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Appendix B

1. j 0 00 23 400 00 0 100 10 0 00 40 400 00 0 100 15 0 00 57 400 00 0 100 400 740 00 10 5 10 40 400 01 44 440 00 10 110 1 A00 01 63 140 00 10 110 23 400 01 25 740 00 10 110 40 400 01 44 440 00 10 110 15 57 400 01 63 140 00 10 o A P E A f o 25 740 01 28 080 00 20 120 44 440 01 48 480 00 20 120 63 140 01 68 880 00 20 120 i 2 i i o o 28 080 01 30 420 00 30 130 48 480 01 52 520 00 30 130 68 880 01 74 620 00 30 130 30 420 01 32 760 00 40 140 52 520 01 56 560 00 40 140 74 620 01 80 360 00 40 140 32 760 01 35 100 00 50 150 56 560 01 60 600 00 50 150 80 360 01 86 100 00 50 150 35 100 01 37 440 00 60 160 60 600 01 64 640 00 60 160 86 100 01 91 840 00 60 160 37 440 01 43 290 00 70 185 64 640 01 74 740 00 70 18596 91 840 01 106 190 00 70 185 43 290 01 46 800 00 80 200 74 740 01 80 800 00 80 200 15 106 190 01 114 900 00 80 200 46 800 01 58 500 00 90 250 80 800 01 101 000 00 90 250 15 114 800 01 143 500 00 90 250 58 500 01 999 999 99 100 251 10 s101 000 01 5999 999 99 100 251 15 143 500 01 999 999 99 100 Family Planning Program Protocol FPP 4 06 Appendix B24 OF 50 5 Accounting Procedure
2. E 95250 i P0117 10 56 Triphasil 28 Poo22 575 A JA jp nd AN A AN sns s efi Se ERE w s P P jJtn jr iure cu o rmi m uu LEE Family Planning Program Protocol FPP 4 06 Appendix B 23 OF 50 Family Size ele je COa co co co co co co co co co co 2 2 2 2 2 2 2 2 2 aaa Ho en aon an e EXHIBIT 4 2006 FEDERAL PROVERTY GUIDELINES FAMILY PLANNING 2006 PERCENT PAY PER FEDERAL POVERTY GUIDELINES Pay Poverty Family High Pay Poverty Family High Pay Poverty Low Income High Income Percent Percent Size LowlIncome Income Percent Percent Size Low Income Income Percent Percent 0 00 ES 100 0 00 ma 10096 EE 0 00 100 9 800 01 10 780 00 10 110 26 800 01 29 490 00 10 110 43 800 01 48 180 00 10 110 10 780 01 11 760 00 20 120 6 29 480 01 32 160 00 20 120 48 180 01 52 560 00 20 120 11 760 01 12 740 00 30 130 6 32 160 01 34 940 00 30 130 52 560 01 56 940 00 30 130 12 740 01 13 720 00 40 140 6 34 840 01 37 520 00 40 140 56 940 01 61 320 00 40 140 13 720 01 14 700 00 50 150 6 37 520 01 40 200 00 50 150 61 320 01 65 700 00 50 150 14 700 01 15 680 00 60 160 6 40 200 01 42 990 00 60 160 65 700 01 70 080 00 60 160 1
3. 250 94 400 01 118 000 00 90 250 33 000 01 999 999 99 100 75 500 01 999 999 99 100 251 12 118 000 01 999 999 99 100 E 0 00 16 600 00 0 100 8 0 00 33 600 00 0 100 13 0 00 50 600 00 0 100 16 600 01 18 260 00 10 110 8 33 600 01 36 960 00 10 110 50 600 01 55 660 00 10 110 18 260 01 19 920 00 20 120 8 36 960 01 40 320 00 20 120 55 660 01 60 720 00 20 120 19 920 01 21 580 00 30 130 8 40 320 01 43 690 00 30 130 60 720 01 65 780 00 30 130 21 580 01 23 240 00 40 140 8 43 680 01 47 040 00 40 140 65 780 01 70 840 00 40 140 23 240 01 24 900 00 50 150 8 47 040 01 50 400 00 50 150 70 840 01 75 900 00 50 150 24 900 01 26 560 00 60 160 8 50 400 01 53 760 00 60 160 75 900 01 380 960 00 60 160 26 560 01 30 710 00 70 185 8 53 760 01 62 160 00 70 185 80 960 01 93 610 00 70 185 30 710 01 33 200 00 80 200 8 62 160 01 67 200 00 80 200 93 510 01 101 200 00 80 200 33 200 01 41 500 00 90 250 8 67 200 01 84 000 00 90 250 13 101 200 01 126 500 00 90 250 41 500 01 999 999 99 100 251 8 84 000 01 999 999 99 100 251 13 126 500 01 999 999 99 100 a E O E k ee 0 00 20 000 00 0 100 9 0 00 37 000 00 0
4. eee 41 44 Family Planning Program Goal It is the goal of the Family Planning Program to make the fee collection process as efficient as possible input from the local health office staff is vital to fulfillment of this goal Family Planning Program Protocol FPP 4 06 Appendix B 1 OF 50 A INTRODUCTION Requirement for Fees Federal regulations governing family planning projects require that fees be assessed for services rendered to clients with incomes above a certain level The charges for various services are based on the actual cost of providing these services Requirements for Providing Services All family planning services will be provided in accordance with legal and constitutional requirements and grantee policy and will be provided without regard to age gender ethnic origin religion handicap marital status sexual preference tribal affiliation citizenship ability to pay contraceptive preference or number of pregnancies except as determined by statute or as otherwise validly specified in program regulation Family Planning services will be provided without residency or physician referral requirements Services must be provided in a manner which protects the dignity of the individual Sliding Scale Fees Fees will be assessed on a sliding scale based on current Federal Poverty Guidelines and a client s ability to pay Both family size and gross annual monthly weekly family income will be used to determine the per
5. Lab Hepatitis A B C Diagnostic 800 Intramuscular Injection of Antibiotics uomen 8 uD Removal ses Norplant Removal VVith Certificate 11976 155 89 Lab Hepatitis B High Risk 8670 Lab Hepatitis B Post Immunization 8734 Lab Hepatitis B Pre Immunization Lab Hepatitis C Antibody 9 8 4 4 1 Norplant Removal WWithout Certificate 11976 155 89 Lab Hepatitis High Risk Hepatitis C Sonogram BPP 175 00 Lab HIV 1 120 00 Sonogram Limited TB Skin Test 86580 TB X ray AP and lateral view Lab Pap Smear Lab UCG Pregnancy Test TB X ray single view 5400 Lab Urinalysis multidip Tubal Ligation Dr Office o 750 00 Lab Vaginal pH Tubal Ligation Hospital 1 400 00 Lab Viral Culture for Herpes 350 00 VAST Screened Lab VVet Prep N Antibody Elution N Antibody identification RBC Abs Lab Procedures Antibody Screen CH Metabolic Screen PKU 84030 Epi B cereus S aureus Culture 87077 Epi Clostridium perfingens toxin GM 87230 Epi Culture Stool Fecal Venipuncture fingerstick heelstick earstic 3541 Venipuncture under age 3 3640 Antibody titer N Glucose blood 1 hr post 50 gm glucose Epi Diptheria N Group B Strep Vaginal Rectal Swab Epi Insect Identification ticks only GTT Fasting specimen Epi Parasitology fecal 30 63 24 31 Epi Parasitology blood Malaria sm
