Forms Mc 6003, Mc 6015, And Mc 6016 - Instructions For Completing Dmc Forms For Odf Group And Individual - Alcohol And Drug Page 2
ADVERTISEMENT
1
2
3State of California – Health and Human Services Agency
Department of Health Care Services
Group Sessions: Enter the total number of group sessions in line N in columns B and C.
EXPENSES:
On page 2, enter the total cost for each category in Column A, Total
Program.
NOTE: Based on revenue and unit information previously entered, the
expenses will be distributed appropriately between Private Pay and Drug
Medi-Cal.
Based on the information entered on pages 1 and 2, the distribution of
costs will be identified on page 3 of form “7895ODF-AD”, as will the
provisional rate for Medi-Cal reimbursement.
nd
Worksheet “7990ODFG-AD” (Group - 2
Tab) (MC 6015)
Line 04:
The Statewide Maximum Allowance (SMA) Rate of $29.57 is identified.
However, if the Prorated Rate is less than the SMA, enter the Prorated
Rate/Provisional Rate. The Prorated Rate/Provisional Rate is found on
form 7895, page 3, column B (Per Person Group Rate).
Line 04a:
For the reporting period (July through June), enter the number of total
units submitted for reimbursement and the number of those units that
were denied (excluding Minor Consent non-Title XIX claims).
Line 04c4:
For the reporting period (July through June), enter the number of total
units submitted for reimbursement for Minor Consent Non-Title XIX only
and the number of those units that were denied.
Line 15a:
In the shaded field, enter the total amount of Revenue/Fees (Share of
Cost).
Line 15b:
In the shaded field, enter the total amount of Revenue from Insurance /
rd
3
Party Fees.
rd
Worksheet “7990ODFI-AD” (Individual - 3
Tab) (MC 6016)
Line 04:
The Statewide Maximum Allowance (SMA) Rate of $69.59 is identified.
However, if the Prorated Rate is less than the SMA, enter in the Prorated
Rate/Provisional Rate. The Prorated Rate/Provisional Rate is found on
form 7895, page 3, column B (Individual Session Rate).
Line 04a:
For the reporting period (July through June), enter the number of total
units submitted for reimbursement and the number of those units that
were denied (excluding Minor Consent non-Title XIX claims).
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal