SH20-037 DOC 2021 EXTENSION - signed by Sheriff

Home Browse Search

Monthly medical billings are to be submitted electronically to the Medical Disbursement Unit at DOCHOMedicalRABQDOCI.WA.GOV. Itemized invoices for services provided onsite by the incarcerating facility should be submitted to the Department on a monthly basis for the previous month's services. Any billing for offsite services should be submitted for reimbursement or payment within 30 days of the date of service. We understand that each monthly billing may have medical invoices for previous months and that is acceptable; however, in an effort to ensure the cleanest billing process, please bill one month at a time whenever possible. Itemized statements must be submitted in the format below with supporting documentation when applicable. Incomplete or missing data or supporting documentation may result in delays or denial of payment. If unable to submit billing electronically, please fax to: Department of Corrections Health Services Contract, Claims and Benefits Unit Fax: (360) 586-1320 A sample billing entry is provided below Monthly billings must include: Reason Split Trip Date ER? Last First DOC # or or date Destination or RX name & name Name Birthdate RX given strength Doe Johne 999999 8/27/12 Gabapentin 30 MG TAB Jackson Joseph 111111 8/1/12 Clonidine 1 MG TAB Smith Joe 888888 8/14/12 Providence St Peter Hospital Monthly billings must include: A coversheet with all pertinent details including the total amount billed, month of service, facility name, contact information for the billing staff( including an email address, phone number and fax number), address for where to submit the payment, an invoice number (this is your internal invoice tracking number) and Federal Tax 1D number; Itemized Charges to include the name of the offender and DOC# who the charges are for, what the charges are for and the total amount of the charges. If you are asking for reimbursement for services paid to offsite providers, a copy of the original healthcare claim form paid by the facility must be included. If charges are for onsite services, the detail of what services were provided must be listed along with copies of any paid bills for those services with a break-out of the amount attributed to the DOC offenders. • SupRorting documentation including verification of DOC hold, any authorizations from the Utilization Management Office and all Health Insurance Claim Forms (CMS 1500 or UB -04) and/or invoices from community providers showing what was billed and documentation of what you paid if requesting reimbursement, for medications, you must provide a copy of the pharmacy bill to include the drug name, dosage and quantity provided and amount paid for the drugs; • Credits for returned prescriptions (if applicable) listed in the same way as noted above and clearly marked as CREDIT. State of Washington K9561(6) Page 4 of 5 Department of Corrections Attachment B-1 Reason Split Amount ER? IP? for Custody Billed to Quantity (YIN) (YIN) Trip/RX # (YIN) DOC 14 N N N 25.00 6 N N N 34.00 Y N Broken Leg 2,500.00 A coversheet with all pertinent details including the total amount billed, month of service, facility name, contact information for the billing staff( including an email address, phone number and fax number), address for where to submit the payment, an invoice number (this is your internal invoice tracking number) and Federal Tax 1D number; Itemized Charges to include the name of the offender and DOC# who the charges are for, what the charges are for and the total amount of the charges. If you are asking for reimbursement for services paid to offsite providers, a copy of the original healthcare claim form paid by the facility must be included. If charges are for onsite services, the detail of what services were provided must be listed along with copies of any paid bills for those services with a break-out of the amount attributed to the DOC offenders. • SupRorting documentation including verification of DOC hold, any authorizations from the Utilization Management Office and all Health Insurance Claim Forms (CMS 1500 or UB -04) and/or invoices from community providers showing what was billed and documentation of what you paid if requesting reimbursement, for medications, you must provide a copy of the pharmacy bill to include the drug name, dosage and quantity provided and amount paid for the drugs; • Credits for returned prescriptions (if applicable) listed in the same way as noted above and clearly marked as CREDIT. State of Washington K9561(6) Page 4 of 5 Department of Corrections Attachment B-1