SECTION 7- SERVICE DELIVERY & DOCUMENTATION Question # Question Guidance/Additional Information Compliant Plan of Correction Yes/No (If not compliant) 7.001 Does service delivery documentation include May be maintained on multiple the following elements below? documents/forms Date of service Review service specific rule for Individual's name documentation requirements Individual's Medicaid # Provider name Provider # Signature or initials of person delivering the service 5123:2-9-06; 5123:2-9-40;, 5123:2-9-39; 5123:2-9-20 7.002 Does the waiver service delivery documentation Place of service in NMT is the vehicle for all waiver billing codes include the place of license plate number service? For Transportation (HPC), this is origination/destination points 5123:2-9-06; 5123:2-9-40;, 5123:2-9-39; 5123:2-9-20 7.003 Does the waiver service delivery documentation Review service specific rule for for all waiver codes include the type of service? documentation requirements NMT: requires type of NMT service – 5123:2-9-06; 5123:2-9-40; 5123:2-9-39; trip or per-mile 5123:2-9-20 7.004 Does the waiver service delivery documentation Not required for services billed using a for all waiver billing codes include the number daily rate except adult day services of units (amount) provided? Documentation may be maintained on multiple documents/forms 5123:2-9-06; 5123:2-9-40;5123:2-9-39; Review service specific rule for documentation requirements
SECTION 7- SERVICE DELIVERY & DOCUMENTATION Question # Question Guidance/Additional Information Compliant Yes/No Plan of Correction (If not compliant) 7.001 Does service delivery documentation include the following elements below? Date of service Individual's name Individual's Medicaid # Provider name Provider # Signature or initials of person delivering the service 5123:2-9-06; 5123:2-9-40;, 5123:2-9-39; 5123:2-9-20 May be maintained on multiple documents/forms Review service specific rule for documentation requirements 7.002 Does the waiver service delivery documentation for all waiver billing codes include the place of service? 5123:2-9-06; 5123:2-9-40;, 5123:2-9-39; 5123:2-9-20 Place of service in NMT is the vehicle license plate number For Transportation (HPC), this is origination/destination points 7.003 Does the waiver service delivery documentation for all waiver codes include the type of service? 5123:2-9-06; 5123:2-9-40; 5123:2-9-39; 5123:2-9-20 Review service specific rule for documentation requirements NMT: requires type of NMT service – or per-mile 7.004 Does the waiver service delivery documentation for all waiver billing codes include the number of units (amount) provided? 5123:2-9-06; 5123:2-9-40;5123:2-9-39; Not required for services billed using a daily rate except adult day services Documentation may be maintained on multiple documents/forms Review service specific rule for documentation requirements trip
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