| Client ID |
Mandatory - When Recipient Code is 'registered' (value 1) or 'collateral' (value 3), report the client's ID. Use the client ID number assigned to the client by the agency and reported on the client's case registration (this may be the same number as the client's SSN number). All nine positions must contain numeric data.
Examples:
000234567
333445555
When Recipient Code is 'unregistered' (value 2), report the age group of the client (A for adults, C for children and adolescents) plus an 8 digit numeric identifier.
Examples:
A00000001 - Adults (age 18+)
C00000001 - Children and Adolescents (ages 00-17)
When Recipient Code is 'community' (value 4) or 'agency' (value 5), leave this field blank.
|
| Service Date |
Mandatory - The date on which the service was performed.
Format: MMDDYYYY
MM - month
DD - day
YYYY - century and year
Example: 08011999 |
| Location Code |
Mandatory, if applicable for Mental Health programs - Report the code for the location at which the service actually occurred.
NOTE: Not used for DD programs. For DD service reporting, leave this field blank.
0 - Own Agency
1 - Social Service Agency
2 - Long Term Care Facility
3 - Client's Residence
4 - Public Place
5 - Law Enforcement/Jail/Court
6 - School/Workplace
7 - General Hospital/Detox/Emergency Room
8 - State Operated Facility
9 - Other |
| Activity Code |
Mandatory, if applicable - Indicates the specific service provided in the program. If the program provides more than one specific service, each must be reported separately.
Mental Health: For Mental Health programs, activity code must be reported. (See Appendix B for detailed listing and descriptions.)
MH Activity Code Categories:
- Service Needs Evaluation
- Crisis Intervention
- Psychiatric Treatment
- Adaptive/Social/Developmental Rehabilitation
- Self-Help and Individual Care Grant Process
- Case Management
- Client-Centered Consultation or Community Education
- Administration/Support
- Day Treatment Programs
- Assertive Community Treatment (ACT)
Developmental Disability:
For Developmental Disability programs, the DD CILA program (program code 600) is the only program for which an activity code must be reported. Report the following activity code:
88 - Residential Habilitation
NOTE: Not used for DD programs. For DD service reporting, leave this field blank (value spaces).
|
| Site |
Mandatory, if applicable - The site number assigned by DHS that represents the unique or specific geographical site as the base for service delivery. Refer to your current DHS contract or Agency Plan 2.0/2.1.
NOTE: Not used for DD programs. For DD service reporting, leave this field blank. |
| Unit |
Mandatory, if applicable - A unique number assigned to a component of the provider's service delivery organization to reflect a distinction of the component, such as location, client population to be served, staff or staff team providing the services, or source of funding for the service. Refer to your current DHS contract or Agency Plan 2.0/2.1.
If unit code is not applicable, leave this field blank. |
| Program Code |
Mandatory - The program number assigned by DHS that represents the program through which services were provided. Refer to your current DHS contract or Agency Plan 2.0/2.1. |
| Hours/Minutes |
Mandatory - The duration of the service.
Valid range for hours: 00-24
Valid range for minutes: 00-59 |
| Start Time |
Optional, for Mental Health programs - The time at which the service began. If used, time must be reported using the 24 hour clock. Report the time at which the service actually started.
If not used, leave blank.
NOTE: Not used for DD Programs and will not appear on the screen. |
| Recipient Code |
Mandatory - Report the code that identifies the type of client served.
1 - Registered
2 - Unregistered
3 - Collateral
4 - Community
5 - Own Agency |
| Satellite Code |
Mandatory - An organizational subpart within an agency that has a unique physical location, but does not have a different FEIN assigned to it.
This code is assigned by DHS.
If no satellite code is assigned, report zeros in this field. |
| DHS Case ID |
Mandatory - The DHS Case ID will be displayed from the client's registration. This is the public aid eligibility Case ID number for the client. The Case ID can be changed on this screen.
If the client does not have a public aid eligibility Case ID or if the Case ID is not known report:
All 0's - Not Applicable
All 9's - Unknown |
| Staff ID |
Mandatory - for MH programs only. Optional for all DD programs. The ID number of the professional staff member responsible for providing the services to this client. The staff ID number must be numeric. Can report up to six different staff ID numbers. |
| Optional Data |
Optional - This area may be used by the agency for any miscellaneous data they may desire to retain on this record. |
| Contract FEIN |
Optional - This field is to be used for special processing purposes only. The FEIN number of the agency who is actually being funded by DHS should be reported here (it must be a different FEIN than the FEIN number which is displayed in the registration information.
