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(4) The contact information for the Contractor's billing staff (including a phone number <br />and an email address or fax number); and, <br />(5) The address for where to submit the payment, an invoice number (this is the <br />Contractor's internal invoice tracking number.). <br />• Any itemized charges must include: <br />(1) The name of the Department offender; <br />(2) The Department offender's DOC# and DOB; <br />(3) The reason for the charges; and, <br />(4) The total amount of the charges. <br />Note: If the Contractor is requesting reimbursement for services paid to an onsite or offsite <br />medical provider(s), a copy of the original healthcare claim form paid by the Contractor must <br />also be included. <br />• Supporting; documentation including verification of the Department's detainer/hold; any <br />authorizations from the Utilization Management Office; all Health Insurance Claim <br />Forms, including those that are needed for medical insurance claims, i.e. the CMS 1500 <br />or the UB -04; and, invoices from community providers showing what was billed <br />including the documentation of what the Contractor paid. <br />o When Contractor is requesting reimbursement for medications Contractor must <br />also provide a copy of the original pharmacy bill to include the Department <br />offender's name, the medication name, the dosage and quantity provided and <br />the amount Contractor previously paid for the medication(s). <br />Credits for returned prescriptions - Contractors wanting credits for returned <br />medications, must document those "credits" following the supporting documentation <br />guidelines with clear demarcation as a CREDIT. <br />Once the Department has completed its' medical bill verification process and is ready to process <br />payment, the Contractor will be notified by email or fax of any denials or credits. <br />For billing questions or concerns, please email DOCHQMedicalRAB@DOCI.WA.GOV. <br />HIPAA <br />HIPAA -The Health Insurance Portability and Accountability Act of 1996 (HIPAA) protects the <br />privacy of individually identifiable, protected health information. <br />This law allows for the exchange of this information between the Department and the <br />Contractor for the purpose of billing and payment which allows the Contractor to provide the <br />required back-up documentation regarding the Department offender's health information and <br />State of Washington K9561 (4) Page 23 of 25 <br />Department of Corrections 158362 <br />