6. e Bad Check Charge Adjustment Code 96 Record amount of 25 00 for fee Used to record the fee charged to the client for a returned Non Sufficient Funds check Records as a Bad Check Charge Appears in the Adjustments field in the Blue Grid Used with Adjustment Code 71 Bad Check Return Note These are the ONLY adjustment codes to be used in the local public health offices for the Family Planning Program 6 General Instructions for Adjusting Payments a Access the Patient Accounts screen Highlight the procedure to be adjusted or paid and select the Pay Adj button From the Select Transaction Type select the Adjust Charge radio button an Adjustment Code box will appear in the lower right corner Select the appropriate adjustment code Enter the Amount in the Amount box Select whether the payment is by cash or check in the Type box and press the Post button Close the Payments Adjustments box Returned Checks e f 0 Access the Patient Accounts screen Press the Pay Adj button From the Select Transaction Type select the Adjust Charge radio button an Adjustment Code box appears in the lower right corner Select 71 Bad Check Return in the Adjustment Code box Enter the amount of the returned check in the Amount box Press the Post button ONCE entry will not show until after Payments Adjustments box is closed Select 96 Bad Check Charge in the Adjustment Code box Enter
7. such as repeat of inadequate Pap smear additional packs of pills if we originally did not have them in stock or follow up visits for sterilization clients Determination should be made by medical staff IUD Insertion CPT4 code 58300 This is a procedure A visit code must also be chosen on the encounter form Norplant Removal CPT4 code 11976 This is a procedure A visit code must also be chosen on the encounter form Call the Help Desk if you are not familiar with the billing procedure In some cases the Certificate from the Norplant Foundation Removal Assistance Network will be taken from the client in lieu of payment for the visit IUD Removal CPT4 code 58301 This is a procedure A visit code must also be chosen on the encounter form Family Planning Procedures Charges Can be found in the GII Click on Training and scroll down to Charges Barrier Methods Charges Depo Provera Charges ECP s Pregnancy Test IUD Charges Norplant Charges OCP s Charges Prenatal Charges STD amp Refugee amp Other EPI Charges Sterilizations Charges TB Note This is an old form and costs have not been updated Costs can be seen on the new encounter form in this protocol The training stays the same Family Planning Program Protocol FPP 4 06 Appendix 14 OF 50 EXHIBIT 3 ENCOUNTER FORM PAGE 1 Name Clinical Encounter Form 2006 Programs Visits Pregnancy EDC and pos Procedure Codes
8. 25 00 in the Amount box Press the Post button Close the Payments Adjustments box Family Planning Program Protocol FPP 4 06 Appendix B 42 OF 50 Hardship Case a b c SL d O gt Access the Patient Accounts screen Check the Show gt checkbox and highlight the Payor 6 Patient Pay row Highlight the first transaction row from the hardship case encounter and press the Pay Adj button From the Select Transaction Type select the Adjust Charge radio button an Adjustment Code box will appear in the lower right corner Select 83 Credit Memo in the Adjustment Code box Enter the Amount in the Amount box Press the Post button Close the Payments Adjustments box Repeat the steps until all the procedures from the hardship case encounter are posted Donations Access the Patient Accounts screen In the summary area highlight the procedure you would like to apply the donation to The procedure must be Payor 6 Patient Pay Remove the check mark on Show Zero Balance and enter a check mark on Show Payor Pick and Show Charges Highlight the first charge and look at the amount Click on Pay Adjust button From the select transaction type box click on the adjust charge button an Adjustment code box will appear to the right of this button select 83 Credit memo In the transaction note type THIS IS A DONATION Enter the amount in t
9. 32 Satellite OMC o 32 Fee Collection Committee 32 c q tii 32 6 Record cns bre tudo dec od Ede cu dads 32 t Use of Norplant 33 Family Planning Services STD 33 34 E Requests for Information Fraud 34 F INPHORM Computer Fee Collection Procedures 34 38 List of Exhibits 1 Income 8 9 2 Consent for Family Planning 10 3 Family Planning Procedure 12 4 Public Health Division Individual Services Encounter 1 1111 13 18 5 Family Planning Poverty Guidelines 2006 19 6 Family Planning Payment Ledger A Monthly report form 24 25 7 Fee Deposit Register A monthly report 26 27 8 Deposit Slips A Monthly report 28 9 Adding Machine Tapes A monthly report Hm 29 10 eI E ora 30 31 11 Billing Letters 1 39 40 12 Copy of the Medicaid application English Spanish
10. 34 OF 50 EXHIBIT 6 Adding Machine Tapes ADDING MACHINE TAPES 2006 Health Office Month _ Today s Charges Amount Paid after adj Tape the adding machine tape here Tape the adding machine tape here Family Planning Program Protocol FPP 4 06 Appendix B 35 OF 50 EXHIBIT 9 Fax Sheet 1 NEW MEXICO DEPARTMENT OF HEALTH FAX TRANSMITTLE SHEET 505 PEE Please Print DATE ATTENTION Lucille Duran AGENCY Family Planning Program SENT TO FAX 505 476 8898 OFFICE PHONE 505 476 8869 NUMBER OF PAGES SENT BY HEALTH OFFICE NAME CITY COUNTY REGION MESSAGE Monthly Report for Comments IMPORTANT CONFIDENTIALITY NOTICE HE INFORMATION CONTAINED IN THIS FACSIMILE MESSAGE IS CONFIDENTIAL AND INTENDED SOLELY FOR THE USE OF THE INDIVIDUAL OR ENTITY NAMED ABOVE IF THE READER OF HIS MESSAGE IS NO HE INTENDED RECIPIENT OR THE EMPLOYEE OR AGENT RESPONSIBLE FOR DELIVERING IT TO THE INTENDED RECIPIENT YOU ARE HEREY BY NOTIFIED THAT ANY DISSEMINATION DISTRIBBUTION COPYING OR UNAUTHORIZED USE OF THIS COMMUNICATIO IS STRICTLY PROHIBITED and possibly illegal IF YOU HAVE RECEIVED HIS FACSIMILE TRANSMISSION IN ERROR IT SHOULD BE RETURNED TO THE SEND
11. 69 Erythromycin 250 mg tab 56 0048 7 06 Ethambutol Tab 100mg 30 P0050 15 70 Pyrazinamide 500mg 60 Ethambutol Tab 100mg 60 Poo51 2770 Pyrazinamide 500mg 100 167 4 15 097 46 85 Pyrazinamide 500mg 90 P0098 6843 Ethambutol Tab 100mg 90 052 3970 Ethambutol Tab 100mg 100 048 51 27 Rifamate 300 150 60 Rifampin Cap 150mg Authorization P0096 7681 0 118 68 18 Rifampin 150mg 30 PO100 23 64 Ethambutol Tab 400mg 30 0053 49 85 Rifampin 300mg 60 u Nitrofurantoin Cap 100 mg 12 Nitrofurantoin Cap 100 mg 40 m Ex Cipro 500mg 1 P0034 8 79 Ciprofloxacin 750mg 50 154 180 88 Clarithromycin 500mg 28 PO160 5634 Ethambutol Tab 400mg 60 0055 51 87 P0054 81 99 131 97 56 Ethambutol Tab 400mg 90 Ethambutol Tab 400mg 100 Appendix B 22 OF 50 Family Planning Program Protocol FPP 4 06 Rifampin Cap 300mg S Epi Authorization HE 075 10 90 P0076 2770 P0082 4 15 0138 6 36 0101 4421 Po139 9 06 EXHIBIT 3 ENCOUNTER FORM PAGE 6 DRUGS 2006 Page 2 cost uwrs se cowrmacerrwesureues cost RifampinSusp 10mgiml_ POAT 1220 Alesse 28 20007 522 Rifampin Susp Mbtures 01421 1570 Condom
