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Broward County GovernmentHuman Services Department
Community Partnerships DivisionFY2015 Provider Information
October 2014
• Provider Resources
• Invoicing
• Quarterly Reports
• Other Required Reports
TOPICS
PROVIDER RESOURCES
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ACCESSBROWARD REGISTRATION CONT.
Contracted Provider website
(http://www.broward.org/HumanServices/CommunityPartnerships/Pages/ContractServicesProviderHandbook.aspx)
CONTRACTED PROVIDER HANDBOOK WEBPAGE
INVOICING
A complete Quarterly Report includes;
• Packet 1
• Packet 2
• Outcome Report
• Demographic Report
• Narrative Report
PACKET 3(submitted quarterly)
• Copy of invoice
• Copy of system generated summary report
• System generated detail activity report
• Certificate of payment to subcontractors and suppliers
PACKET 2(submitted monthly)
• Original invoice
• System generated summary report
PACKET 1(submitted monthly)
REGULAR INVOICE SUBMISSION
• Copy of invoice• Copy of system generated
summary report for current invoice
• System generated detail activity report for current invoice
• Copy of “Before and After” system generated summary report from month in which services were rendered
• Copy of completed Required Services Documentation form for all added or disallowed billing
• Certificate of payment to subcontractors and suppliers
PACKET 2(submitted monthly)
• Original invoice
• System generated summary report for current invoice
• “Before and After” system generated summary reports from month in which services were rendered
• Completed Required Services Documentation form for all added or disallowed billing
PACKET 1(submitted monthly)
INVOICES CONTAINING CORRECTED BILLING INFORMATION ADDITIONAL OR DISALLOWED
When the invoice is received, the CommunityPartnerships staff reviews the invoice forcorrectness. Incorrect invoices will be voidedand returned and may delay payment. Therevised invoice must include a new signature anddate upon resubmission.
Late submission (past date due) of invoices andor other documents will be noted on monitoringreports and may result in a remedial orcorrective action.
INVOICE REVIEW
***IMPORTANT***
Providers are only allowed to back bill once for any given month.
Quarterly Reports due at the end of each quarter.
*If due date falls on a weekend or a County observed holiday, invoices/correction packets are due the next business day.
Month of
ServiceOct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Invoice
Due*Nov 15 Dec 15 Jan 15 Feb 15 Mar 15 Apr 15
May
15Jun 15 Jul 15
Aug
15
Sep
15Oct 15
Corrections
Due*Feb 15 Mar 15 Apr 15 May 15 Jun 15 Jul 15
Aug
15
Sep
15
Oct
15Nov 15
Nov
15Nov 15
Quarter 4Quarter 3Quarter 2Quarter 1
INVOICING AND BACK BILLING SCHEDULE
Billing Period: October-12
Agency Name: Customer #
Contract #: Address 1
Program Name: Address 2
Program #: City, St, Zip
Contract/Prog.
Amount:
A. Grand Total $ For Units Delivered This Month (from page 2, "A")
B. Match this month
C. Net Amount Requested for Reimbursement/Month
D. Net Amount Requested Year-to-Date
E. Match Contribution YTD
F. CERTIFICATION: The undersigned, as an authorized signator for the contract between Broward County and
G. Approved Signator Name (typed): Title:
H. Authorized Signature: Date:
THIS SECTION FOR COUNTY USE ONLY Fund/Agency/Organization/Object:
Division Reviewer/Date:
Comments:
Submission of previously unbilled units: Y or N. If "Y", submit additional backup documentation to substantiate the unbilled units of service.
I hereby certify that the backup documentation is complete, accurate, supports the payment and pricing
requested and is on file in the Division.
served have met the program eligiblity requirements, and that sufficient written information is available to document services. Provider also represents to
hereby affirms and certifies that the services billed herewith have been delivered to clients on behalf of Broward County per agreement, that all clients
Are any disallowed units from previous monitoring visits or Medicaid or Medicare payments included in this
invoice? (Y or N. If "Y" then see p.2 )
CERTIFICATION OF PAYMENTS TO SUBCONTRACTORS AND SUPPLIERS
pExhibit C Required pNot Required; subcontracting not authorized by COUNTY
County that no other reimbursement is used for invoiced services.
Administrative Services Reviewer/Date:
Outcomes met for quarter? Yes, invoice not adjusted □ No, invoice adjusted □
FY 2014 (page 1 for Contracts with Match)
Board of County Commissioners, Human Services Department
Contracted Services Invoice
DATE STAMP AREA
On Time Late
INVOICE, PAGE 1
Billing Period: October-12 Contract #:
Program Name: Program #:
A.
Taxonomy Unit/Service Type (Unit Cost) x (# Units this month - # Disallowed Units) = Total $ Value90% of Total $ Value of
Units
Total Billable Value
YTDAnnual Maximum
1 x - =
2 x -=
3 x - =
4 x - =
5 x - =
6 x - =
7 x - =
8 x - =
9 x - =
10 x - =
11 x - =
12 x - =
13 x - =
14 x - =
15 x -=
16 x -=
17 x -=
1 Total Match This Month
2 Previous Month YTD
3 Required Contribution (10% of the amount billed year-to-date):
Total Billable Value for This Month (to page 1, "A")
FY 2014 (page 2)
Board of County Commissioners, Human Services Department
Contracted Services Invoice
Agency Name:
Grand Total Units Billed (add additional sheets if more than 17 types of units)
INVOICE, PAGE 2
REQUIRED SERVICES DOCUMENTATION
Agency Name:
Billing Period:
Contract #:
Taxonomy/Unit:
Program Name:
Program #:
Client ID:
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
date of entry:
date of exit:
Total units:
3rd Party Payments
Type:
Client ID:
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
date of entry:
date of exit:
Total units:
3rd Party Payments
Type:
Client ID:
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
date of entry:
date of exit:
Total units:
3rd Party Payments
Type:
Client ID:
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
date of entry:
date of exit:
Total units:
3rd Party Payments
Type:
Client ID:
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
date of entry:
date of exit:
Total units:
3rd Party Payments
Type:
Client ID:
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
date of entry:
date of exit:
Total units:
3rd Party Payments
Type:
Client ID:
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
date of entry:
date of exit:
Total units:
3rd Party Payments
Type:
Total # units this page:
Total 3rd party $$ this page:
FIRST PAGE
ONLY:
Grand total # units:
Grand total 3rd party $$:
Verified by:
REQUIRED SERVICES DOCUMENTATION
QUARTERLY REPORTS
• Demographic Report – remember to circle appropriate quarter.
