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INSTRUCTIONS FOR COMPLETING

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					                                                                                                         Performance Contract
                                                                                                       SAMH Services Program



                                       INSTRUCTIONS FOR COMPLETING
                                                 EXHIBIT E-1 and E-2
                                  WORKSHEET FOR REQUEST FOR PAYMENT

 Follow the procedures below when completing the worksheet for request for payment.
 The department may advance funds one month at a time for up to the first three months of a contract period based on
 documented and anticipated cash needs of the contractor unless the Department of Financial Services has approved an
 extended period of time. If advances are approved by the department, the worksheet should not be completed.
 *For cost centers paid for on the basis of utilization, Column D & J MUST NOT BE > than, and Column E
 MUST NOT BE < than, the # of units reported to the MHSA Data Warehouse.
 Column B ........... Hide the Activities and Cost Centers NOT included in the contract with DCF by selecting the row
                      or rows to Hide, right clicking the mouse, and selecting "hide" from the pull-down menu.
 Column C........... Enter the state unit cost rate from the Exhibit G for each Cost Center listed in Column B.
 Column D........... Enter the total Y-T-D number of units provided to enrolled clients and non-client-specific units.
                   Represents the Y-T-D units provided which are billable to Medicaid, local match, or the
                   department.
                   Units provided in cost centers paid for on the basis of availability shall be calculated as follows:
                   - For staff hours, enter the total Y-T-D staff hours actually provided based on duty rosters and the
                   Y-T-D units provided which are billable to Medicaid, local match, and the department.
                   - For bed-days, enter the result of the number of bed-days specified on Exhibit A of the contract
                   divided by the number of months in the contract times the number of months since the beginning of
                   the contract period (including the month covered by this request for payment) and the Y-T-D units
                   provided which are billable to Medicaid and local match.
                   - For facility days, enter the Y-T-D actual number of days the facility has been open for client
                   services for at least 4 hours.
                   -For those cost centers paid for on the basis of utilization, the number of units specified in Column
                   D shall not exceed the units reported by the contractor in the department’s substance abuse and
                   mental health data warehouse pursuant to the requirements of section 65E-14.022, F.A.C.
                   -For cost centers paid for on the basis of bed day or facility day availability, the year-to-date
                   number of units reported shall not exceed the prorated share of contracted units.
Column E............. Enter the total Y-T-D number of units actually provided to enrolled clients that are billable to
                      Medicaid, whether they have been billed to or paid for by Medicaid. "Billable to Medicaid"
                      includes those units which are eligible for Medicaid payment, have already been billed to Medicaid
                      and awaiting determination; or those service units which have already been paid by Medicaid.
                   -Medicaid funds paid through an HMO or MCO should also be reported in this column.
                   -Medicaid units paid through the CCST cost center should be deducted on a unit per unit basis.
                   For the purpose of documenting and reporting, units of service billed to Medicaid shall represent
                   the actual documented duration of the billable event, except in the Crisis Stabilization Unit,
                   Substance Abuse Detox, and Short-term Residential cost centers where the licensed bed-day
                   capacity does not exceed 16 beds. In these cost centers, the total YTD amount billed to Medicaid
                   shall be divided by the provider’s contracted unit cost rate to convert the billable Medicaid dollar
                   amount to comparable service event units to be deducted in the invoice process. For example, if the
                   provider’s contracted unit cost rate for a CSU bed-day is $250.00 and the contractor bills Medicaid
                   YTD for $6,000 for one or more discrete services, divide $6,000 by $250.00 to get 24 units. This
                   number should be entered into column E. If Column E is greater than Column D, 0 units will be
                   paid by the department.

                   If a unit billed to Medicaid is denied for payment but is otherwise eligible for payment by the
                   department, that unit may then be billed to the department.

 Rev.07/01/10                                                Page 1 of 2                                               PSMAI No. HC02
                                                                                                        Performance Contract
                                                                                                      SAMH Services Program



                  For those cost centers paid for on the basis of utilization, the number of units specified in Column
                  E shall not be less than, the units reported by the contractor in the department’s substance abuse and
                  mental health data warehouse pursuant to the requirements of section 65E-14.022, F.A.C.
Column F ........... Enter the total Y-T-D number of units provided to enrolled clients and non-client-specific units that
                     have been paid for by local matching funds.
                  [Local matching funds include patient fees from first-, second-, and third-party payers as well as
                  any other revenue sources that are eligible as local match.]
                  Where local matching revenues are earned in a cost center on some basis other than units of service
                  provided, revenues are converted to units by dividing the revenues earned by the cost center’s
                  contracted unit rate.
                  Column F does not represent all of the contractor’s local matching funds, only those earned in cost
                  centers funded by the department’s Substance Abuse and Mental Health Programs.
                  Please Note: Second party payers include representative payees and trustees, not as individuals, but
                  in the fiduciary capacity for handling benefit payments, trusts and estates established or received for
                  the financial support of the client.
Column G .......... The spreadsheet will subtract the sum of Columns E and F from Column D.
                  Represents the Y-T-D units provided which are billable to the department under the contract.
Column H .......... The Spreadsheet will subtract Column J from Column G. This is the Y-T-D Non-TANF units
                    eligible to be billed to SAMH.
                  Represents a sub-set of Column G. (Columns H and J should equal Column G)
Column I ............ The spreadsheet will multiply Column C times Column H.
                  Represents the Y-T-D maximum amount of non-TANF funds that have been earned for services
                  provided that are eligible for payment under the contract.
                  For each Cost Center, the spreadsheet will transfer the dollar amount in Column I to Exhibit E-1,
                  Part 1, Column 3, per the instructions provided for that form.
Column J ........... Enter the Y-T-D TANF units eligible to be billed to SAMH.
                  Represents a sub-set of Column G. (Columns H and J should equal Column G)
                  For those cost centers paid for on the basis of utilization, the number of units specified in Column J
                  shall not exceed the TANF units reported by the contractor in the department’s substance abuse and
                  mental health data warehouse pursuant to the requirements of section 65E-14.022, F.A.C.
                  For cost centers paid for on the basis of bed day and facility day availability, the year-to-date
                  number of units reported shall not exceed the prorated share of contracted units.
Column K .......... The spreadsheet will multiply Column C times Column J.
                  Represents the Y-T-D maximum amount of TANF funds that have been earned for services provided
                  that are eligible for payment under the contract.
                  For each Cost Center, the spreadsheet will transfer the dollar amount in Column K to Exhibit E-2,
                  Part 1, Column 3, per the instructions provided for that form.




Rev.07/01/10                                                 Page 2 of 2                                              PSMAI No. HC02

				
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