12. Abstinence Primary contraceptive client left with continued STD Gonorrhea Genitourinary site Cervical Cap Male Condom STD Gonorrhea other site Depo Provera Method unknown STD Gonorrhea Throat Diaphragm Natural Family Planning STD Herpes Genital Penis ECP No Method Other reason STD Herpes Genital Vulvovaginal Female Condom One Month Hormonal Injection STD Herpes other places Hormonal Implant Oral contraceptive STD HP Genital Warts IUD Other method STD Molluscum Contagiosum Male Condom Partner Pregnant or Seeking Pregnancy STD Mucopurulent Cervicitis Method unknown Patch STD NGU Natural Family Planning Pregnant or Seeking Pregnancy STD NGU Contact to No Method Other reason Rely on Female Method STD No Evidence of STI One Month Hormonal Injection Spermicide 5 5 5 TD Pelvic Pain Oral contraceptive Sponge D Penile Discharge Other method Tubal Ligation TD PID Partner Pregnant or Seeking Pregnancy Vaginal Ring STD Rash non specific Patch Vasectomy STD Scabies Pregnant or Seeking Pregnancy Withdrawal TD Syphilis Congenital Rely on Female Method Family Planning Visit Type Family Planning Supplemental has feur required fields for every Family Planning Client at each visit They ara History Option gt Family Planning tab Primary Contraceptive prior to to
13. Alert in the INPHORM system Confidential do not contact a red dot on the outside of the chart on the label with client s name and a red dot inside on the Client Information Form on the labels with the client s name and current visit date are When the client is no longer a Confidential Client draw a black line through the red dot on the outside label It is imperative that the client s confidentiality is upheld within the INPHORM system Clerks are required to shut down or lock their workstations when leaving their computer area Medicaid coverage can be used for confidential clients with Medicaid and Salud Coverage should be billed to Medicaid Explanation of Benefits EOB or correspondence will not go to the client s home THE DISTRICT DIRECTORS ARE RESPONSIBLE FOR ENSURING THAT LOCAL HEALTH OFFICE STAFF COMPLY WITH THESE REGULATIONS NURSE MANAGERS AND DIRECTORS OF NURSING SERVICES DNS WILL ASSIST WITH QUALITY ASSURANCE IMPLEMENTATION Family Planning Program Protocol FPP 4 06 Appendix B 2 OF 50 B DEFINITIONS Ability to pay Means an evaluation of a client s family size and gross annual family income to determine the percentage of assessed charges that will be billed to client Adolescent growth amp development definition Any individual between the ages of 12 19 years age 19 included but not age 20 Adjustment Discount the dollar amount deducted from the client s charges based on the client s Percentage Pay Rat
14. SCHIP children have small ee co payment requirements Native American children who are eligible for SCHIP do not make co payments W MEDICAID FOR PREGNANCY RELATED SERVICES ONLY covers only those servicas that are related to the pregnancy Coverage for these services are provided for up to two months after the month in which the child is born or the pregnancy ends W MEDICAID FOR FAMILY PLANNING SERVICES covers only those services that are related to family planning for women of child bearing age You need to provide proof of the following W income for the past four weeks W Social Security Number SSH or proof of application for SSN W Children s ages W Other health insurance if any Pregnancy due date H you need help filling in this application or in getting the needed information contact your local ISD office After your application is received all documents will be reviewed If the documents are incomplete you will be asked to provide the needed information decision on your application will be made within 45 days unless you ask for more time to get information You will be sent a letter about your application APPLICANT Please keep this sheet for your records if you parson with disability and you require this infarmation in an alternative format cr require a special accommodation to participate in public hearing program services please contact the NM Huraan Sarvices Depa
15. custodian changed by phone and she will request the information that is required ii She will then initiate the memorandum to your District Financial Officer for their authorization iii After receiving authorization from your DFO Ferm submits a voucher to Dept of Finance and Administration for the final authorization and they will issue the change fund warrant iv The warrant will then be sent directly to the health office and cashed by the assigned custodian for change 2 To change a custodian Submit a memorandum stating the name of the person replacing the primary custodian and the reason for the change Send the memorandum to the attention of Kathy Tall Bear General Accounting PO Box 26110 Santa Fe NM 87502 3 Theft of a Change Fund i In the case that the change fund or a portion of the fund is stolen the police should be notified immediately ii Submit a memorandum addressed to Accounting Bureau and Dept Finance and Administration stating the theft and the amount that needs to be replaced attach the original police report Send this documentation to the attention of Kathy Tall Bear General Accounting PO Box 26110 Santa Fe NM 87502 with a copy to Ferm Najera Family Planning Program P O Box 26110 Santa Fe NM 87502 DEPOSITS MUST BE MADE DAILY AT THE DESIGNATED BANK WITHIN TWENTY FOUR 24 HOURS OF RECEIPT PER ADM 01 15 01 Cash counts shall be made and documented as required by Title X Guidelines Periodic un
16. due to the INPHORM system s ability to maintain tracking of clients past due accounts Remember in the eyes of the State of New Mexico the account is not forgiven Client accounts will remain active within the INPHORM System If client comes in who had an old balance the PH Turbo write off from their ledger card needs to be entered into the INPHORM System as a beginning balance The only possible exceptions are Bankruptcy and client deaths These need to be decided on a case by case basis with the Fee Collection Liaison at 476 8869 Corrections Corrections need to be made according to appropriate Systems directions Corrections must be done with the help of the INPHORM help desk staff in order to maintain the integrity of the INPHORM System The help desk number is 1 800 280 1618 Enter the call ticket number on the McBee card for documentation on percent pay clients m Accounts Receivable Report A R Presently Waiting For INPHORM Reports Design At present the Family Planning Payment Ledger Exhibit 5 will serve as the Accounts Receivable Report Until the INPHORM management along with the Family Planning Program can design and implement the reports for the Fee Collection piece The clerk and the nurse manager should check these reports for accuracy before signing and submitting them n Monthly Report Packet Due by the 5 of every month Family Planning Program Protocol FPP 4 06 Appendix B 27 OF 50 At the end of each
