Yes/No (If not compliant) 7.001 Does service delivery documentation include May be maintained on multiple the following elements below? 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 5123:2-9-06; 5123:2-9-40; 5123:2-9-39; origination/destination points 5123:2-9-20 7.003 Does the waiver service delivery documentation Review service specific rule for for all waiver include the type of service? documentation requirements 5123:2-9-06; 5123:2-9-40; 5123:2-9-39; NMT: requires type of NMT service – 5123:2-9-20 trip or per-mile 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 5123:2-9-06; 5123:2-9-40; 5123:2-9-39; multiple documents/forms 5123:2-9-20 Review service specific rule for documentation requirements For Transportation (HPC, NMT, and SELF), this is total number of miles as indicated by the odometer readings 7.005 Does the waiver service delivery documentation Scope- the definition of each waiver for all waiver billing codes include scope? service must describe in concrete terms the 5123:2-9-06; 5123:2-9-40; 5123:2-9-39 goods and services that will be provided to waiver participants, including any conditions that apply to the provision of the service
Yes/No (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 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 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; 5123:2-9-20 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 For Transportation (HPC, NMT, and SELF), this is total number of miles as indicated by the odometer readings 7.005 Does the waiver service delivery documentation for all waiver billing codes include scope? 5123:2-9-06; 5123:2-9-40; 5123:2-9-39 Scope- the definition of each waiver service must describe in concrete terms the goods and services that will be provided to waiver participants, including any conditions that apply to the provision of the service trip
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