jagomart
digital resources
picture1_Excel Sample Sheet 33678 | Pe01 05 Invoice Samples And Wraparound Reporting


 133x       Filetype XLSX       File size 0.04 MB       Source: www.oregon.gov


File: Excel Sample Sheet 33678 | Pe01 05 Invoice Samples And Wraparound Reporting
sheet 1 instructions invoice instructions for pe 0105 local active monitoring 1 include all required elements on the invoice including lpha contract number 2 send all invoices to ohaphdexpendrevreport dhsohastateorus ...

icon picture XLSX Filetype Excel XLSX | Posted on 10 Aug 2022 | 3 years ago
Partial file snippet.
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.

Sheet 2: Invoice Summary Sample
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






Sheet 3: FFS Detail Sample
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.






The words contained in this file might help you see if this file matches what you are looking for:

...Sheet instructions invoice for pe local active monitoring include all required elements on the including lpha contract number send invoices to ohaphdexpendrevreport dhsohastateorus should be submitted at least quarterly but preferred monthly final no later than january funding under this is period of march december amendments will issued after are reviewed and approved payment once agreement executed activity areas requirements a base does not need invoiced ohaphd funds distributed each within two weeks being by oha b fee service items detailed below with supporting documentation cases use per case includes orpheus id do patient name or other hipaa protected information c wraparound services total amount due category description detailing vendor paid purchased dates purchase descriptions housing such as hotels motels cleaning food d transportation e communications cell phones f health care selfmonitoring supplies covered insurance g child reimbursable costs car payments credit cards st...

no reviews yet
Please Login to review.