"Native American Tribal Program Time Survey for Employees Performing Medi-Cal Administrative Activities and/Or Targeted Case Management" - California

Native American Tribal Program Time Survey for Employees Performing Medi-Cal Administrative Activities and/Or Targeted Case Management is a legal document that was released by the California Department of Health Care Services - a government authority operating within California.

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Download "Native American Tribal Program Time Survey for Employees Performing Medi-Cal Administrative Activities and/Or Targeted Case Management" - California

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State of California--Health and Human Service Agency
California Department of Health Services
Page 1 of 2
Native American Tribal Program Time Survey for Employees Performing Medi-Cal Administrative Activities and/or Targeted Case Management
Normal Working Hrs:
Training Date:
Name (Last, First, MI)
Job Classification
Employee Number
Claiming Unit
Department
S PMP
Record 5 consecutive days
Date
Date
Date
Date
Date
- Start with first hour paid
Total
- Record the type of activity by code in
1
2
3
4
5
6
7
8
1
2
3
4
5
6
7
8
1
2
3
4
5
6
7
8
1
2
3
4
5
6
7
8
1
2
3
4
5
6
7
8
15 minute increments
1) Other Programs/Activities
2) Direct Medical Services
3) Non-Medi-Cal Outreach
4) Initial Medi-Cal Outreach
5) Facilitating Application for
Non-Medi-Cal Programs
6) Facilitating Medi-Cal Eligibility
Determination
7) Referral, Coordination, and Monitoring of
Non-Medi-Cal Services
8) Ongoing Referral, Coordination &
Monitoring of Medi-Cal Services
9) Arranging Transportation for
Non-Medi-Cal Services
10) Arranging Transportation for Medi-Cal
Services
11) Providing Transportation for
Non-Medi-Cal Services
12) Providing Transportation for Medi-Cal
Services
13) Non-Medi-Cal Translation Services
14) Translation Related to Medi-Cal
Services
15) Program Planning, Policy Development
& Interagency Coordination (PPPD) Related
to Non-Medi-Cal Services
16) PPPD Related to Medi-Cal Services
17) Skilled Professional Medical Personnel
(SPMP) PPPD Related to Non-Medi-Cal
Services
18) SPMP PPPD Related to Medi-Cal
Services
19) Medi-Cal Administrative Activities
(MAA) Training
20) MAA Coordination and Claims
Administration
21) General Administration & Paid Time Off
22) Targeted Case Management
TOTAL HOURS
Employee Signature (blue ink)
Telephone Number
Date (blue ink)
Supervisor Signature (blue ink)
Date (blue ink)
Confirm sum in the bottom right hand corner equals sum of the bottom row. In blue ink, sign & date your survey on the last day worked and give it to your supervisor. If using two pages, sign & date second page in blue ink also.
NO WHITE-OUT ALLOWED
See reverse side for sample documentation page.
State of California--Health and Human Service Agency
California Department of Health Services
Page 1 of 2
Native American Tribal Program Time Survey for Employees Performing Medi-Cal Administrative Activities and/or Targeted Case Management
Normal Working Hrs:
Training Date:
Name (Last, First, MI)
Job Classification
Employee Number
Claiming Unit
Department
S PMP
Record 5 consecutive days
Date
Date
Date
Date
Date
- Start with first hour paid
Total
- Record the type of activity by code in
1
2
3
4
5
6
7
8
1
2
3
4
5
6
7
8
1
2
3
4
5
6
7
8
1
2
3
4
5
6
7
8
1
2
3
4
5
6
7
8
15 minute increments
1) Other Programs/Activities
2) Direct Medical Services
3) Non-Medi-Cal Outreach
4) Initial Medi-Cal Outreach
5) Facilitating Application for
Non-Medi-Cal Programs
6) Facilitating Medi-Cal Eligibility
Determination
7) Referral, Coordination, and Monitoring of
Non-Medi-Cal Services
8) Ongoing Referral, Coordination &
Monitoring of Medi-Cal Services
9) Arranging Transportation for
Non-Medi-Cal Services
10) Arranging Transportation for Medi-Cal
Services
11) Providing Transportation for
Non-Medi-Cal Services
12) Providing Transportation for Medi-Cal
Services
13) Non-Medi-Cal Translation Services
14) Translation Related to Medi-Cal
Services
15) Program Planning, Policy Development
& Interagency Coordination (PPPD) Related
to Non-Medi-Cal Services
16) PPPD Related to Medi-Cal Services
17) Skilled Professional Medical Personnel
(SPMP) PPPD Related to Non-Medi-Cal
Services
18) SPMP PPPD Related to Medi-Cal
Services
19) Medi-Cal Administrative Activities
(MAA) Training
20) MAA Coordination and Claims
Administration
21) General Administration & Paid Time Off
22) Targeted Case Management
TOTAL HOURS
Employee Signature (blue ink)
Telephone Number
Date (blue ink)
Supervisor Signature (blue ink)
Date (blue ink)
Confirm sum in the bottom right hand corner equals sum of the bottom row. In blue ink, sign & date your survey on the last day worked and give it to your supervisor. If using two pages, sign & date second page in blue ink also.
NO WHITE-OUT ALLOWED
See reverse side for sample documentation page.