to the subcontract (e.g.; name, address, type of
      organization) and their legal basis to do business
     Description of the payment methodology and applicable rates
     Terms and conditions for providing interpreters
     Copy of the DSHS Language Interpreter and Translator Code of
      Professional Conduct, signed by an officer authorized to represent and
      sign for the agency
     Requirement to maintain a current file for each interpreter assigned to
      provide interpreter services to LEP Clients. The file must provide:

         1. Proof of Authorization, Certification, or Qualification; per Section II;
            Required Interpreter Qualifications of this Manual
         2. Signed copy of the DSHS Language Interpreter and Translator Code
            of Professional Conduct
         3. Signed statement that he/she will not seek payment separate from
            DSHS, or from LEP Clients.

Subcontracted Interpreter Agencies must:

     Verify, prior to billing, that the Medicaid Service or Medicaid Related
      Service being provided is within the scope of care of the LEP Client’s
      health care program at the time the care and interpreting was provided,
      by:

         1. Obtaining a photocopy of the LEP Client’s Medicaid ID (MAID) Card,
            Client Services Card, or successor card; or

         2. Verifying the LEP Medicaid Client’s eligibility free of charge through
            the Washington State Medicaid (WAMED) web site.

     Accept full fiscal responsibility for their billings. In the event of a state or
      federal audit, the Interpreter Agency will be responsible for any
      repayments.




                                         - 54 -
Section VIII – Program/Contract Management and
Monitoring

PROGRAM MANAGEMENT REQUIREMENTS

The HRSA Program Manager:

     Oversees monitoring of activities for the PH/PHD Interpreter Services Medicaid
      Administrative Match (MAM) program;
     Coordinates communication and processes between HRSA and the PH/PHD, via
      the PH/PHD’s MAM Coordinator, regarding all requirements described in the
      Interlocal Agreement and this Manual;
     Provides “Train the Trainer” MAM training to the MAM Coordinator as applicable
      for the MAM program;
     If requested and as available, provides MAM training to interpreter staff;
     Conducts one monitoring desk review and/or visit for each PH/PHD at least once
      every three years;
     Provides technical assistance as needed/requested to MAM Coordinator as
      availability permits;
     Oversees any Amendments to or further development of the Interlocal
      Agreement;
     As needed/required, updates PH/PHD Interpreter Services Medicaid
      Administrative Match Program documents (e.g., Interlocal Agreement, training
      materials, billing worksheets, Manual, etc.), and ensures necessary documents
      are posted to the HRSA/MAM Web-site. The HRSA Program Manager notifies the
      MAM Coordinator of such updates via e-mail; and
     Communicates by e-mail and/or phone with the MAM Coordinator regarding
      impending contract modifications/amendments, and emails necessary
      documents to the MAM Coordinator.


CONTRACT MONITORING PLAN

Scope of the Monitoring Plan

  This monitoring plan covers all PH/PHD Interpreter Services Medicaid
  Administrative Match program Interlocal Agreements in effect as of July 1,
  2009 for MAM reimbursement for Medicaid-related activities including, but
  not limited to, outreach, eligibility determinations, interpreting (including
  translation) for LEP Clients for services covered by the state’s Medicaid State
  Plan, and training on Medicaid services and related interpreting processes
  described in this Manual.




                                        - 55 -
Monitoring Coordinator

  The HRSA/MAM Program Manager for the PH/PHD Interpreter Services
  Medicaid Administrative Match program, or designee, is responsible for
  monitoring the related Interlocal Agreement.

Risk Factors

  Participants in the PH/PHD Interpreter Services Medicaid Administrative
  Match program have multiple funding sources. As a governmental agency,
  they are covered under the Single Audit Act. Thus, the risk factor of multiple
  funding sources is reduced. Audit requirements under the Single Audit Act
  serve as an auxiliary monitoring tool.

  PH/PHDs are audited frequently across multiple federal funding streams, and
  consequently, tend to have a great deal of practice and experience in
  maintaining good fund and grant accounting systems and audit trails.
  Because of long experience with federal and state grants and contracts, they
  are also familiar with and experienced in the need for compliance with
  requirements of an Interlocal Agreement.

