Filetype Excel XLSX | Posted on 10 Aug 2022 | 3 years ago
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134x Filetype XLSX File size 0.04 MB Source: www.oregon.gov
Sheet 1: instructions
| Invoice Instructions for PE 01-05 (Local Active Monitoring) | ||||||||||
| 1. Include all required elements on the invoice including LPHA Contract Number. | ||||||||||
| 2. Send all invoices to OHA-PHD.ExpendRevReport@dhsoha.state.or.us | ||||||||||
| 3. Invoices should be submitted at least quarterly, but preferred monthly. | ||||||||||
| 4. Final invoices should be submitted no later than January 31, 2021. | ||||||||||
| 5. Funding under this PE is for the period of March 27-December 30, 2020. | ||||||||||
| 6. Amendments will be issued after invoices are reviewed and approved. Payment will be issued once agreement is executed. | ||||||||||
| Activity Areas and Requirements for the invoice: | ||||||||||
| A) Base Funding | Base funding does not need to be invoiced to OHA-PHD. Funds will be distributed to each LPHA within two weeks of the agreement being executed by OHA. | |||||||||
| B) Active Monitoring Fee for Service | Invoice will need to include the items detailed below with supporting documentation | |||||||||
| 1 | Number of cases. | |||||||||
| 2 | Use the approved fee per case, $1,140.58. | |||||||||
| 3 | Supporting documentation required with the invoice includes ORPHEUS Case ID. | |||||||||
| 4 | Do not include patient name or other HIPAA protected information. | |||||||||
| C) Active Monitoring Wraparound Services | Invoice will need to include the items detailed below with supporting documentation | |||||||||
| 1 | Total amount due for wraparound services by category | |||||||||
| 2 | Supporting documentation should include by description detailing vendor name, amount paid, items purchased and dates of purchase. | |||||||||
| 3 | Descriptions are: | |||||||||
| a. | Housing, such as hotels or motels | |||||||||
| b. | Cleaning services | |||||||||
| c. | Food | |||||||||
| d. | Transportation | |||||||||
| e. | Communications, such as cell phones | |||||||||
| f. | Health care and self-monitoring supplies not covered by insurance | |||||||||
| g. | Child care | |||||||||
| Reimbursable costs do not include: car payments, credit cards payments, or student and personal loans. LPHAs are expected to utilize other existing benefits in the community before using PE 01-05 funds for the above-listed items. | ||||||||||
| Reporting Expenses on Quarterly Revenue/Expense Reports | ||||||||||
| A) Base Funding: | Reporting base funding expenses should reflect your approved budget plan and be shown in areas of personnel; supplies; contractual; indirect; etc. | |||||||||
| B) Active Monitoring Fee for Service | Reporting invoice amounts for active monitoring fee for service should be recorded on line 2A Professional Services/Contracts only. | |||||||||
| C) Active Monitoring Wraparound Services | Reporting invoice amounts for active monitoring wraparound services should be recorded on line 2A Professional Services/Contracts only. | |||||||||
| Invoice Summary Sample - PE01-05 | ||||||
| LPHA Name | ||||||
| Address | ||||||
| City, State, Zip | ||||||
| Billing Period from mm/dd/yyyy - mm/dd/yyyy | ||||||
| LPHA Contract # - xxxxxx | ||||||
| Activity | Amount | |||||
| A) Base Funding - do not invoice for base funding | ||||||
| B) Active Monitoring Fee for Service | ||||||
| # of Cases | Fee per Case | Total Due | ||||
| 1,140.58 | - | |||||
| Total Fee for Service | - | |||||
| * will need to include backup summary including ORPHEUS Case ID - do not include patient name or other HIPAA protected information. Please see instruction tab and budget guidance for more information. | ||||||
| C) Active Monitoring Wraparound Services | ||||||
| Description | Total Due | |||||
| Housing | ||||||
| Cleaning Services | ||||||
| Food | ||||||
| Transportation | ||||||
| Communications | ||||||
| Health Care / Self Monitoring | ||||||
| Child Care | ||||||
| Total Wraparound Services | - | |||||
| * will need to include backup summary information by category detailing vendor name, amount paid, items purchased and dates of purchase. Please see instruction tab and budget guidance for more information. | ||||||
| Grand Total Invoice | - | |||||
| All invoices should be sent to OHA-PHD.ExpendRevReport@dhsoha.state.or.us | ||||||
| Active Monitoring Fee for Service Detail Sample - PE01-05 | ||||||
| LPHA Name | ||||||
| Address | ||||||
| City, State, Zip | ||||||
| Billing Period from mm/dd/yyyy - mm/dd/yyyy | ||||||
| LPHA Contract # - xxxxxx | ||||||
| Case | Amount | ORPHEUS Case ID | Item # | Category | ORPHEUS Case ID | |
| 1 | 1,140.58 | 23 | ||||
| 2 | 24 | |||||
| 3 | 25 | |||||
| 4 | 26 | |||||
| 5 | 27 | |||||
| 6 | 28 | |||||
| 7 | 29 | |||||
| 8 | 30 | |||||
| 9 | 31 | |||||
| 10 | 32 | |||||
| 11 | 33 | |||||
| 12 | 34 | |||||
| 13 | 35 | |||||
| 14 | 36 | |||||
| 15 | 37 | |||||
| 16 | 38 | |||||
| 17 | 39 | |||||
| 18 | 40 | |||||
| 19 | 41 | |||||
| 20 | 42 | |||||
| 21 | 43 | |||||
| 22 | TOTAL | |||||
| All cases being claimed on the invoice should be listed and categorized. |
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