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MONTHLY LME REPORT OF EXPENDITURES
(NOTE: ONLY cost for LME functions are to be reported on this form. Instructions and transmittal memo dated 3/30/06 accompany this form)
Name of LME: Report Month/Year:
1 2 3 4 5 6 7 8
Current Job SPMP % of Time in
SPMP LME Description or Status Activities
Position Employee (E) Function Contract On File: Verified: Requiring Total Monthly
Category of Expenditure/Cost Category or Contract (C) Performed Yes Yes an SPMP Cost
Part 1: Total expenditures for Claims Processing, less
purchase of equipment or other depreciable assets. 0.00
Part 2: Salary & Fringe Benefits Cost of Skilled
Professional Medical Personnel and their direct clerical
support staff (list individually for SPMPs; aggregate
clerical support FTEs):
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
# of Employee FTEs in Clerical Support of SPMPs: Support E Clerical 0.00
# of Contract FTEs in Clerical Support of SPMPs: Support C Clerical 0.00
Subtotal - SPMP and Related Clerical Support Cost 0.00
Part 3: All other expenditures, less purchase of
equipment of other depreciable assets 0.00
Part 4:
Monthly Depreciation 0.00
Monthly Indirect Cost 0.00
Total Expenditures/Cost 0.00
I certify that the above accounting represents the true cost as reflected in the official accounting records of the agencies for the time period covered by this report
I further certify that the expenses reported for Skilled Professional Medical Personnel (SPMP) represent only the portion of their time and cost which require the
service of an SPMP and the agency has on file documentation of each SPMP's functions and documentation that each reported SPMP meets the qualifications of an
SPMP. The data in this report is supported by timesheets and other auditable documentation. Positions or FTEs reported as contracted have signed contracts on
file between the LME and the contracted agency or individual.
Signature LME Finance Officer: Date: Phone:
Reporting Instructions: Monthly LME Report of Expenditures (DRAFT)
These instructions are to be used in conjunction with the transmittal memo date January xx, 2006
Header: Enter name of reporting LME and the month and year of the expenditures/cost being reported.
Part 1: Enter total expenditures for Claims Processing, less purchase of equipment and depreciable assets associated with Claims Processing.
Part 2: SPMP cost and their direct clerical support staff cost. Cost for SPMPs and clerical support in Part 2 are limited to salary and fringe only.
Other cost for these staff such as travel, supplies, etc., must be listed in Part 3.
Column 1: a. Enter the name of each qualifying SPMP.
b. For clerical support, enter the FTE count of clerical and contracted clerical support staff which directly support the SPMPs listed on
the report. Example, if there are 3 full-time clerical support positions which support the reported SPMPs and each clerical support position
spends 20% of their time in these functions, the FTE count would be .60 (3 positions x 20% = .60 FTE).
The same FTE reporting example applies for clerical support staff which may be contracted.
Column 2: Enter the appropriate acronym for the SPMP position category from the list below. If you have questions about reporting an
SPMP not listed below, please contract Mary Tripp at 919-881-2446 or via e-mail at Mary.Tripp@ncmail.net
MD = M.D. or D.O. LPA = Licensed Psychological Associate LCSW = Licensed Clinical Social Worker
PE = Physician Extender* LPC = Licensed Professional Counselor P-LCSW = Provisional Licensed Clinical Social Worker
NR = Nurse** LCAS = Licensed Clinical Addictions Specialist *PE includes Physician Asst. & Nurse Practitioner
LP = Licensed Psychologist CCS = Certified Clinical Supervisor ** NR = RNs, Psy. Nurse Practitioner & Certified Nurse Spec.
Column 3: a. SPMPs:
Indicate whether the SPMP reported is an Employee (E) or a Contractor (C). If reported as a contractor, the LME must have a current
contract on file with another public agency for the services of the contracted SPMP.
b. Clerical Support:
The term "Support" has been pre-entered on the form to indicate the position category is clerical support.
Column 4: For SPMP positions, indicate the LME function performed from the following list. More than one function may be listed for an SPMP
if they perform multiple functions which are reportable in Part 2.
