Reimbursement - Quality Assurance/ Utilazation Review Costs

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STATE OF CALIFORNIA – Health and Human Services Agency

Department of Health

SHORT DOYLE/MEDI-CAL MONTHLY CLAIM FOR

Fiscal Year

REIMBURSEMENT QUALITY ASSURANCE

UTILAZATION REVIEW (QA/UR) COSTS

Claim For (Month)

(See instruction on reverse side

Date:

County Code

County

Name:

Position #:

Classification:

Form #

SPMP (Skilled Professional Medical Personnel)

SPMP

OTHER

Salary

Benefits

Training

Travel

General Expense

Communication

Facility Operation

TOTAL (1 thru 7)

Percent of Time Spent on QA/UR

Percent of Time Spent on QA/UR for Medi-Cal

Claimable Amount (8) x (9) x (10)

FFP – 75% Amount (11A) x (0.75)

FFP – 50% Amount (11B) x (0.50)

County Match to FFP

(11A minus 12A) and (11B minus 13B)

TOTAL AMOUNT CLAIMABLE (12A + 13B)

I HEREBY CERTIFY under penalty of perjury that I am the official responsible for the administration of Community Mental Health Services in and for said

claimant; that I am authorized to sign this certification form on behalf of the County; that I have not violated any of the provisions of Section 1090 et. seq.

of the Government Code; that the amount for which reimbursement is claimed herein is in accordance with Chapter 3, Part 2, Division 5 of the Welfare and

Institutions Code; and that to the best of my knowledge and belief this claim is in all respects true, correct, and in accordance with law. The County

further certifies under penalty of perjury that: all claims for services provided to county mental health clients have been provided to the clients by the

County; the services were, to the best of the County’s knowledge, provided in accordance with the client’s written treatment plan; and that all information

submitted to the Department is accurate and complete. The County understands that payment of these claims will be from Federal and/or State funds, and

any falsification or c oncealment of a material fact may be prosecuted under Federal and/or State laws. Pursuant to Section 433.32 of Title 42, Code of

Federal Regulations (CFR), the County agrees to keep, for a minimum of three years after the final determination of costs is made through the DMH

reconciled Cost Report settlement process and retained beyond the three year period if audit findings have not been resolved, a printed representation of

all records which are necessary to disclose fully the extent of services furnished to the client. The County agrees to furnish these records and any

information regarding payments claimed for providing the services, on request, within the State of California, to the California Department of Health Care

Services (DHCS), the Medi-Cal Fraud Unit, California Department of Justice, Office of the State Controller, U.S. Department of Health and Human

Services, or their duly authorized representatives. The County further certifies under penalty of perjury that services are offered and provided without

discrimination based on race, religion, color, national or ethnic origin, sex, age, or physical or mental disability.

Date: ___________________________________________________

Signature: ______________________________________

Local Mental Health Director

Executed at_______________________________________________

, California

I CERTIFY under penalty of perjury that I am a duly qualified and authorized official, as delegated by the Board of Supervisors, of the herein claimant

responsible for the examination and settlement of accounts and that I am authorized to sign this certification on behalf of the County. I understand that

misrepresentation of any information provided herein constitutes a violation of state and federal law. I further certify that the claim is based on actual,

total-funds expenditures necessary for claiming Federal Financial Participation (FFP) pursuant to all applicable requirements of state and federal law

including, but not limited, to Sections 430.30 and 433.51 of Title 42, Code of Federal Regulations (CFR). I understand that DHCS may deny any payment if it

determines that the certification is not adequately supported for purposes of claiming FFP. I understand that all records of funds included in this claim

are subject to review and audit by DHCS and/or the federal government and that, pursuant to Section 433.32, Title 42, CFR all records of funds must

be kept for a m inimum of three years after the final determination of costs is made through the DHCS reconciled Cost Report settlement process and

retained beyond the three year period if audit findings have not been resolved.

Date: __________________________________________

Signature: ______________________________________

Title: ___________________________________________

Executed at ____________________________________, California

County Auditor-Controller, City Finance Officer, or

Local Mental Health Accounting Officer

FOR STATE DEPARTMENT OF HEALTH CARE SERVICES USE ONLY

County Claim for Reimbursement

$ ____________________________________________________