17. knowledge 1 give my permission to HSD to contact persons or agencies to obtain needed information about me Ihave been given my Medicaid rights and responsibilities Applicant s Signature Date Signature of Person Who Helped Complete the Application Witness if applicant signed with an X Family Planning Program Protocol FPP 4 06 Appendix B 51 OF 50 SOLICITUD DE MEDICAID PARA MUJERES NINOS Y FAMILIAS favor de rellenar todos los espacios en blanco en la solicitud respecto a Ud y las personas que viven en su hogar Si necesita m s espacio para responder a cualquiera de las preguntas use una hoja de papel Devuelva la solicitud a la Oficina Local de Asistencia Econ mica Income Support Division ISD o ala persona que est a cargo de determinar si Ud tiene derecho de recibir los beneficios temporales de Medicaid Esta es una solicitud para los cuatro programas de Medicaid indicados en la lista m s abajo Hay otros programas de Medicaid que requieren una solicitud distinta que no sea sta Para que Ud califique para recibir los beneficios de Medicaid las personas que viven con Ud en su hogar tienen que satisfacer ciertos requisitos que constan en las directivas Ud puede indagar acerca de esas directrices comunic ndose con la oficina ISD o llame gratis al n mero 1 888 997 2583 W JUL MEDICAID provee los beneficios de Medicaid a padres madres o parientes que tienen nifios menores de 19 que dependen en alguna
18. month the following reports are to be prepared as a packet A copy of the report is to be sent or faxed to The Fee Collection Liaison Family Planning Program PO Box 26110 Santa Fe New Mexico 87502 505 476 8869 or FAX 505 476 8898 Mail a separate copy to Financial Control Attn Kathy Tall Bear Runnels Bldg Room S3150 1190 St Francis Santa Fe NM 87502 Fax 827 0873 phone 505 827 2693 The FP Fee Collection Liaison will review each Monthly Report Packet received to ensure that each local health office is complying with this requirement and that all reports are being submitted on time The Fee Collection Liaison keeps track of the Monthly reports received from each office including whether they were late or incomplete as this is part of the clerks PAD If you did not charge any clients or collect any money during the month please make a note on the Payment Ledger and send it in by itself The monthly packet should include in this order 1 Family Planning Payment Ledger On top This is for percent pay clients Medicaid clients and clients who are 0 pay do not need to be listed Please fill in all the information requested on this form Exhibit 6 2 Federal Fee Deposit Register Second from the top Please note at the bottom of the Fee Deposit Register form under Notes Comments Put in the date of when you mailed your last bills for Family Planning 3 Copy of deposit slips validated by bank Attached t
19. persona para que los sostenga a n si la familia no califica para recibir asistencia en efectivo o no desea solicitar asistencia en efectivo El programa de Medicaid est totalmente separado de la asistencia en efectivo y los beneficios de Medicaid que la persona recibe no cuentan en el limite de tiempo de la asistancia que la persone recibe en efectivo W MEDICAID PARA NI OS facilita cobertura para los menores de 19 a os Algunos ni os podr n tener derecho de recibir los beneficios confarme al Programa de Seguro de Salud para Ni os State Children s Health insurance Program SCHIP Los ni os que tienen el programa SCHIP tienen que satisfacer jos co pagos minimos Ni os Nativo Americanos que re nen los requisitos para ta cobertura SCHIP no paganios co pagos M MEDICAID SOLO PARA SERVICIOS RELACIONADOS CON EL EMBARAZO cubre Gnicamente tos servicios relacionados con el mbarazo Este programa cubre estos servicios hasta por dos meses despu s del mes en que la madre da aluz o cuando termina el embarazo MEDICAID PARA SERVICIOS DE PLANIFICACI N FAMILIAR cubre nicamente log servicios relacionados con la planificaci n familiar pera mujeres de edad en que pueden dar a luz Ud tiene que proveer las siguientes pruebas W Sus ingresos durante las ltimas cuatro semanas de su Seguro Social NSS o prueba que Ud ha solicitado su n mero de seguro social M Las edades de sus ni os Otro seguro de salud qu
20. recibo los beneficios de Medicaid mi y o para otras personas autom ticamente yo le cedo al HSD todos mis derechos de recibir apoyo m dico y la suma para pagar la atenci n m dica Un tercero podr incluir a un padre o madre ausente a una compa a de seguro o otra persona que deber pagar la atenci n m dica y los servicios Entiendo que tengo que ayudarle al HSD a s identificar al pedre del ni o que reciba la cobertura de Medicaid y que naci sin que el padre haya estado casado con le madre del ni o y 8 Idenil icer a todos los terceros que tengan que pagar la atenci n m dica y los servicios Entiendo que sino le ayud al HSD es posible que no reciba los beneficios de Medicaid o posiblemente pierda mis beneficios salvo que yo indique porque no puedo ayudarle al HSD EMISI N DE INFORMACION MEDICA Al firmar esta solicitud le doy permiso al HSD que examine las hojas cl nicas y expedientes m dicos que sean necesarios pare tomar decisiones sobre mis derechos y o tas pagos de beneficios DECLARACI N DE DERECHOS CIVILES Todos los programas que administre el Departamento de Servicios Humanos HSD son programas en los que se observa la igualdad de oportunidades Es que HSO discrimine en contra de la persona que solicita los beneficios de cuaiquiera de los programas debido a raza color origen nacional sexo edad religi n creencias politicas o discapscidad Las quejas de discriminaci n se pueden pres
21. referral or a report to a legal authority will be filed as required by law Entiendo que mis expedientes se mantendr n confidencialmente y ser n compartidos s lo con mi permiso o en caso que sean requerido por la ley y que mi informaci n de la salud no ser compartido a otra agencia o otra persona excepto como especifica el Aviso Acerca de la Privacidad de las Pr cticas de Salud de la cual he recibido una copia Entiendo que en caso de abuso o la negligencia de menores o en las emergencias m dica tales como riesgo de suicidio o riesgo de lastimar a otra persona una referencia o un informe a una autoridad legal ser archivado como es requerido por la ley 3 lunderstand that if am seen in the clinic and receive Family BUE services and supplies may be charged from a sliding fee scale 1 will be responsible for these charges if they apply Entiendo que si recibo tratamiento en la cl nica y recibo los servicios de Planificaci n Familiar ser responsable de los costos seg n el nivel de mis ingresos Ser responsable por los costos de los servicios recibidos Client s Signature Date Firma de Cliente Fecha Family Planning Program Protocol FPP 4 06 Appendix B 12 OF 50 4 Explanation Of Family Planning Service Visit Please refer to Using the INPHORM Encounter Form Manual Appendix A Decisions for Use of Clinical Visit Codes located in the for detailed information when selecting the type of visit New P
