Quarterly LOS Reporting Form for Out of Home Services by NewJersey

VIEWS: 0 PAGES: 3

									                                                                                                     STATE OF NEW JERSEY
                                                                                         DEPARTMENT OF CHILDREN AND FAMILIES
                                                                               Quarterly Level of Service (LOS) and Accounts Receivable Report

          Agency Name:                                                                                                                                                Contract Term:
     Contract Number:                                                                                                                                 Medicaid Provider Number:
         Report Period:                                             Year:                                                                                           Program Name(s):
          Contract Year:
                               Indicate if reporting on 1st year or 2nd year
                               if contract is renewed every two years

     COMPLETE THE FOLLOWING FOR SERVICES UNDER THIS CONTRACT
     RELATING TO THE ABOVE CONTRACT TERM:


                                                                                Maximum
                                                                                                                                                       Amount
       Contract       # of      Contracted             #      # of Actual
                                                                                 Monthly                                                Amount         Billed for
                                                                                                                                                                                                               Differential/
       Month of      Days in     Per Diem         Contracted     Slots          Contracted    Actual Units Utilization   Cumulative     Billed for     Runaway                         Maximum Monthly      Funding Impact to                 YTD Accounts
       Service       Month         Rate           Slots (LOS)    Filled           Units       of Service* Percentage     Percentage   Hospital Days      Days           Total Billed   Contracted Ceiling       Contract                       Receivable

     Sample            30         $200.00              12            11            360             340         94%         94%           $500          $1,000           $69,500.00        $72,000.00            $2,500.00                 $         2,000.00

1                                                                                   0                                       0%                                             $0.00             $0.00                $0.00

2                                                                                   0                                       0%                                             $0.00             $0.00                $0.00

3                                                                                   0                                       0%                                             $0.00             $0.00                $0.00         1st Qtr
4                                                                                   0                                       0%                                             $0.00             $0.00                $0.00

5                                                                                   0                                       0%                                             $0.00             $0.00                $0.00

6                                                                                   0                                       0%                                             $0.00             $0.00                $0.00         2nd Qtr
7                                                                                   0                                       0%                                             $0.00             $0.00                $0.00

8                                                                                   0                                       0%                                             $0.00             $0.00                $0.00
9                                                                                   0                                       0%                                             $0.00             $0.00                $0.00         3rd Qtr
10                                                                                  0                                       0%                                             $0.00             $0.00                $0.00
11                                                                                  0                                       0%                                             $0.00             $0.00                $0.00
12                                                                                  0                                       0%                                             $0.00             $0.00                $0.00         4th Qtr

                         0                       TOTAL                    0             0                        0%          $0.00         $0.00              $0.00                          $0.00               $0.00
     * Include actual service days and therapeutic days only. Hospital days and runaway days are tracked separately.
     This report is being completed for the above contract on a quarterly basis by Medicaid provider number. The above information should only be provided for those
     units that are contracted and billed to Medicaid via the Unysis Payment System. Further the information, regarding actual slots, must be consistent with and reflect
     actual children in the Absolute system through the CSA. This report is being submitted as an addendum to reporting requirements that are required within the Annex B-
     2.
     I certify that the above information is accurate and reflects a true reporting of the information being requested.

     Prepared By:                                                                                 Date:

     Title:                                                                                   Phone No:

     Agency Address:                                                                     E-Mail Address:




                                                                                                                                  Year 1
                                                                                                     STATE OF NEW JERSEY
                                                                                         DEPARTMENT OF CHILDREN AND FAMILIES
                                                                               Quarterly Level of Service (LOS) and Accounts Receivable Report

          Agency Name:                                                                                                                                                Contract Term:
     Contract Number:                                                                                                                                 Medicaid Provider Number:
         Report Period:                                             Year:                                                                                           Program Name(s):
          Contract Year:
                               Indicate if reporting on 1st year or 2nd year
                               if contract is renewed every two years

     COMPLETE THE FOLLOWING FOR SERVICES UNDER THIS CONTRACT
     RELATING TO THE ABOVE CONTRACT TERM:


                                                                                Maximum
                                                                                                                                                       Amount
       Contract       # of      Contracted             #      # of Actual
                                                                                 Monthly                                                Amount         Billed for
                                                                                                                                                                                                               Differential/
       Month of      Days in     Per Diem         Contracted     Slots          Contracted    Actual Units Utilization   Cumulative     Billed for     Runaway                         Maximum Monthly      Funding Impact to                 YTD Accounts
       Service       Month         Rate           Slots (LOS)    Filled           Units       of Service* Percentage     Percentage   Hospital Days      Days           Total Billed   Contracted Ceiling       Contract                       Receivable

     Sample            30         $200.00              12            11            360             340         94%         94%           $500          $1,000           $69,500.00        $72,000.00            $2,500.00                 $         2,000.00

