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Monthly medical billings are to be submitted electronically to the Medical Disbursement Unit at DOCHOMedicaIRAB@DOC1.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 electronicall/, please fax to: Department of Corrections Health Services Contract, Claims and Benefits Unit Fax: (360) 586-1320 A sample billing entry is provided below TriP'Ps1t last First DOC # or or date Destination or RX name & nalne Name Birthdate RX given strength Doe John 999999 8127112 Gabapentin 30 [/G TAB Jackson Joseph 111111 811112 Clonidine 1 MG TAB Smith Joe 888888 8114112 Provrdence StPeter Hospital Reason Split Amount ER? lP? for Gustody EillEdto Quanti$ (Y/N) (Y/N) Tdp/RX# (YJN) DOc 14N N N 25,00 6N N N 34,00 Y N Broken Leg 2,500,00 Monthlv billines must include: r 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 intemal invoice tracking number) and Federal Tax ID 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. r Supporting 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; r Credits for returned prescriptions (if applicable) listed in the same way as noted above and clearly marked as CREDIT. State of Washington Department of Corrections Kes51(6) Attachment B-1 Page 4 of 5