22. ya puedo solicitar una audiencia imparcial va sea por tel fono en persona o por escrito dentra de 90 dias a partir de la fecha en que se axpida la decisi n en mi caso Puedo nombrer a persona que me represente Entiendo que si no estoy de acuerdo con cualquiera decisi n tomada en cualquier asunto concerniente a mi caso antes de audiencia tengo el derecho de examinar el expediente de mi caso y otros documentos que se hayan utilizado para decidir mi casa INFORMACI N CONFIDENCIAL Toda la informaci n que yo facilite al HSD es confidencial El HSD facilitar dicha informaci n ajos empleados del HSD que la necesiten para administrar los beneficios de los programas que yo he solicitado Se podr remitir la informaci n confidencial a otras agencias oue administran programas federales o programas financiados con fondos federales Se utilizar toda la informaci n con el fin de determinar si tengo derecho de recibir ios beneficios que ya he solicitad y o para que faciliten los servicios OBLIGACI N DE REPORTAR CAMBIOS La informaci n que yo facilito durante el tramite de la solicitud se usa para determinar si tengo derecho de recibir los beneficios Dentro de diez 10 d as a partir la fecha del cambio o seg n se requiera tengo la obligaci n de reporter cambios Lo anterior engloba cambios de direcci n ingresos recursos seguro de salud y de personas que viven conmigo en mi hogar CESI N DEL DERECHO DE PAGO Entiendo que si
23. 100 14 0 00 54 000 00 0 100 20 000 01 22 000 00 10 110 9 37 000 01 40 700 00 10 110 54 000 01 59 400 00 10 110 22 000 01 24 000 00 20 120 9 40 700 01 44 400 00 20 120 14 59 400 01 64 800 00 20 120 24 000 01 26 000 00 30 130 9 44 400 01 48 100 00 30 130 14 64 900 01 70 200 00 30 130 26 000 01 28 000 00 40 140 9 48 100 01 51 800 00 40 140 70 200 01 75 600 00 40 140 E y 0 A 0 28 000 01 30 000 00 50 150 9 51 900 01 55 500 00 50 150 14 75 600 01 81 000 00 50 150 000 000 00 60 160 500 01 59 200 00 60 160 1 000 01 86 400 00 60 160 30 000 01 32 000 00 60 160 9 55 500 01 59 200 00 81 000 01 86 400 00 60 160 N A Jb o E o 32 000 01 37 000 00 70 185 9 5920001 68 450 00 70 185 86 400 01 99 900 00 70 185 1000 1000 Jb d A5D 000 5 300 Don o 37 000 01 40 000 00 80 200 9 68 450 01 74 000 00 80 200 99 900 01 108 000 00 80 200 40 000 01 50 000 00 90 000 01 92 500 14 108 000 01 135 000 00 90 A 40 000 01 50 000 00 90 250 9 s74000 01 92 500 00 90 250 14 108 000 01 135 DO0 00 90 50 000 01 999 999 99 100 251 9 92500 01 5999 999 99 100 251 14 135 000 01 999 999 99 100 pai Eee
24. 27 58 Total Cash 160 27 Clerk s Signature Title Page 1 of 1 EXHIBIT 7 BLANK PAYMENT LEDGER FAMILY PLANNING PAYMENT LEDGER 2006 Month Name of Health Office Region Co site Family Planning Program Protocol FPP 4 06 Appendix B 30 OF 50 Total Checks Month Total Cash amp Checks Total Cash Clerk s Signature Title Page of Date Deposit Patient Name Birth File Today s Previous Amount Donations Payment Balance Date Charges Balance Paid Type Due Family Planning Program Protocol FPP 4 06 Appendix B 31 OF 50 EXHIBIT 7 FEE DEPOSIT REGISTER A MONTHLY REPORT EXAMPLE FEE DEPOSIT REGISTER 2006 Region 2 Site Office SantaFe Submitted by LucilleDuran Phone Number 505 476 8869 Fax Number 505 476 8898 Deposit Number Date of Deposit Amount Deposited Deposited by TOTAL OF DEPOSIT 227 58 Notes Comments Billing Letters sent on January 30 2006 Family Planning Program Protocol FPP 4 06 Appendix B 32 OF 50 EXHIBIT 6 BLANK FEE DEPOSIT REGISTER FEE DEPOSIT REGISTER 2006 Region Site Office Submitted by Phone Number Fax Number Deposit Number Date of Deposit Amount Deposited Deposited by TOTAL OF DEPOSIT Notes Comments Billing Letters sent on Family Planning Program Protocol FPP 4 06 Appendix B 33 OF 50 EXHIBIT 6 COPIES OF DEPOSITS SLIPS COPIES OF DEPOSIT SLIPS VALIDATED BY BANK 2006 Health Office Family Planning Program Protocol FPP 4 06 Appendix B
25. 3 7 5 00 Number in household supported by this income Numero de personas en la casa sostenida por estos ingresos Weekly Por semana MULTIPLY BY 52 Bi Weekly Quincena MULTIPLY BY 26 Semi Monthly 2 veces mes MULTIPLY BY 24 Monthly Mensual MULTIPLY BY 12 Annual Annual MULTIPLY BY 1 16 500 00 STAFF USE Client is at 0 P t P lent is a wv ay 516 500 00 I have seen this document and witness client signatures STAFF SIGNATURE amp TITLE Lucille Duran Clerk S pecialist Dates 1 12 06 INCOME AFFIDAVIT DECLARACION DE INGRESO On the following lines please tell how much you provide for your basic needs Who pays rent utilities food etc If you receive cash how much and from whom Is this full time part time or seasonal employment En las siguiente l neas por favor d ganos como provees por sus necesidades b sicas Qui n paga el alquiler las utilidades la comida etc Si usted recibe el dinero en efectivo cuanto y de quien Este trabajo es de tiempo completo medio tiempo o por temporadas Staff The client should answer the above questions for this affidavit to be considered complete Family Planning Program Protocol FPP 4 06 Appendix B 10 OF 50 My husband worksand stay at hometaking care of our ba by I have told the truth about ALL sources of my family s income To the best of my knowledge I have not given false or withheld in
26. 5 680 01 18 130 00 70 185 6 42 980 01 49 590 00 70 185 70 080 01 81 030 00 70 185 18 130 01 19 600 00 80 200 6 49 580 01 53 600 00 80 200 81 030 01 87 600 00 80 200 19 600 01 24 500 00 90 250 6 53 600 01 67 000 00 90 250 587 600 01 109 500 00 90 250 24 500 01 999 999 99 100 251 67 000 01 999 999 99 100 251 11 109 500 01 999 999 99 100 HA AN eae ko A A A eet O jk O a 0 00 13 200 00 0 100 0 00 30 200 00 0 100 12 0 00 47 200 00 0 100 13 200 01 14 520 00 10 110 30 200 01 33 220 00 10 110 47 200 01 51 920 00 10 110 14 520 01 15 840 00 20 120 33 220 01 36 240 00 20 120 51 920 01 56 640 00 20 120 15 840 01 17 160 00 30 130 36 240 01 39 260 00 30 130 56 640 01 61 360 00 30 130 17 160 01 18 480 00 40 140 39 260 01 42 280 00 40 140 61 360 01 66 080 00 40 140 18 480 01 19 900 00 50 150 42 280 01 45 300 00 50 150 66 080 01 70 800 00 50 150 19 800 01 21 120 00 60 160 45 300 01 48 320 00 60 160 70 800 01 75 520 00 60 160 21 120 01 24 420 00 70 185 48 320 01 55 870 00 70 185 75 520 01 87 320 00 70 185 24 420 01 26 400 00 80 200 55 870 01 60 400 00 80 200 587 320 01 94 400 00 80 200 26 400 01 33 000 00 90 250 60 400 01 75 500 00 90
