Unit Reference Procedure No. of Frequency Duration Payment Service(s) Rate Provider Type Assessment Code Units Planning Goal Source (3) (4) (2) Tool (5) (1) 1. To 2. To 3. To 4. To *Reference Assessment Tool (1): Units (2): Frequency (3): Payment Source (5): 1. PCPT 15 min Singular DDD Contract 2. DDD Assessment Tool 30 min Daily FI (Agency) 3. Hour(s) Weekly Natural 4. Other Day(s) Monthly Generic Month(s) Yearly Medicaid Service(s) DVRS Trip(s) Mile(s) Personally Defined Outcomes & Services (Outcome #2 of ) Personally Defined Outcome: Unit Reference Procedure No. of Frequency Duration Payment Service(s) Rate Provider Type Assessment Code Planning Goal Source (3) (4) (2) Tool (5) (1)
Planning Goal Service(s) Procedure Code Reference Assessment Tool (1) No. of Units Unit Type (2) Rate Frequency (3) Duration (4) Provider Payment Source (5) 1. To 2. To 3. To 4. To *Reference Assessment Tool (1): Units (2): Frequency (3): Payment Source (5): 1. PCPT 15 min Singular DDD Contract 2. DDD Assessment Tool 30 min Daily FI (Agency) 3. Hour(s) Weekly Natural 4. Other Day(s) Monthly Generic Month(s) Yearly Medicaid Service(s) DVRS Trip(s) Mile(s) Personally Defined Outcomes & Services (Outcome #2 of ) Personally Defined Outcome: Planning Goal Service(s) Procedure Code Reference Assessment Tool (1) No. of Unit Type (2) Rate Frequency (3) Duration (4) Provider Payment Source (5)
NJISPFinal3-26-14.docx