DOCUMENTATION BILLING TRAINING FOR INDEPENDENT …

NORTH EAST OHIO NETWORK

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DOCUMENTATION &

BILLING TRAINING FOR INDEPENDENT PROVIDERS

CONTENTS__________________________________________

EXAMPLE OF WAIVER SERVICE DELIVERY DOCUMETNATION

PROVIDER BILLING

BILLING INFORMATION AT A GLANCE

IMPORTANT TO REMEMBER FOR BILLING

NAVIGATING THE PROVIDER PAGE

IMPLEMENTATION GUIDELINES

COMPLETE SET OF FORMS

SERVICE DOCUMENTATION ODODD Administrative Rule 5123: 2-9-06

The Service Documentation rule describes the requirements for services provided to individuals receiving services funded by a Medicaid Waiver.

The following elements must be part of Service Documentation:

1. Date of Service 2. Place of Service 3. Name of Recipient 4. Recipient Medicaid number 5. Name of Provider 6. Provider contract number 7. Signature of Provider 8. Type of Service being provided 9. Number of Units delivered 10. Group Size (ratio) 11. Time-in & Time-out 12. A description of the service 13. Frequency & Duration

Reimbursements made to the Provider for services delivered that does not include the required elements may be recovered by the Ohio Department of Developmental Disabilities.

Service Documentation must be made available upon request to any agency with the authority to review such records.

Keep the Service Documentation for 7 years.

Rev. 1/14

Homemaker Personal Care (HPC) ? WAIVER SERVICE DELIVERY DOCUMENTATION ? Cuyahoga County

CONSUMER NAME: ADDRESS of SERVICE:

MEDICAID #: RESIDENT #:

PROVIDER: PROVIDER #: SERVICE MONTH: __________

YEAR: _

____

***SERVICES ARE ROUTINE HPC UNLESS OTHERWISE INDICATED AS ON-SITE/ON CALL OR LEVEL ONE EMERGENCY***

DATE

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Time In

Time out

# of Units

# OF INDIVIDUALS SHARING SUPPORTS , if

other than 1:1.

Supports in Plan Duration / Frequency

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*ALL SERVICES ARE PROVIDED IN THE PERSON'S HOME UNLESS OTHERWISE NOTED BELOW. R indicates consumer refused service.

DATE

Service locations if other than home, problems delivering services, refusal, unusual incidents & reasons, etc.

SIGNATURE: Prepared by AggieG 04/26/12

_____________

______

INITIALS:

DATE:

Homemaker Personal Care (HPC) ? WAIVER SERVICE DELIVERY DOCUMENTATION ? Cuyahoga County

CONSUMER NAME: ADDRESS of SERVICE:

MEDICAID #: RESIDENT #:

PROVIDER: PROVIDER #: SERVICE MONTH: __________

YEAR: _

____

DATE Time In

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Time out

Time In

Time out

Total # of Units

1:1 ratio, unless otherwise noted Supports in Plan Duration / Frequency

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