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Forms Mc 6013 And Mc 6014 And Mc 6004 - Instructions For Completing Dmc Forms For Odf Group And Individual - Perinatal

State of California – Health and Human Services Agency

Department of Health Care Services

INSTRUCTIONS FOR COMPLETING DMC FORMS FOR

ODF GROUP AND INDIVIDUAL – PERINATAL

(MC 6013 and MC 6014 and MC 6004)

This form must be completed for each direct provider of Drug Medi-Cal services with

ODF Individual and/or ODF Group services.

The filename for the FY 2011-12 Cost Report Forms is “1112_DP_ODF-P.xls”. A

separate worksheet has been created for each document within the file (there are

three tabs on the bottom of the file). The worksheets are “7895ODF-P”, “7990ODFG-

P”, and “7990ODFI-P”. Enter data only in the shaded (light blue or pink) fields on

the forms, all other fields are automatically calculated. Please do not change any of

the formulas.

NOTE: Several fields on form “7895ODF-P” are formulas that carry back unit or funding

data from forms “7990ODFG-P” and “7990ODFI-P”. Additionally, cost data from

form “7895ODF-P” carries forward to forms “7990ODFG-P” and “7990ODFI-P”.

Consequently, some calculated fields on all three forms will not have correct

numbers until all entries on all three forms are complete. Complete all

necessary entries on all three forms before reviewing the results.

Worksheet “7895ODF-P” (1

Tab) (MC 6013)

HEADING:

Enter the County Name, Contractor, Contract Period, Date Prepared,

Contract Number, 4 digit Medi-Cal Provider Number and 6 digit Provider

Number.

NOTE: Lines A-G1 will auto calculate once data is keyed on 7990 forms.

REVENUES:

Enter the revenues for each applicable cost; in the applicable line (lines

H through K3 in columns B and C).

UNITS:

Group: Enter the applicable Group Face-to-Face visits on line L1 and L3 in

column B and on line L2 only, in columns B and C.

NOTE: Column C, lines L1, L3, and L4 are formulas, which will

automatically be calculated based on the amounts entered on the Form

7990ODFG-P “Total DMC Units” column, Line 04a, and 04c4.

UNITS:

Individual: Enter the applicable Individual Face-to-Face visits on Lines L6

to L8 in column B and, on line L7 only, column C.

NOTE: Column C, Lines L6, L8 and L10 are formulas, which will

automatically be calculated based on the amounts entered on Form

7990ODFI-P “Total DMC Units” column, Line 04a, and 04c4.

Forms Mc 6013 And Mc 6014 And Mc 6004 - Instructions For Completing Dmc Forms For Odf Group And Individual - Perinatal