A = Access, Screening, Triage and Referral
P = Provider Relations and Support
S = Service Management
C = Customer Services
For clerical support, the term "Clerical" has been pre-entered.
Column 5: Indicate whether a current job description or contract is on file for allowable LME functions requiring an SPMP:
a. For SPMPs:
i. Enter Yes if such a job description is on file. If No, cost must be reported in Part 3 and NOT in Part 2.
ii. For contracted SPMPs, enter Yes to indicate whether the scope of work within the contract sets forth the allowable functions
(those indicated in Column 4 above) the SPMP will perform on behalf of the LME. If No, cost must be reported in Part 3
and NOT in Part 2.
b. For Clerical Support:
i. Enter Yes if such a job description is on file. If No, cost must be reported in Part 3 and NOT in Part 2.
ii. For contracted clerical support, enter Yes to indicate if the scope of work in the contract sets forth the clerical duties.
If No, cost must be reported in Part 3 and NOT in Part 2.
Column 6: For SPMPs only: Indicate if the individual's status as an SPMP has been verified by entering Yes. If the answer is No, the cost
must be included in Part 3 rather than Part 2. This applies to both SPMP employees and contracted SPMPs.
Column 7: a. SPMPs: Enter the percent of time the individual performed functions reported in Column 4.
b. Clerical Support: No entry is necessary; this is accounted for in determining the reportable FTEs in Column 1.
Column 8: Enter the total reportable monthly cost for the respective lines as outlined on the report. For cost associated with SPMPs and clerical
support for the SPMPs, cost are limited on to the cost of salary and fringe benefits associated with the employee or contractor.
Part 3: With the exception of Monthly Depreciation and Monthly Indirect Cost, enter all other allowable monthly LME systems management
cost not otherwise reported in Parts 1 and 2.
Part 4: Enter the monthly expenditures/costs associated with Depreciation and Indirect Cost.
Signature: Read the certification statement. Form is to be signed by the Finance Officer and dated, and the phone number included.
MONTHLY LME REPORT OF EXPENDITURES
(NOTE: ONLY cost for LME functions are to be reported on this form. Instructions and transmittal memo date 1/xx/06 accompany this form)
Name of LME: Coastal Human Services Report Month/Year: March 2006
1 2 3 4 5 6 7 8
Current Job SPMP % of Time in
SPMP LME Description or Status Activities Total Monthly
Position Employee (E) Function Contract On File: Verified: Requiring Cost (Salary +
Category of Expenditure/Cost Category or Contract (C) Performed Yes Yes an SPMP Fringe Only)
Part 1: Total expenditures for Claims Processing, less
purchase of equipment or other depreciable assets. 11,563.89
Part 2: Salary & Fringe Benefits Cost of Skilled
Professional Medical Personnel and their direct clerical
support staff (list individually for SPMPs; aggregate
clerical support FTEs):
Nancy Smith MD E A Yes Yes 100.00% 14,583.00
Bob Green NR E A, S Yes Yes 50.00% 2,083.00
Alice White LCSW C P, C Yes Yes 75.00% 2,812.50
Jim Blue LP E S Yes Yes 100.00% 4,166.66
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
# of Employee FTEs in Clerical Support of SPMPs: 1.0 Support E Clerical Yes 2,291.66
# of Contract FTEs in Clerical Support of SPMPs: .5 Support C Clerical Yes 958.33
Subtotal - SPMP and Related Clerical Support Cost 26,895.15
Part 3: All other expenditures, less purchase of
equipment of other depreciable assets 125,000.00
Part 4:
Monthly Depreciation 2,500.00
Monthly Indirect Cost 1,700.00
Total Expenditures/Cost 167,659.04
I certify that the above accounting represents the true cost as reflected in the official accounting records of the agencies for the time period covered by this report
I further certify that the expenses reported for Skilled Professional Medical Personnel (SPMP) represent only the portion of their time and cost which require the
service of an SPMP and the agency has on file documentation of each SPMP's functions and documentation that each reported SPMP meets the qualifications of an
SPMP. The data in this report is supported by timesheets and other auditable documentation. Positions or FTEs reported as contracted have signed contracts on
file between the LME and the contracted agency or individual.
Signature LME Finance Officer: Date: Phone:
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