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