• Outcome Report – needs to have all required signatures and dates.
• Narrative Report - needs to list any barriers in outcome achievement & noteworthy activities. Evidence based programs must include methodology used to complete outcome report.
QUARTERLY REPORTS
Provider's Name: 1 2 3 4
Program name/number: Contract#: Date completed:
CIRCLE ONE or
Qtr
1
Qtr
2
Qtr
3
Qtr
4Total
a. Number of Clients at the beginning of quarter. 0
b. Number of NEW Clients entering services during quarter. 0
c. Number of Clients (discharged in FY14) re-entering services during quarter. 0
d. Total of Line A, B and C. 0 0 0 0 0
e. Number of Clients discharged during quarter. 0
f. Total number of Clients at the end of quarter. 0 0 0 0 0
g. Total number of UNDUPLICATED Clients served, year-to-date. 0 0 0 0 0
Under Over
< >
M F M F M F M F M F M F M F M F M F M F M F
RACE / ETHNICITY
1. Asian 0 0 0
2. Black 0 0 0
3. White 0 0 0
4. Haitian 0 0 0
5. Hispanic
7. Native American 0 0 0
8. Other 0 0 0
9. Total 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
CIRCLE THE QUARTER#:
Est Pov. Level
D
a
t
e
S
t
a
m
p
0-5
Data below must reflect the total of ALL (unduplicated) clients served year to date for this Agreement (See f. above).
6-10 11-14 15-17 18-21 22-29 30-39 40-49 50-59 60+AGE
An unduplicated client is defined as an individual who is counted one time during the contract year, even though that individual may receive multiple services or
have more than one episode of care.
RevisionOriginal
Total
all
ages
Total
GENDER
DEMOGRAPHICS FORM
Provider's Name:
Agreement #:
Program Name/Number:
1 Submission Status (Circle appropriate status): Revision
1 2 3 4
Item
2
3
Clients who have received the service referenced in the indicator.
Item Qtr 2 Qtr 3 Qtr 4 YTD
4 0
5 0
6 0
7 0
8 0
9 0 0 0 0
10 0
11 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
Item
2
3
Clients who have received the service referenced in the indicator.
Item Qtr 2 Qtr 3 Qtr 4 YTD
4 0
5 0
6 0
7 0
8 0
9 0 0 0 0
10 0
11 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
# Clients pending first evaluation (have not been in services
long enough).
# Clients unable to be evaluated (data missing and other -
explain in narrative)
# Clients previously evaluated for the indicator.
# of Clients attaining the Indicator
# Clients who dropped out of program and were unable to be
evaluated (Only Children's Services Providers)
% Attainment reported for the Quarter
Original
Qtr 1
Dat
e R
ec'd
:
Total # of Clients receiving services referenced in indicator
during each quarter
Outcome Measure #
Indicator #
Relevant Clients:
Approver Signature:Preparer Signature:
Circle Quarter #:
# Clients pending first evaluation (have not been in services
long enough)
# Clients unable to be evaluated (data missing, and other -
explain in narrative)
# Clients previously evaluated for the indicator# of Clients meeting time frame to be evaluated for the
indicator
# Clients who dropped out of program and were unable to be
evaluated (Only Children's Services Providers)
% Attainment reported for the Quarter
Preparer Name/Title (Print): Approver Name/Title (Print):
# of Clients attaining the Indicator
Total # of Clients receiving services referenced in indicator
during each quarter
0
Qtr 1
Outcome Measure #
Indicator #
Relevant Clients:
# of Clients meeting time frame to be evaluatedfor the indicator
OUTCOMES FORM
CPD will deduct 3% of the thirdinvoice of any quarter in which aperformance indicator is not metwithin 5% of the outcome goalfor that quarter.
IMPORTANT!
OTHER REQUIRED REPORTS
• Monitoring reports issued byagencies or funding source forsimilar services.
• Accreditation reports
• Single audit reports
THE FOLLOWING REPORTS MUST BE SUBMITTEDTO CONTRACT GRANTS ADMINISTRATORWITHIN 30 CALENDAR DAYS OF RECEIPT BYPROVIDER:
• Blank Copy of Provider’s Client Satisfaction Survey• Due when Agreement is executed, and when
updated
• Compiled Client Satisfaction Survey• Due annually by July 15th
CLIENT SATISFACTION SURVEY
All required reports must be received on or before the due
date to avoid suspension of payment.
IMPORTANT!
Lunar Blue
THE WELL ANTICIPATEDPAPER COLOR OF FY2015
IS… ….. … . …
CALL US AT:
(954) 357-7880 CSA
(954) 357-6101 HIP
(954) 357-5385 HCS
ADDITIONALQUESTIONS?
THE END!