1                                                                                   0                                       0%                                             $0.00             $0.00                $0.00

2                                                                                   0                                       0%                                             $0.00             $0.00                $0.00

3                                                                                   0                                       0%                                             $0.00             $0.00                $0.00         1st Qtr
4                                                                                   0                                       0%                                             $0.00             $0.00                $0.00

5                                                                                   0                                       0%                                             $0.00             $0.00                $0.00

6                                                                                   0                                       0%                                             $0.00             $0.00                $0.00         2nd Qtr
7                                                                                   0                                       0%                                             $0.00             $0.00                $0.00

8                                                                                   0                                       0%                                             $0.00             $0.00                $0.00
9                                                                                   0                                       0%                                             $0.00             $0.00                $0.00         3rd Qtr
10                                                                                  0                                       0%                                             $0.00             $0.00                $0.00
11                                                                                  0                                       0%                                             $0.00             $0.00                $0.00
12                                                                                  0                                       0%                                             $0.00             $0.00                $0.00         4th Qtr

                         0                       TOTAL                    0             0                        0%          $0.00         $0.00              $0.00                          $0.00               $0.00
     * Include actual service days and therapeutic days only. Hospital days and runaway days are tracked separately.
     This report is being completed for the above contract on a quarterly basis by Medicaid provider number. The above information should only be provided for those
     units that are contracted and billed to Medicaid via the Unysis Payment System. Further the information, regarding actual slots, must be consistent with and reflect
     actual children in the Absolute system through the CSA. This report is being submitted as an addendum to reporting requirements that are required within the Annex B-
     2.
     I certify that the above information is accurate and reflects a true reporting of the information being requested.

     Prepared By:                                                                                 Date:

     Title:                                                                                   Phone No:

     Agency Address:                                                                     E-Mail Address:




                                                                                                                                  Year 2
                                               Instructions for Completing Annex B-2 Service Report



                                   Please utilize the Annex B2 for reference in completing this form

General
The Quarterly report must be completed electronically. There are two tabs for contracts which renew every two years. Please use
corresponding tabs accordingly.

Submission Requirements

This is a cumulative report and is to be submitted by the 10th day of the month following the end of the quarter. For
example, if contract term is July to June, reports are due on October 10, January 10, April 10 (and as the annual LOS
report) on July 10. Reports are to be submitted electronically to your contract administrator and to Ruby.Goyal-
Carkeek@dcf.state.nj.us.
Step by Step Instructions

                      Agency Name       Indicate agency name as listed in executed contract package and Annex B2

                   Contract Number      Number assigned to contract by Department of Children and Families as
                                        listed on contract Annex B-2
                                        (two digit number representing state fiscal year of contract commencement followed by
                                        4 alpha characters, which are the unique identifier assigned to contract and do not change
                                        year to year)

                      Report Period     Period for which agency is reporting at time of submission. This is a cumulative report so
                                        information regarding other reporting periods will already be listed. Make selection of Reporting
                                        Period and Year from items listed in drop down menu

                     Contract Term      Indicate term of contract that corresponds to report and contract number

                      Contract Year     Indicate if first or second year of contract term

          Medicaid Provider Number      Report is to be completed by Medicaid provider number and should correspond to
                                        number used to bill for the service to the program/component, as found
                                        on Annex B-2

                     Program Name       List program name (s) as listed on Annex B2 assigned to this Medicaid provider number

          Contract Month of Service     This is a cumulative report and first month listed should correspond to the first month of
                                        the contract. Select month from drop down.

           Number of Days in Month      Select number of days from drop down for month listed in adjacent column

          Contracted Per Diem Rate      Contract rate for program/component, as found on Annex B-2.

                  # Contracted LOS      The total amount of the contracted level of service, i.e slots, as listed on Annex B-2

             # of Actual Slots Filled   Number of actual slots filled under Medicaid Provider Number. Note: If one child left on
                                        October 10, and another child started October 11, this counts as one slot. As actual
                                        number of children can fluctuate throughout the month, please place the number that
                                        indicates the most frequency(mode) (ex. 9 slots filled for 25 days, 3 slots filled for 2 days
                                        and 8 for 3 days--you would place 9 slots as your actual).


Maximum Monthly Contracted Units        Formula is automatically calculated and represents the maximum number of contracted
                                        units allowable per month.
                                        Example: Number of contracted LOS is 5 and the amount of days in the month of June is 30 -
                                        5 x 30=150 maximum monthly contracted units

            Actual Units of Service     The actual number of units; this is the number that is used to bill Medicaid; include
                                        therapeutic leave days as actual units of service; do not include hospital days or runaway

    Amount Billed for Hospital Days     Indicate total amount billed for hospital days per month

   Amount Billed for Runaway Days       Indicate total amount billed for runaway days per month

          YTD Accounts Receivable       Indicate payment due to your agency by quarter




     Please indicate who the report was prepared by and related contact information

								
To top