27. 96 pay for clients Hardship Case Clients may experience problems beyond their control which constitute a temporary financial hardship like death or illness in the family fire theft high medical bills drug abuse bankruptcy etc The charges for that day only can be discounted to 0 See page 7 Special Circumstances and page 36 Credit Memo Adjustment Code 83 Income and Family Size Declaration The form on which the client attests to family size and gross income to establish their Percentage Pay Rate Remember teens adolescents are to be considered under their own income MCO Managed Care Organization An organization that is licensed to manage coordinate and assume financial risk on a capitated basis for the delivery of a specified set of services to enrolled members in a given geographic area Medicaid Waiver 1115 35F A provision of Federal law that allows HCFA to approve a Family Planning program in the State s Medicaid plan In New Mexico the waiver applies to women at 185 of poverty or below Partial Payment The designation for clients who receive an adjustment to their charges in setting their fee Patient Account Card Ledger Card The individual patient account card reflecting all charges adjustments and payments made on a historical basis McBee Ledger Cards must be kept for percent pay clients t should be noted that under certain circumstances cards may not match what is in INPHORM for instance if patient vi
28. 98 Isoniazid 100mg 30 Albendazole Tabs 200mg 1 P0124 4 32 Albendazole Tabs 200mg 10 P0151 73 15 Amoxicillin 500mg caps 21 P0029 7 69 Amoxicillin 500mg caps 30 0126 9 40 Isoniazid 100mg 60 Isoniazid 300mg 30 P0133 23 03 PO065 454 066 4 90 Meclizine 25mg 5 Azithromycin 500mg 2 tabs P0175 12 60 BAYRHO D 300gm Syringe each P0158 109 30 Metronidazole 250 mg 28 Bicillin Inj 1 24 Units P0032 5 67 Metronidazole 250 mg 90 P0068 3 74 0163 5 53 P0070 3 77 Metronidazole 250 mg 8 P0071 475 Cetpodoxime 200mg 2 PO159 3 80 Ceftriaxone 250 mg vial P0033 7 82 Metronidazole 250 15 0135 6 40 0072 4 06 Mycobutin Cap 150mg 100 P0074 26144 Cephalexin 250mg 28 P0149 5 10 Nystatin Topical Cream Clarithromycin 250mg 60 Ofloxacin 400mg 28 Clotrimazole vag cream 45gm Permethin 5 Cream 60m 161 8840 0035 5 65 Combivir Tab 60mg 8 P0037 60 16 Permethin Lotion 196 Lice Treatment Phenazopyridine 200mg 9 P0164 53 82 P0165 620 PO166 6 96 Podophyllin 20 Topical Doxycycline 100 mg cap 6 P0128 4 66 Doxycycline 100 mg cap 14 POO42 5 03 Doxycycline 100mg cap 20 129 6 90 Doxycycline 100 mg cap 28 P0043 8 18 Premarin Cream 42 g tube Prenatal S Vitamins 100 Promethazine Supp 25mg 4 Pooss 469 090 35 02 PO146 17 09 P0094 5
29. 99214 104 76 Comprehensive 99215 128 45 No Charge Visit documented in chart 99211nc SP Problem Focused Brief 94 76 Expanded Problem Focused 142 14 Diabetes SMT services group 2 or more per 30 m Medicaid MOSAA Application Presumptive Eligibility Application Detailed 189 52 Comprehensive Moderate 99344 236 90 SP Home Visit Establish Patient CODE COST Problem Focused Brief 99347 47 38 Expanded Problem Focused 99348 71 07 Detailed 94 76 Family Planning Application Child Health Application Prenatal MOSAA Application Prenatal Presumptive Eligibility Child Health Presumptive Eligibility Pregnancy Intendedness Did you want this pregnancy now Comprehensive Moderate 118 45 500 0108 CODE 9999M 9999P 4738 COST 73 18 7318 59214 47 38 Home Management of Gestational Diabetes Alert Date Family Planning Program Protocol FPP 4 06 later never EDC Date mmddyy Notes Appendix 15 OF 50 Family Planning Program Protocol FPP 4 06 Appendix B 16 OF 50 Name Programs Visits Pregnancy EDC and Procedures Codes 2006 Page 2 Procedures 1 CODE cost sP Clinical Breast Exam DOB Date Lab Procedures CODE COST Lab Hepatitis A Diagnosis 8670 Destruction of a Lesion VVart Tx Lab Hepatitis A Immune Status 8670 Diaphragm Fitting
30. B 46 OF 50 Oficina de Salud Publica Family Planning Program Protocol FPP 4 06 Appendix B 47 OF 50 MEDICAID APPLICATIO FOR WOMEN CHILDREN AND FAMILIES INFORMATION FOR THE APPLICANT Please complete all the spaces on the application about you and your household members If more space is needed to answer any of the questions on this application you may use another sheet Return the application to the local Income Support Division ISD office or to the person who is determining your temporary Medicaid eligibility This is an application for the four Medicaid programs listed below There are other Medicaid programs that require an application different from this one To qualify for Medicaid your household must meet certain guidelines You may be eligible for benefits for up to three months before your application date You may ask about these guidelines by contacting the ISD office or by calling toll free 1 888 997 2583 W JUL MEDICAID provides Medicaid to parents or caretaker relatives with dependent children under age 18 even if the household does not qualify for cash assistance or does not wish to apply for cash assistance Medicaid is totally separate from cash assistance and receiving Medicaid benefits will not count toward the cash assistance time limit M MEDICAID FOR CHILDREN provides coverage for children under age 19 Some children may ba eligible under the State Children s Health Insurance Program SCHIP
31. Balance fields in the Blue Grid e Donations Adjustment Code 83 a Use to record donations from clients already registered in the INPHORM system Remove the Check mark on Show Zero Balance Enter a check mark on Show Payor Pick and Show Charges This is a list of unpaid charges The first line of charges will be highlighted in dark blue See the amount in the Charge Balance post a payment for that amount or is the donations is less post the donation amount give To post donation click on Pay Adjust then Adjust charge Code Adjustment enter 83 In the Transaction note type THIS IS A DONATION Enter the amount in the Amount box and press Post button This must be done to each of the charges listed in this area if posting a large donation Family Planning Program Protocol FPP 4 06 Appendix B 41 OF 50 e Check Return Adjustment Code 71 Used to reverse a client payment previously made when a check is returned for non sufficient funds Records as a Bad Check Return Appears in the Adjustments field in the Blue Grid Used along with Adjustment Code 96 Bad Check Charge e Credit Memo Adjustment Code 83 Used to adjust charges for percent pay clients deemed a hardship case Records as a Credit Memo Appears in the Adjustments field in the Blue Grid Note This is ONLY to be used for hardship cases DO NOT reduce the client s income This credit properly adjusts the charge so that the client does not pay for today s visit
