Community Pathways Waiver Behavioral Support Services Detailed Service Report (DSR) Template Instructions- Effective 7/1/21
      For Provider payment of Behavioral Support Services (BSS), all complete and accurate monthly invoices for services shall be signed by the Provider and submitted electronically to the DDA 
      Regional Office no later than the end of the month following the month in which service was provided. The required backup documentation for the invoice should be 1) a Detailed Service 
      Report (DSR) and 2) federal billing claim forms or the remittance advice for claims submitted directly to Medicaid.
      Invoices submitted without the backup documentation will not be processed for payment until the Provider submits the required information. 
      The amount of the invoice and payment shall be the total of itemized services reflected in the Detailed Service Report.  
       
      To capture federal funding for Behavioral Services, providers will submit HFCA 1500 forms or submit electronic claims directly to Medicaid for all services provided to individuals enrolled in the 
      DDA Community Pathways Waiver. Providers may verify participant eligibility using PCIS2, LTSSMaryland or Medicaid’s EVS system at https://encrypt.emdhealthchoice.org/emedicaid/. 
      Providers may acquire billing software or use a third-party billing service to submit the federal claims directly to Medicaid. The Provider shall comply with applicable laws and regulations 
      governing the secure electronic submission of billing claims. Information on HIPAA Electronic Claims Submission can be found at https://dda.health.maryland.gov/Pages/Federal
      %20Billing.aspx. The Provider shall have a process for resolving invoice and federal billing errors and discrepancies in a timely manner.
      DSR Template Instructions
      1) This template should be used to record services for individuals in the Community Pathways Waiver or State-Funded BSS services.  Information can only be entered into unshaded 
      cells. Shaded cells contain formulas and are locked.
      2) The name and address fields should be completed and are self-explanatory.
      3) The MA# is the individual's 11 digit Medical Assistance number. If the  MA# begins with a 0, it must be typed as the field requires exactly 11 digits or you will get an error.
      4) CP Waiver?- If the person is in the Community Pathways Waiver enter Yes. Enter No if not eligible for the CP Waiver.  1500 forms do not need to be submitted for services provided to 
      individuals that are not in the Waiver. This invoice should not be used to bill for individuals in the FSW and CSW programs.
      5) Date of Service- Only dates of service from 7/1/21 through 6/30/22 can be entered on this form. Only one date of service for the same service for the same individual should be billed. All 
      units of a service provided to a person on a date of service should be added together and billed on one line or it's considered a duplicate claim. 
      6) Service Type- Choose the service from the drop-down list and it will populate the Procedure Code and Unit Rate for the service. ATTENTION: Yellow highlighted rows are duplicate claims. 
      Please correct the information in the row to resolve the duplicate claim error.
      Procedure Code (locked)- This code is populated by the Service Type selected and should be entered in field 24D on the 1500 forms for services provided to Waiver eligible individuals.
      7) Unit Rate (locked)- The FY22 rate for the service is populated by the Service Type selected.
      8) # of Units- Units must be entered in this field to calculate the Total Charges for the service. Only whole numbers are allowed. (BCS and BSIS are billed in 15 minute increments, so if 2 1/2 
      hours of service are provided, you would enter 10 units, etc.) The unit for BAS and BP is always 1. A maximum of 32 units (8 hours)  may be entered for BCS and BSIS as this is the daily service 
      limit that may be provided in a day for an individual.  
      9) Total Charges (locked)- This amount is populated by the Unit Rate multiplied by the # of Units that are entered. Please remember to enter a 1 for the # of Units for BAS and BP or no charges 
      will be included.
      A table has been added to calculate the number of units entered on the sheet for each service. These amounts would be entered on the invoice to bill for services included on this DSR.
Community Pathways Waiver Behavioral Support Services Detailed Service Report (DSR) Template Instructions- Effective 7/1/21
For Provider payment of Behavioral Support Services (BSS), all complete and accurate monthly invoices for services shall be signed by the Provider and submitted electronically to the DDA 
Regional Office no later than the end of the month following the month in which service was provided. The required backup documentation for the invoice should be 1) a Detailed Service 
Report (DSR) and 2) federal billing claim forms or the remittance advice for claims submitted directly to Medicaid.
Invoices submitted without the backup documentation will not be processed for payment until the Provider submits the required information. 
The amount of the invoice and payment shall be the total of itemized services reflected in the Detailed Service Report.  
 
To capture federal funding for Behavioral Services, providers will submit HFCA 1500 forms or submit electronic claims directly to Medicaid for all services provided to individuals enrolled in the 
DDA Community Pathways Waiver. Providers may verify participant eligibility using PCIS2, LTSSMaryland or Medicaid’s EVS system at https://encrypt.emdhealthchoice.org/emedicaid/. 
Providers may acquire billing software or use a third-party billing service to submit the federal claims directly to Medicaid. The Provider shall comply with applicable laws and regulations 
governing the secure electronic submission of billing claims. Information on HIPAA Electronic Claims Submission can be found at https://dda.health.maryland.gov/Pages/Federal
%20Billing.aspx. The Provider shall have a process for resolving invoice and federal billing errors and discrepancies in a timely manner.
DSR Template Instructions
1) This template should be used to record services for individuals in the Community Pathways Waiver or State-Funded BSS services.  Information can only be entered into unshaded 
cells. Shaded cells contain formulas and are locked.
2) The name and address fields should be completed and are self-explanatory.
3) The MA# is the individual's 11 digit Medical Assistance number. If the  MA# begins with a 0, it must be typed as the field requires exactly 11 digits or you will get an error.
4) CP Waiver?- If the person is in the Community Pathways Waiver enter Yes. Enter No if not eligible for the CP Waiver.  1500 forms do not need to be submitted for services provided to 
individuals that are not in the Waiver. This invoice should not be used to bill for individuals in the FSW and CSW programs.
5) Date of Service- Only dates of service from 7/1/21 through 6/30/22 can be entered on this form. Only one date of service for the same service for the same individual should be billed. All 
units of a service provided to a person on a date of service should be added together and billed on one line or it's considered a duplicate claim. 
6) Service Type- Choose the service from the drop-down list and it will populate the Procedure Code and Unit Rate for the service. ATTENTION: Yellow highlighted rows are duplicate claims. 
Please correct the information in the row to resolve the duplicate claim error.
Procedure Code (locked)- This code is populated by the Service Type selected and should be entered in field 24D on the 1500 forms for services provided to Waiver eligible individuals.
7) Unit Rate (locked)- The FY22 rate for the service is populated by the Service Type selected.
8) # of Units- Units must be entered in this field to calculate the Total Charges for the service. Only whole numbers are allowed. (BCS and BSIS are billed in 15 minute increments, so if 2 1/2 
hours of service are provided, you would enter 10 units, etc.) The unit for BAS and BP is always 1. A maximum of 32 units (8 hours)  may be entered for BCS and BSIS as this is the daily service 
limit that may be provided in a day for an individual.  
9) Total Charges (locked)- This amount is populated by the Unit Rate multiplied by the # of Units that are entered. Please remember to enter a 1 for the # of Units for BAS and BP or no charges 
will be included.
A table has been added to calculate the number of units entered on the sheet for each service. These amounts would be entered on the invoice to bill for services included on this DSR.
                                                                                             FY22 DDA Community Pathways Waiver
                                                                                                    Behavioral Support Services
                                                                                                   Detailed Service Report (DSR)
          Last Name, First Name     Address Line                       City        State  Zip Code