NOTE: If not used this field must be blank. |
| Total Dollars Spent |
Optional - This field is for MH program codes 131, 572, 573, 574 and specific designated activity codes only. This field indicates the dollars expended on behalf of a specific client for the service and can be reported with or without associated client service hours. |
| MH BILLING DATA |
*** Individual Entry Screen *** |
| Billing Option |
Mandatory - Report the appropriate code:
D - Service Reporting Only
C - MH Medicaid Clinic option (Not valid after 7/01/2004)
N - MH Billable, Non-Medicaid (See Appendix B for MH Billable and Non- Medicaid Activity Codes/Billing Option)
R - MH Medicaid Rehab option
T - MH Medicaid Targeted Case Management option |
| Medicaid Site ID |
Mandatory, if applicable for MH billing - Report the three digit Department of Public Aid (DPA) site location number of the site the service was provided.
NOTE: The Medicaid Site ID is assigned by DPA when the agency is enrolled for MH Medicaid and is the three digits which are appended to the agency's nine digit Federal Employer Identification Number (FEIN). |
| Diagnosis |
Mandatory, if applicable for MH billing - Report the ICD-9-CM or DSM-IV diagnostic code which describes the condition primarily responsible for the client's treatment. (See Appendix C for valid codes to be used for MH Medicaid billing.) |
| MH Billable Hours/Minutes |
Mandatory, if applicable for MH billing - The duration of the service that is billable to MH.
Hours - Value range 00-24
Minutes - Value range 00-59
NOTE: If no MH Billable Hours of Service were reported, the minimum value for this field is eight minutes of services.
Exception: For activity codes 2D & 25, this field represents the number of events for service dates after 07/31/04 (valid range 01-03). |
| Location Desc |
Mandatory, if applicable for MH Medicaid billing - When the service is provided off-site and a Location Code of 9 (other) is reported, a description of where the service was provided must be reported. |
| Third Party Liability |
Mandatory, if applicable for MH billing - These fields are used for MH billing only; if not applicable, these fields must be blank.
(See Appendix H)
Code: Report the TPL Code contained on the client's Medical Eligibility Card (MEC).
Status: Report the appropriate code indicating the disposition of the third party billing.
Amount: Report the amount of payment received from the third party resource. A dollar amount is required when TPL Status Code 01 is reported.
Date: A TPL Date is required for all TPL status codes. |
| MONTHLY ENTRY SCREEN |
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| DAYS OF THE MONTH |
Mandatory -
Hours/Minutes: To report hours and minutes, report the duration of hours (valid range; 00-24), and the duration of minutes (valid range: 00-59).
Attendance: To report attendance, report one of the following codes of the corresponding day of the month.
P - Present
A - Absent
B - Bed-hold |
| GROUP SERVICES DATA |
*** Individual and Monthly Screens *** |
| Group ID |
Optional - (for agency use only) If the service was performed in a group setting, report the Group ID.
If not a group service, leave this field blank. |
| * of Clients |
Mandatory, if applicable - If the service was performed in a group setting, report the total number of clients involved in the group service.
If not a group service, this field must be blank. |
| * of Staff |
Mandatory, if applicable - If the service was performed in a group setting, report the total number of staff involved in the group service.
If not a group service, this field must be blank. |
| INFORMATONAL DATA |
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| Charge Amount |
Charge Amt is the total charge for the service, not deducting the TPL amount if there is one. This field is displayed for MH billing only. |
| Record Status |
Display only. Record Status - Indicates the status of the record.
Pending - The record has not been submitted to DHS.
Submitted - The record has been submitted to DHS and is waiting results.
Accepted - The record has been approved.
Rej by DPA - (MH billing only) The record has been rejected by DPA with an error.
Rej by DHS - The record has been rejected by DHS with an error.
Aprvd NV - (MH billing only) The record has been approved but not vouchered. |
| Tot TPL Amt |
Tot TPL Amt is the sum of the TPL amounts reported. This field is displayed for MH billing only. |
| Submit Date |
Submit Date - The date on which the record was submitted to DHS for processing. |
| RIN |
The Recipient ID (RIN) as it appears on the client registration information. |
| Approved Amt |
Approved Amt is the total amount approved on the original service. This field is displayed for MH billing adjustments only. |
| Adjust Type |
Adjust Type is the type of adjustment being processed. This field is displayed for adjustments only. |
| Net Charge Amt |
Net Charge Amt is the difference between the Charge Amount minus the Total TPL Amount. This field is displayed for MH billing only. |
