Student Support Services Project



Medicaid Certified School Match Quality Review ChecklistDocuments submitted must support the review periodOriginals cannot be acceptedProviders must submit the following documentation (in this order): ____ Direct service documentation supporting the randomly sampled Fee-for-service claim:Evaluation report and any additional documentation/observation notesTherapy/session notes, including student progress notesBehavioral services record/session notesNursing service notes/medication administration logTransportation trip log and corresponding documentation for Medicaid service provided____ IEP/POC that encompasses the date being reviewed____ Previous IEP/POC (or subsequent IEP, if IEP for the review date was the initial IEP)____ Most recent medical evaluation/assessment related to claim service type (if service records requested are for an evaluation claim, please include the prior evaluation, if applicable)____ Original prescriptions (as applicable)____ Professional licenses/certificates for all treating providers related to claim service type requested for review (for example: OT, OTA and original evaluating OT, if different)____ Contract or agreement with local health department to provide nursing services, if applicable____ Contract or agreement with local behavioral services organization, if applicable____ Electronic signature policy____ Copy of the policy that describes the security procedures in place to prevent unauthorized use if electronic documentation and signatures are usedPlease do not staple or affix sticky notes/tabs to documents, as all records will be scanned into our system for records retention purposes (district may use highlighter to mark pertinent sections of records). Organize all documentation by claim (including provider licenses). ................
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