  Staff turnover, and staff that have complex multiple duties, may contribute
  to potential contract non-compliance and billing errors. MAM Coordinators
  new to the MAM program may be more likely to make errors in claiming due
  to the program’s complexity. MAM Coordinator and staff training
  requirements, desk monitoring activities, and scheduled “on-site” monitoring
  visits are designed to help avert claiming errors, and to identify those errors
  that may occur. HRSA requires that participating PH/PHDs submit a
  corrective action plan, when deemed necessary.

Monitoring Activities and Schedule

  The following monitoring activities will be conducted for the participating
  PH/PHDs receiving MAM reimbursement:

     The PH/PHD MAM Coordinator is responsible for providing ongoing Time
      Study Code and Time Study process training to participating staff,
      reviewing staff Time Study Sheets for accuracy, and collating the Time
      Study data onto the respective HRSA/MAM electronic time tracking and
      Billing Worksheets as well as completing and submitting all other required
      electronic claiming forms for review, authorization, and payment.
     HRSA Desk Review: The HRSA/MAM Program Manager regularly reviews
      Time Study results supporting the Billing Worksheets and other claiming
      documents in an effort to spot inconsistencies, trends, or inappropriate




                                      - 56 -
    claiming.

   Interlocal Agreement performance standards and MAM policies are
    reviewed, and claims will be checked for accuracy, compliance and to
    ensure there has been no duplication of claimed time. HRSA may
    interview participating staff concerning Time Study results during
    scheduled monitoring. Staff interviews will assess the validity of the
    staff’s responses based on their understanding of the Time Study Codes,
    the specific examples of allowable MAM activities, and their ability to
    describe the specific MAM activities they performed. The need for any
    additional staff training will also be evaluated.

   HRSA is responsible as part of the monitoring process for assuring that
    the indirect cost rate has been calculated correctly, includes only
    allowable costs, and is applied appropriately by the PH/PHD.




                                    - 57 -
- 58 -
  Section IX – Forms, Resources, Calculations, Glossary

 Forms

  The following forms are used in the Public Hospital/Public Hospital District
  Interpreter Services Medicaid Administrative Match Program. These and other
  important documents are located on the PH/PHD Interpreter Services MAM
  Program web site.

  A19-1A Invoice Voucher
  Certificate of Indirect Costs
  DSHS MAM Language Interpreter and Translator Code of Professional Conduct
  DSHS form 06-155 Local Match Certification
  Local Match worksheet
  PH/PHD MAM 24 Hour Time Study Form
      For eligible Interpreter Staff And/Or Designated Support Staff
  PH/PHD Quarterly 24 Hour Time Study Roll-Up form
      Jan-Mar
      Apr-Jun
      Jul-Sep
      Oct-Dec
  PH/PHD MAM Quarterly Travel Log
      Jan-Mar
      Apr-Jun
      Jul-Sep
      Oct-Dec
  PH/PHD Agency Information Worksheet
  PH/PHD Medicaid Eligibility Rate (MER) Worksheet and Certification Form
  PH/PHD MAM Billing Worksheet With Fringe %
  PH/PHD MAM Billing Worksheet No Fringe %
  PH/PHD Subcontractor Billing Worksheet

 Calculations in the Public Hospital A19 and Billing Worksheet Workbook

  Helpful Information to Use When Viewing/Using the Public Hospital A19 and Billing
  Worksheet Workbook

      Note: Because Excel formulas are transparent, and to maximize the value of this
      summation, we encourage you to review the applicable documents and worksheets
      concurrently.

  Once a PH/PHD completes the Agency Information worksheet, Information from the worksheet transfers
  to the Medicaid Eligibility Rate (MER) Certification Form and worksheet, and the Billing Worksheets. Then
  the MER itself also transfers to the Billing Worksheets for participating staff. It is also used to calculate
  MAM claimable costs on the Subcontractor Billing Worksheet. Total MAM Claimable Costs and FFP Claimed
  at Match Rate 50% (A19 Dollar Amount) from the Billing Worksheet and Subcontractor Billing Worksheet
  are entered on the A19-1A Invoice mailed to DSHS for payment. Quarter total data is entered on the
  Billing Worksheet With Fringe % and Billing Worksheet No Fringe %, where applicable for each staff
  participating in the time study. Following is some of the data/information that you must enter in the Billing
  Worksheet to ensure accurate calculation of Total MAM Claimable Costs and FFP Claimed at Match Rate
  50% (A19 Dollar Amount):




