"Rate Certification Form - Residential" - Delaware

This "Rate Certification Form - Residential" is a part of the paperwork released by the Delaware Department of Services for Children, Youth and their Families specifically for Delaware residents.

The latest fillable version of the document was released on December 1, 2013 and can be downloaded through the link below or found through the department's forms library.

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Download "Rate Certification Form - Residential" - Delaware

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State of Delaware
Division of Management Support Services
The Department of Services
Cost Recovery Unit
For Children, Youth and
Their Families
Dear Service Provider:
Under an agreement between DSCYF and Delaware Medicaid, DSCYF is the exclusive provider of Medicaid
behavioral health and substance abuse services to children in Delaware.
In order for DSCYF’s Cost Recovery Unit to pursue reimbursement from Medicaid for services provided to Delaware
children through a third party such as your organization, we must annually obtain documentation from you. In your
Contract or Statement of Agreement (Article I, Section B.5) with DSCYF you agreed to provide this information.
Completing these forms and supplying the below requested information will not enroll you in Medicaid. It will simply
enable the State of Delaware to lower its cost by requesting partial compensation from Medicaid. We are requesting
the following:
1. Rate Certification Form (enclosed)
2. Usual and Customary Rate Schedule showing your rates for services like the services in this contract
3. CMS Sanctions Certification Form (enclosed)
4. Accreditation Status Form (enclosed)
5. Letters of Accreditation, such as JCAHO (copy)
6. State issued licenses (copy)
7. National Provider ID (NPI) Number (copy of NPI letter or printout from NPI Registry)
8. State issued Medicaid Letter, showing your Medicaid enrollment and rates (copy)
9. Provider Disclosure Statement (attached as separate document)
Please return the completed forms and other documents via email, fax, or mail:
You can scan and email to:
brian.calio@state.de.us
This is the preferred method
302.661.7224 (This is a shared fax number, so include a
You can fax to:
cover page to Brian Calio’s attention)
(Must use all 10 digits)
STATE OF DELAWARE
DSCYF-DMSS-N301
You can mail to
COST RECOVERY UNIT (ATTN: BRIAN CALIO)
1825 FAULKLAND ROAD, WILMINGTON, DE 19805
If you expect a delay of more than two weeks in your response or if you have any questions, please contact me. The
funds we recover from Medicaid allow us to provide more services, through service providers like you, to the children
of Delaware. Once you send these documents, you may call the number below to confirm receipt.
Brian Calio
Fiscal Management Analyst
DSCYF Cost Recovery Unit
Phone: 302.892.4570
Residential
Revised 12/2013
Page 1 of 4
State of Delaware
Division of Management Support Services
The Department of Services
Cost Recovery Unit
For Children, Youth and
Their Families
Dear Service Provider:
Under an agreement between DSCYF and Delaware Medicaid, DSCYF is the exclusive provider of Medicaid
behavioral health and substance abuse services to children in Delaware.
In order for DSCYF’s Cost Recovery Unit to pursue reimbursement from Medicaid for services provided to Delaware
children through a third party such as your organization, we must annually obtain documentation from you. In your
Contract or Statement of Agreement (Article I, Section B.5) with DSCYF you agreed to provide this information.
Completing these forms and supplying the below requested information will not enroll you in Medicaid. It will simply
enable the State of Delaware to lower its cost by requesting partial compensation from Medicaid. We are requesting
the following:
1. Rate Certification Form (enclosed)
2. Usual and Customary Rate Schedule showing your rates for services like the services in this contract
3. CMS Sanctions Certification Form (enclosed)
4. Accreditation Status Form (enclosed)
5. Letters of Accreditation, such as JCAHO (copy)
6. State issued licenses (copy)
7. National Provider ID (NPI) Number (copy of NPI letter or printout from NPI Registry)
8. State issued Medicaid Letter, showing your Medicaid enrollment and rates (copy)
9. Provider Disclosure Statement (attached as separate document)
Please return the completed forms and other documents via email, fax, or mail:
You can scan and email to:
brian.calio@state.de.us
This is the preferred method
302.661.7224 (This is a shared fax number, so include a
You can fax to:
cover page to Brian Calio’s attention)
(Must use all 10 digits)
STATE OF DELAWARE
DSCYF-DMSS-N301
You can mail to
COST RECOVERY UNIT (ATTN: BRIAN CALIO)
1825 FAULKLAND ROAD, WILMINGTON, DE 19805
If you expect a delay of more than two weeks in your response or if you have any questions, please contact me. The
funds we recover from Medicaid allow us to provide more services, through service providers like you, to the children
of Delaware. Once you send these documents, you may call the number below to confirm receipt.
Brian Calio
Fiscal Management Analyst
DSCYF Cost Recovery Unit
Phone: 302.892.4570
Residential
Revised 12/2013
Page 1 of 4
State of Delaware
Division of Management Support Services
The Department of Services
Cost Recovery Unit
For Children, Youth and
Their Families
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
YES
NO
education through a State’s public school system?
Where is the education provided?
On-Site
Off-Site
Facility /
Healthcare
Usual &
Usual &
Usual &
Program
Service
Procedure
Contracted
Customary
Customary
Customary
Medicaid
Name
Description
Billing
DSCYF
Education
Residential
Total
Rate
Code
Rate
Rate
Rate
Rate
Example:
Example: Treatment Group 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).
Residential
Revised 12/2013
Page 2 of 4
State of Delaware
Division of Management Support Services
The Department of Services
Cost Recovery Unit
For Children, Youth and
Their Families
CMS SANCTIONS CERTIFICATION FORM
Per the “SOCIAL SECURITY ACT, SEC. 1128, 42 USC Sec. 1320A-7 “Exclusion of Certain Individuals and Entities from
Participation in Medicare and State Health Care Programs,” the Secretary of U.S. Department of Health and Human
Services may exclude individuals and entities from participation in any Federal health care program, including
Medicaid and Medicare, or any State health care program.
As an authorized representative of this agency, I certify that the following is true regarding sanctions by the Centers for
Medicare & Medicaid Services (CMS), formerly HCFA.
This agency or individuals working for it have never been sanctioned by CMS.
This agency or individuals working for it were sanctioned by CMS. The agency or individuals were sanctioned on
(date)
. Please select one option below.
The sanctions have not been removed.
The sanctions were removed on (date)
. Please provide supporting documentation.
Signature of Authorized representative
Printed Name
Date
Title
Phone Number
Email Address
Agency Name
Agency Address
Agency City, State, Zip
You may attach supporting documentation if necessary.
Residential
Revised 12/2013
Page 3 of 4
State of Delaware
Division of Management Support Services
The Department of Services
Cost Recovery Unit
For Children, Youth and
Their Families
ACCREDITATION STATUS FORM
This agency is not accredited.
This agency is accredited. Documents confirming accreditation such as certificates are attached.
Agency Name
Accrediting Organization(s),
i.e. JCAHO, CARF, COA, etc.
Period of Accreditation START Date
Period of Accreditation END Date
Please detail which parts of your organization are covered by the accreditation standards. If your entire organization is accredited, it
is only necessary to indicate “All” instead of providing a comprehensive list. In addition please specify facility or campus names, if
applicable, included in the survey within each service area.
Signature of Person Completing Form
Printed Name of Person Completing Form
Date
Phone Number
Email address
Please provide copies of accreditation certificate(s).
Residential
Revised 12/2013
Page 4 of 4
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