32. Date SP Program Codes CODE Program Codes CODE 16 Adult Health AH Immunization 8 Breast and Cervical Cancer BCC Refugee Health 3 Children Medical Services CMS 4 STD HIV AIDs STD SNaP Pagar CODE Payor Class AN A AAA A A A EAN AAA A A pi A EA E A AA PE AN FEAT A SNAP 7 Encounter Visit Code AA E APPEAR E A ES m maki a t imt COE AAA some sn Dro wa aa e Y Pesa e AAA AAA sP CODE cost Telephone Counseling Office Visit New Patient prre ia Problem Focused Brief Problem Focused Brief Pay AA Codes SP _ EM EN ew E E Eu mm SEES Em re cone CODE o 0 Detailed 99202 88 87 88203 112 66 Expanded Problem Focused Detailed Comprehensive High Prenatal Visit Codes Prenatal Visit 1 3 use reg Visit codes Comprehensive Moderate 99204 136 35 Comprehensive High 99205 152 14 sP Office Visit Establish Patient CODE COST Problem Focused 99212 48 17 99213 81 08 Prenatal Visit 5 6 7 8 9 10 CODE 4 D 3 COST 7 90 15 79 4738 COST Prenatal visit 4 58425 280 00 Prenatal visit 7 Patient Training Code Diabetes SMT services individual per 30 min 58426 CODE 0108 504 89 COST 47 38
33. E SALUD Alguna persona s que vive con Ud en su hogar tiene seguro de salud Osi nes m s abajo MAD 009 must be completed 1 2 3 Sicontesta S indique quie je ha cancelado la cobertura de seguro para un ni o o ni os dentro de los ltimos seis meses si Ud contesta Si favor de indicar el nombre del ni o o de los ni os y la fecha que se concel el seguro 1 2 3 Explique por qu se cancel el seguro si D No Family Planning Program Protocol FPP 4 06 Appendix B 55 50 MADSP 048 Reexaminado 11 12 04 P gina 4 INGRESOS Indique m s abajo la cantidad de dinero que reciben las personas que viven en su hogar con Ud Incluya el dinero qu reciben del entrenamiento para trabajar o de su trabajo auto empleo prestaciones del gobierno SSA VA etc pensi n alimenticia regal as pensiones fideicomisos inversiones ingresos de propiedades sostenimiento de los ni os desempleo y toda otra cantidad de dinero devengado o no devengado Nombre de la Persona Nombre del Empleador Persona Cada Cu nto Tiempo que Recibe el Dinero o Agencia que Provee el Dinero lo Recibe sin CUIDADO DE CARGAS FAMILIARES Paga Ud a alguna persona para que cuide a un ni o suyo o familiar para que Ud trabaje se entrene para trabajar Osi A qui n cuida 2 3 Qui n Facilita El Cuidado Suma de Dinero Que Paga Cada Cu nto Tiempo Pa
34. ER AS SOON AS POSSIBLE Family Planning Program Protocol FPP 4 06 Appendix B 36 OF 50 EXHIBIT 7 Fax Sheet 2 NEW MEXICO DEPARTMENT OF HEALTH FAX TRANSMITTLE SHEET 505 Please Print DATE ATTENTION Kathy Tall Bear AGENCY Administrative Services Division of DOH SENT TO FAX 505 827 0873 OFFICE PHONE 505 827 2693 NUMBER OF PAGES SENT BY HEALTH OFFICE NAME COUNTY REGION MESSAGE Monthly Report for Comments IMPORTANT CONFIDENTIALITY NOTICE THE INFORMATION CONTAINED IN THIS FACSIMILE MESSAGE IS CONFIDENTIAL AND INTENDED SOLELY FOR THE USE OF THE INDIVIDUAL OR ENTITY NAMED ABOVE IF THE READER OF THIS MESSAGE IS NOT THE INTENDED RECIPIENT OR THE EMPLOYEE OR AGENT RESPONSIBLE FOR DELIVERING IT TO THE INTENDED RECIPIENT YOU ARE HEREY BY NOTIFIED THAT ANY DISSEMINATION DISTRIBBUTION COPYING OR UNAUTHORIZED USE OF THIS COMMUNICATION IS STRICTLY PROHIBITED and possibly illegal IF YOU HAVE RECEIVED THIS FACSIMILE TRANSMISSION IN ERROR IT SHOULD BE RETURNED TO THE SENDER AS SOON AS POSSIBLE Family Planning Program Protocol FPP 4 06 Appendix B 37 OF 50 Appointment Book Log For a
35. Entry a From the Patient Accounts screen select the Pay Adj Button b Go to Select Transaction Type and activate the Patient Prepayment button c Enter the Amount of the payment in the Amount box Choose Check or Cash in the Type box and press the Post button d Close the Payments Adjustments box The payment will record as a Prepayment 4 Back Out Client Prepayment Entry If a client has prepaid for services and then comes in to the Health Office and receives the services you must back out the prepayment entry and post the payment as a simple payment a From the Patient Accounts screen select the Pay Adj Button b Go to Select Transaction Type and activate the Patient Prepayment button c Enter the NEGATIVE Amount Example 75 00 of the payment in the Amount box Choose Check or Cash in the Type box and press the Post button d Close the Payments Adjustments box The payment will record as a Prepayment e After you back out the Prepayment follow the Simple Client Payment steps to enter the payment If you have questions about Backing Out Client Prepayment or need help posting Client Prepayment Entries call the Help Desk 5 ADJUSTMENTS Adjustment Codes e Overpayment Adjustment Code 58 Use to record overpayments credit balances from clients already registered in the INPHORM system who have received services Records as an Overpayment Affects the Payment and
36. G RIGHTS understand may request a fair hearing either by telephone in person or in writing within 90 days of the cate the decision was made on my case may have another person represent me understand that if do not agree with any decision made any matter concerning my case have the right to look at my case record and other documents used to dacide my case before the hearing CONFIDENTIALITY All information 1 give to HSD is confidential This information will be given to HSD employees who need it to manage the programs for which have applied Confidential information may also be released to other agencies managing federal or federally tunded programs All information will be used to determine eligibility and or to provide ser vices RESPONSIBILITY TO REPORT CHANGES The information give during the application process is used to determine aligibil ity itis my responsibility to report changes within ten 10 days of the date of the change or as otherwise required This includes changes in address incorne resources health insurance and persons living with me ASSIGNMENT OF RIGHTS TO PAYMENT understand that by getting Medicaid benefits for myself and or other persons automatically give HSD all rights to medical support and to payment for medical care from a third party A third party can include an absent parent an insurance company or another person who must pay for medical care and services l understand that m