                                                      - 59 -
       Staff Name
       Job Title
       Total Staff Salary for the Quarter (benefits will be added to this column on the Billing Worksheet
        No Fringe % worksheet)
       Total Staff Salary that is not Matchable (non-federal grant dollar)
       Total Allowable Staff Salary
       Total Allowable Travel Expense
       Total Units Worked from the Time Study Form
       Total Medicaid (TM) Time 100% from the Time Study Form
       Total Proportional Medicaid (PM) Time from the Time Study Form
       Total General Administration (R) Time from the Time Study Form

Embedded formulas on each staff line will calculate the Percent of Staff Time Spent Performing Total
Medicaid (TM) Activities and Percent of Staff Time Spent Performing Total Proportional Medicaid (PM)
Activities using:

       Total Units Worked from the Time Study Form;
       Total Medicaid (TM) Time 100% from the Time Study Form; and
       Total Proportional Medicaid (PM) Time from the Time Study Form.

From the individual staff lines on the Billing Worksheet:

Total Allowable Staff Salary Times the Fringe Benefits Rate is calculated by summing the amount for the
Total Allowable Staff Salary with the product of Total Allowable Staff Salary multiplied by the Quarterly
Average Fringe Benefits Rate Per PH/PHD. (For the Billing Worksheet No Fringe %, the amount for Total
Allowable Staff Salary will include allowable costs for both salary and fringe benefits.)

Total Medicaid (TM) Costs Times 100% Total Medicaid MER is calculated by multiplying the Total Allowable
Staff Times the Fringe Benefits Rate by the Percent of Staff Time Spent Performing Total Medicaid (TM)
Activities and the Total Medicaid Eligibility Rate (MER).

Total Proportional Medicaid (PM) Costs Times Quarterly MER is calculated by multiplying Total Allowable
Staff Times the Fringe Benefits Rate by the Percent of Staff Time Spent Performing Total Proportional
Medicaid (PM) Activities and the Quarterly Medicaid Eligibility Rate (MER).

Total Direct Costs Claimed is calculated by adding the Total Medicaid (TM) Costs Times 100% Total
Medicaid MER and the Total Proportional Medicaid (PM) Costs Time Quarterly MER.

The MAM Claimable Direct Cost is calculated by adding the Total Direct Costs Claimed and the
Proportionate Medicaid costs of reallocated General Administration activities.

The MAM Claimable Indirect Costs are calculated by multiplying the MAM Claimable Direct Costs by the
PH/PHD Indirect Costs Rate.

Total MAM Claimable Costs are calculated by adding the MAM Claimable Direct Costs and the MAM
Claimable Indirect Costs.

The Billing Worksheet FFP Claimed At Match Rate 50% (A19 Dollar Amount) is calculated by dividing the
Total MAM Claimable Costs by two (2).

At the bottom of the Billing Worksheet:

Total General Administration (R) Time for all participating staff is divided by Total Paid Units at the bottom
of the Billing Worksheet to calculate the percent for Total General Administration Time.




                                                    - 60 -
  Total (TM) and (PM) Time Units for all participating staff are added together and divided by Total Paid
  Time Units minus General Administration (R) Time Units at the bottom of the Billing Worksheet to
  calculate a percent for Total (TM) and (PM) Divided by Total Paid Units minus General Administration.

  The MAM Reallocated percent of General Administration Time at the bottom of the Billing Worksheet is
  calculated by multiplying the percent for Total General Administration Divided by Total Units by the
  percent of Total (TM) and (PM) Divided by the Total Paid Units minus General Administration.

  MAM-Reallocated Costs of General Administration Activities is calculated by multiplying the Total Allowable
  Staff Salary and Fringe Benefits by the MAM Reallocated percent of General Administration Time.

  Proportional Medicaid Costs of reallocated General Administration activities is calculated by multiplying the
  MAM-Reallocated Costs of General Administration Activities by the Quarterly Medicaid Eligibility Rate
  (MER).

