FY14 POST-PAYMENT REVIEW TOOL
||FY14 POST-PAYMENT REVIEW TOOL
|A. PROVIDER NAME:
||B. REVIEW DATE: Dates of on-site review
|C. PROVIDER #: Collaborative provider/NPI
||D. Time Period Covered: Date span for bills reviewed.
All claims reviewed will have been processed and approved by DHS/HFS. The claim review period is the 12 month period
prior to the PPR.
CONTRACT AND RULE COMPLIANCE
- No valid note documenting the service could be located.
- Note describes a service intervention or activity that is not billable.
- Service provided by unqualified staff.
- No amount of time documented.
- No valid Mental Health Assessment could be located.
- No valid Individual Treatment Plan could be located.
- Specific service does not appear on ITP.
- ITP review does not demonstrate both a review of progress towards goals and an evaluation of needed services.
- Time billed is greater than time documented.
- Location of service not correctly noted on-site vs. off-site.
- Note describes a different service than billing submitted.
Reviewer comments of any other positives or concerns identified during the review
||Yes / No
||Documentation is sufficiently detailed corresponding to time billed.
||MHA contains sufficiently detailed information to guide clinical treatment.
Reviewer comments of any other positives or concerns identified during the review.
Reviewer: _____________________________________________ Date__________________
Reviewer: _____________________________________________ Date_________________
Results verbally reviewed with provider and copy of summary provided to:
Name: _____________________________________________ Date___________________
- Signature of Provider Representative
A copy of this summary document is left with the Provider