RATE CERTIFICATION FORM - Residential Usual and Customary Charges to the General Public Complete a separate form for each location for which services are contracted by DSCYF. If a service is program funded, not per diem, please check for Funded.” Please list both your and customary rate” and the DSCYF contracted rate “Yes” “Program “usual for all services. If you operate an education program as part of the treatment program, please show the education cost as a separate rate. If children in the program attend public school, it is not necessary to list the public education cost. Contract ID # (found on your DSCYF Contract) Contract Period From: To: Program Funded YES NO Do children in your residential program receive public YES NO education through a State’s public school system? Where is the education provided? On-Site Off-Site Healthcare Usual & Usual & Usual & Facility / Procedure Contracted Customary Customary Customary Medicaid Program Service Billing DSCYF Education Residential Total Rate Name Description Code Rate Rate Rate Rate Example: Example: Treatment Home H0019 $240.62 Education billed $230.00 $230.00 North structured behavioral health separately Campus, treatment includes documented Wellness psychotherapy services, and Bldg. evaluation and management services Is your agency enrolled with Medicaid? YES NO If yes, in which States? Signature of Authorized Representative Title of Authorized Representative Printed Name of Authorized Representative Agency Name Date Phone Email Please provide a copy of your State’s Medicaid letter showing your enrollment and your rate(s).
RATE CERTIFICATION FORM - Residential Usual and Customary Charges to the General Public Complete a separate form for each location for which services are contracted by DSCYF. If a service is program funded, not per diem, please check “Yes” for “Program Funded.” Please list both your “usual and customary rate” and the DSCYF contracted rate for all services. If you operate an education program as part of the treatment program, please show the education cost as a separate rate. If children in the program attend public school, it is not necessary to list the public education cost. Contract ID # (found on your DSCYF Contract) Contract Period From: To: Program Funded YES NO Do children in your residential program receive public education through a State’s public school system? YES NO Where is the education provided? On-Site Off-Site Facility / Program Name Service Description Healthcare Procedure Billing Code Contracted DSCYF Rate Usual & Customary Education Rate Usual & Customary Residential Rate Usual & Customary Total Rate Medicaid Rate Example: North Campus, Wellness Bldg. Example: Treatment Home structured behavioral health treatment includes documented psychotherapy services, and evaluation and management services H0019 $240.62 Education billed separately $230.00 $230.00 Is your agency enrolled with Medicaid? YES NO If yes, in which States? Signature of Authorized Representative Title of Authorized Representative Printed Name of Authorized Representative Agency Name Date Phone Email Please provide a copy of your State’s Medicaid letter showing your enrollment and your rate(s).
cru_fp_Residential_2014.docx