  Proportional Medicaid Costs of reallocated General Administration activities is added to the Total Direct
  Costs Claimed to calculate the MAM Claimable Direct Costs.

  Travel Expense Costs

  Calculations to add participating staff travel expense costs are also provided in the Billing Worksheet.



 Resources

  Interlocal Agreement with DSHS/HRSA – In PH/PHD Audit File

  Office of Management and Budget (OMB)
  Circular A-87, Cost Principles for State, Local and Indian Tribal Governments

  PH/PHD Interpreter Services MAM Program Web site

  Registry of Interpreters for the Deaf (RID)

  National Association of the Deaf (ND)

  Medicaid School-Based Administrative Claiming Guide, dated May 2003




                                                      - 61 -
- 62 -
 Glossary

  “A19-1A Invoice Voucher” means the State of Washington Invoice Voucher used by Contractors to submit claims for
  reimbursement in return for goods and/or services provided to the Department or its Clients.
  “Access Broker” means an entity that has an active contract with DSHS to provide non-emergent medically necessary
  interpreter services and/or transportation to DSHS Clients in order to receive Medicaid Covered Services.
  “Activities” means activities defined by Time Study Code Descriptions or Time Study Codes provided in the Manual,
  and used by the Contractor’s employees in an approved MAM Time Study methodology for determining costs.
  “Administrative Fee” means the amount charged to the Contractor by HRSA based on a percentage of each Contractor
  FFP reimbursement billing, to offset the HRSA administrative costs incurred in administering the MAM Program and
  this Agreement.
  “Allowable Cost” means a Direct or Indirect Cost that is reimbursable in accordance with this Agreement, and was
  incurred by the Contractor to provide LEP Interpreter Services.
  “Billing Quarter” means a quarter in a state fiscal year in which the Contractor submits claims for FFP reimbursement.
  "Categorically Needy Program" or "CNP" means the state and federally funded Medicaid program that provides the
  broadest scope of medical coverage for Medicaid Clients.
  "Certified Sign Language Interpreter" means an interpreter who has passed either the Registry of Interpreter for the
  Deaf (RID) or National Association of the Deaf (ND) certification process for American Sign Language.
  “CMS” means the United States Department of Health and Human Services (DHHS), Centers for Medicare and
  Medicaid Services.
  “Cognizant Agency” means the federal or state agency responsible for reviewing, negotiating, and approving cost
  allocation plans or Indirect Cost Rates of the Contractor under the Office of Management and Budget (OMB) Circular A-
  87 “Cost Principles for State, Local and Indian Tribal Governments” on behalf of all federal agencies.
  "Direct Claimable Cost" means an allowable cost directly incurred by the Contractor to provide LEP Interpreter
  Services.
  “DSHS Authorized Interpreter” means an interpreter who has passed the language fluency test of a DSHS recognized
  interpreter testing body such as, but not limited to, the State of Washington Administrator of the Courts, or the Federal
  Courts.
  “DSHS Certified Interpreter” means an interpreter who has passed the DSHS language fluency examination in one of
  the seven (7) DSHS certified languages (Spanish, Chinese, Vietnamese, Korean, Russian, Cambodian, or Laotian), and is
  certified as either a medical interpreter or social service interpreter.
  “DSHS MAM Language Interpreter and Translator Code of Professional Conduct” means a document that is
  agreed to and signed by each interpreter that provides LEP Interpreting Services in accordance with this Agreement. The
  document can be found in the Manual.
  “DSHS Qualified Interpreter” means an interpreter who has passed the DSHS screening examination in languages
  other than the seven (7) DSHS certified languages or another DSHS recognized qualification process.
  “Eligible Designated Support Staff” means an employee of the Contractor whose job description identifies them as
  staff who will be performing paperwork, clerical activities, tasks involving the scheduling of interpreters, and completing
  and maintaining Interpreter Service Encounter records in support of providing interpreting services during an Interpreter
  Service Encounter. A Contractor employee may be part-time Eligible Designated Support Staff and part-time Eligible
  Interpreting Staff.
  "Eligible Interpreting Staff" means an employee of the Contractor who is bi-lingual or multi-lingual and deemed
  qualified to act as an interpreter because he or she is a DSHS Authorized, Certified, or Qualified Interpreter, or Certified
  Sign Language Interpreter, and whose job description identifies them as staff that is required to perform interpreting
  services. A Contractor employee may be part-time Eligible Interpreting Staff and part-time Eligible Designated
  Support Staff.




