133x 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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