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Instructions For Form Form Mc 6012 - California Narcotic Treament Perinatal - Health And Human Services Agency

State of California – Health and Human Services Agency

Department of Health Care Services

INSTRUCTIONS FOR COMPLETING DMC FORMS FOR

NARCOTIC TREAMENT – PERINATAL

(Form MC 6012)

Fiscal Year 2011-12

The EXCEL filename for the FY 2011-12 Year End Expenditure Report Forms is “1112_DP_NTP_P”. Enter data only

in the blue-shaded fields, all other fields are automatically calculated.

HEADING: Enter the County, Provider Name, Contract Number, 4-Digit Medi-Cal Provider Number, and the 6-

digit Provider Number.

UNIT OF SERVICE RATE:

CHANGES IN THIS AREA MUST BE MADE IF, AND ONLY IF, THE PROVIDER BILLS AT A

CUSTOMARY CHARGE WHICH IS LESS THAN THE DMC MAXIMUM RATE. If that is the case, enter

the customary charge under the “Provider Rate” column for the affected service(s). DO NOT CHANGE THE

ADMINISTRATIVE RATE.

UNITS OF SERVICE:

Enter the total units of service submitted for the fiscal year in the Submitted UOS column for each service

provided.

Enter the total number of denied units of service for the fiscal year in the Denied UOS column for each service

provided.

Enter the total units of service for Non-Title XIX Minor Consent provided and approved during the fiscal year in

the Non-Title XIX Minor Consent column for each service provided. This total should include any services billed

under the Minor Consent aid codes (Aid Code 7M, 7N, or 7P).

TOTAL PROGRAM UNITS:

Enter the Share of Cost Amount.

Enter revenue from Insurance and / or 3

Party fees.

Enter the total number of Methadone Units dispensed during the fiscal year for the entire program (DMC and

Private Pay).

Instructions For Form Form Mc 6012 - California Narcotic Treament Perinatal - Health And Human Services Agency