                                                              - 63 -
“FFP” or “Federal Financial Participation” means the federal matching funds provided for the partial reimbursement
of administrative activities that directly support efforts to identify and enroll potential Medicaid clients or directly
support the provision of medical services covered under the Medicaid state plan.
“FFP Claimable Amount” means the amount of FFP for each Billing Quarter that the Contractor requests on an A19-
1A Invoice Voucher submitted to HRSA in accordance with this Agreement.
“Guide” means the publication of United States Department of Health and Human Services, Centers for Medicare and
Medicaid Services, Medicaid School-Based Administrative Claiming Guide, dated May 2003, and includes any
supplements, amendments or successor documents.
“Health and Recovery Services Administration” or “HRSA” or “Department” means the Washington State
Department of Social and Health Services, Health and Recovery Services Administration.
"Independent Interpreters" means individual interpreters who are self-employed and with whom the Contractor
subcontracts to perform Interpreting Services, including signing and translating, under this Agreement.
“Indirect Costs” means those costs incurred by the Contractor for common or joint purposes. These costs benefit more
than one cost objective and cannot be readily identified with a particular cost objective without much more effort than
would be apparent based on the results achieved. The Contractor can opt to claim Indirect Costs as part of its FFP
Claimable Amount, but cannot apply the Indirect Cost Rate to Subcontractor costs.
"Indirect Cost Rate" means the ratio of Indirect Costs to Direct Costs that complies with OMB Circular A-87, as
approved by the Contractor’s Cognizant Agency based on the Contractor’s current year Indirect Cost Rate Certificate.
"Indirect Cost Rate Certificate" means the documentation the Contractor submits to its Cognizant Agency to
substantiate its request for an Indirect Cost Rate.
“Interpreter Service Encounter” means an Interpreter Service appointment arranged by the Contractor or
Subcontractor to run concurrent with a Medicaid Related Service or Medicaid Covered Service appointment for an LEP
Client. The encounter also includes time spent providing necessary interpreting services before and/or after the LEP
Client’s Medicaid Related Service or Medicaid Covered Service appointment.
“Interpreting” means the process by which a neutral third party facilitates communication between speakers of different
languages, those who are deaf, deaf-blind, or hearing impaired including signing and translating.
“Interpreting Agencies” means entities or companies with whom the Contractor subcontracts for Interpreting, including
signing and translating, under this Agreement.
“LEP Client” means a person who has a limited ability or an inability to speak, read, or write the English language well
enough to understand and communicate effectively; or is deaf, deaf-blind, or hearing impaired; and who may be either a
LEP Other Client or a LEP Medicaid Client.
“LEP Medicaid Client” means a person who is a LEP Client and has been determined to be eligible to receive Medicaid
Covered Services.
“LEP MER” or “LEP Medicaid Eligibility Rate” means the total unduplicated number of LEP Medicaid Clients
served during a Billing Quarter divided by the total unduplicated number of LEP individuals seen during the same
Quarter.
“LEP Other Client” means a person who is a LEP Client and has been determined not to be eligible for Medicaid
Covered Services, but receives Medicaid Related Services.
“Limited Casualty – Medically Needy Program” or “Medically Needy Program” or “MN” means the state and
federally funded Medicaid program for aged, blind, or disabled Medicaid Clients, as well as pregnant women, children
and refugees with income and/or resources above CNP limits.
“Limited English Proficient” or “LEP” means a limited ability or inability to speak, read, or write the English
language well enough to understand and communicate effectively, including deaf, deaf-blind, or hearing impaired.
“Local Match Certification Form” means DSHS form 06-155 Local Match Certification used to report Local
Matching Funds information to HRSA annually.
“Local Match Worksheet” means a worksheet to accompany the Local Match Certification Form used to identify the




                                                          - 64 -
type and source of funds certified as Local Matching Funds.
“Local Matching Funds” means financial support provided by the Contractor that:
        Is revenue received by the Contractor from sources other than DSHS, charitable organizations, Enrolled
         Providers (other than nonfederal revenue provided by health plans and health maintenance organizations to the
         public hospital organization for patient services rendered), or federal governmental agencies;
        Is designated/certified to match the FFP rate of reimbursement;
        Has not and will not be used as matching funds under other federal programs;
        Meets other applicable federal funding regulations; and
        The Contractor has included in its budget and within its control.
“MAM Program” or “Medicaid Administrative Match Program” means the program within the Division of
Healthcare Services, Health and Recovery Services Administration, Washington State Department of Social and Health
Services.
“MAM Program Manager” or “HRSA MAM Program Manager” means the DSHS/HRSA/MAM Contact identified
on page one (1) of this Agreement, or successor Agreement.
“Manual” or “Public Hospital Medicaid Administrative Match Interpreter Services Manual” means the manual or
successor manual wherein required time tracking/ time study processes and billing processes for the State of Washington
Public Hospital Medicaid Administrative Match Interpreter Services Program are provided.
“Matchable Activity” means an activity performed by the Contractor’s Eligible Interpreting Staff or Eligible
Designated Support Staff or an Independent Interpreter or Independent Interpreting Agency that meets the description of
a Medicaid reimbursable activity as provided in the Manual.
“Medicaid” or “Medicaid Program” means the Categorically Needy Program, CNP, or the Limited Casualty –
Medically Needy Program, LC-MNP or MN, or other federal Medicaid programs of HRSA, specifically excluding the
following programs:
        G01 (without CNP) (19) – General Assistance – Unemployable (GA-U);
        W01 and W02 – Alcoholism and Drug Addiction Treatment and Support Act (ADATSA);
        F08 – Children’s Health Program (CHP);
        M99 – Psychiatric Indigent Inpatient (PII);
        F07 – State Children’s Health Insurance Program (S-CHIP); and
        That portion of services provided to clients eligible under the Alien Emergency Medical (AEM) Program that
         are not Medicaid Covered Services.
“Medicaid Client” or “LEP Medicaid Client” means a person who has been determined to be eligible to receive
Medicaid Covered Services.
“Medicaid Client Interpreter Service Encounter” means an Interpreter Service Encounter arranged by the Contractor
to run concurrent with an appointment to provide a Medicaid Covered Service to a LEP Medicaid Client. The encounter
also includes time spent providing necessary interpreting services before and/or after the LEP Client’s Medicaid Related
Service or Medicaid Covered Service appointment.
“Medicaid Covered Service” means a service within the scope of care of the Medicaid Client’s medical assistance
program, and is covered under the Medicaid State Plan.
“Medicaid Related Service” means a service related to medical, dental, mental health, substance abuse prevention or
treatment, or family planning services, that is covered under the Medicaid State Plan.
“Medicaid Related Service Rates” means both of the following calculations, respective to the time units being
considered:
    1.   “Proportional Medicaid Related Service Rate” or “PM Medicaid Related Service Rate”, which is equal to
         Proportional Medicaid (PM) units divided by the Total Time (TT) units (PM ÷ TT), and
    2.   “Total Medicaid Related Service Rate” or “TM Related Service Rate”, which is equal to Total Medicaid (TM)




                                                           - 65 -
        units divided by Total Time (TT) units (TM ÷ TT).
“Medicaid State Plan” means the officially recognized statement describing the nature and scope of Washington State’s
Medicaid program. It is Washington State’s agreement with DHHS that it will conform to the requirements under
Section 1902 of the Social Security Act and the official issuances of DHHS.
“Non-allowable Activity” means a Contractor’s Eligible Interpreting Staff or Eligible Designated Support Staff or an
Independent Interpreter or Independent Interpreting Agency activity that does not meet the description of a “Matchable
Activity”.
“Subcontractor” means an Independent Interpreter or an Interpreting Agency that has a contract with the Contractor to
provide interpreting services, including signing and translating, under this Agreement.
“Time Tracking Sheet” or “24 Hour Time Study Form” or “Time Study Form” means the form where the
Contractor’s Eligible Designated Support Staff and/or Eligible Interpreting Staff record the required data to document
the amount of time spent performing Matchable Activities and Non-allowable Activities for paid time and non-paid time
on a work day when time tracking occurs.




                                                         - 66 -
- 67 -

								
To top