37. INCOME List all money received by people in your household This includes money from job training or work self employment government benefits SSA VA etc alimony royalties pensions trusts investments property income child support unemployment and any other earned or unearned money from any source Name of Employer Person or Agency Providing the Money Do you pay anyone lo care for a child or other household member so you can work or train for a job 0 ves Who is being cared for 1 2 3 WhoProvides the Care AmountPaid How Often is the Amount Paid COMPLETE THIS SECTION ALSO IF YOU ARE APPLYING FOR PRESUMPTIVE ELIGIBILITY Are you or your child ren receiving Medicaid now O ves If Yes tell the agency or doctor you or your child ren already have Medicaid and show your Medicaid card If you or a household member are pregnant has presumptive eligibility been granted for this pregnancy ves If Yes you are not eligible for presumptive eligibility for the remainder of this pregnancy Has your child ren received presumptive eligibility within the last six months O ves No If Yes your child ren is not eligible for presumptive eligibility have read all of the information in this application or it has been read to me This application is only for Medicaid I swear under penalty of law that the information have given in this application is true complete and correct to the best of my
38. NEW MEXICO PUBLIC HEALTH DIVISION FAMILY PLANNING PROGRAM FEE COLLECTIONS PAGE u L 2 B Dennllion8 uuu c M m 3 5 C Telephone Appointment Screening centres eee 5 D System Components and 0 nes 5 1 System Components and Policies 6 2 Declaration of Family Size and Income 6 3 Special Circumstances 7 4 Explanation of Family Planning 11 12 5 Accounting 20 a FUMAS m 20 D PMOI u uk EE 20 107 COOP ES 21 2 2 E E E 21 e Bankruptcy Notices E 21 OM Mi 21 9 DOM A oe 21 A 21 Bank Withdrawals 21 jo Biling and Fee 22 k Wie OI rm qw 22 epi eren 22 m Accounts Receivable 22 n Monthly Report 23 o Appointment BOOK L0g tire i AA e Gu vede dua
39. actical reasons cannot be expected to be collected in due course Clerks can enter a green alert in INPHORM so clerks at other health offices will know to collect from the client Write off Write offs are no longer be done at the local level Contact the Fee Collection Liaison if there are special circumstances such as bankruptcy or death If a client owes a balance do not archive the financial file even if the client has not received services for several years If and when the client appears at any health office in the future the documentation can be found and the charges can then be explained to the client C TELEPHONE APPOINTMENT SCREENING Important information to obtain to determine priority of clients served The Family Planning Program s priority is providing services to adolescents and low income clients and women with high risk factors The Family Planning program encourages partner involvement in all Family Planning related health visits Family Planning client s partners are always welcome 1 Age 2 Income Bracket As part of the preliminary consultation the client should be advised that there is a sliding scale charge for the services to be rendered which is based on gross family income and family size and that payment at the time of services is expected You can explain that the fee is necessary in order to continue operations and to expand the program Adolescents including age 19 attending clinic and who want confi
40. ad Date Dear According to our records your account is month s past due Please remit payment or contact our office to make other payment arrangements Your current balance as of is for services you have received Call 505 if have any questions Thank you for your attention to this matter Your balance is Overdue since DOB Account If paying by check or money order please make it out to Family Planning Title X Mail to Your health office name Your office address Your city state amp zip code Attention Family Planning Clerk Sincerely Your Local Health Office Staff Family Planning Program Protocol FPP 4 06 Appendix B 45 OF 50 EXHIBIT 9 Billing Letter Spanish 1 Example Print on letterhead Fecha Estimado Paciente Seg n nuestros registros su cuentaes mes s vencido Remita por favor el pago o avise nuestra oficina para hacer otros arreglos del pago Su equilibrio seg n es para los servicios que usted ha recibido Llama 505 si usted tiene cualquiera pregunta Gracias para su atenci n a esta cuesti n Su equilibrio es Atrasado desde que Fecha de nacimiento Numero de Referencia Si paga por cheque o giro postal por favor haga lo a Family Planning Title X Envia el pago a Your health office name Your office address Your city state amp zip code Atenci n Family Planning Clerk Sinceramente Family Planning Program Protocol FPP 4 06 Appendix
41. ancial hardship and after documenting the hardship in the medical record may instruct the clerk to adjust fees for past services The charge for services that day only will be assessed at zero The clerk and nurse should take a team approach in making the decision The hardship must be recorded as a green alert status in the INPHORM System along with the date encounter number applicable to the hardship The clerk does a credit memo in the Patient Accounts Module and use Code 83 to make the charges Zero 0 for that day s Family Planning services Document the Hardship in the McBee ledger card Advise the client to bring in proof of income for the next visit or they will be asked to sign an income affidavit again A client is able to document hardship as many times as necessary b Adolescents 19 years of age or less The only time an adolescent s income is based on that of their parents or guardian s economic unit is when there is absolutely no issue with confidentiality Clients who are attending clinics with their parents knowledge can still be assessed on their own income and not on the basis of their family s economic unit and income if there is any confidentiality concern Adolescents who are seeking confidential services can do so and therefore be assessed only on their own income Local Health Office staff should determine the income status of adolescents and those with incomes should have that income assessed as their own e
42. anning Program Protocol FPP 4 06 Appendix B 52 OF 50 Family Planning Program Protocol FPP 4 06 Appendix B 53 OF 50 MADSP 048 Reexaminado 10 3 02 P gina 2 REESE n nx Lea cuidadosamente antes de completar esta solicitud AL FIRMAR ESTA SOLICITUD YO ME OBLIGO A LO SIGUIENTE e Proveer toda la informaci n y las pruebas necesarias para determinar si tengo derecho a los beneficios e Proveer el n mero del Seguro Social para todas las personas que viven conmigo en mi hogar que solicitan los beneficios e Permitir que el Departamento de Servicios Humanos HSD se comunique con personas agencias con el fin de verificar la informaci n necesaria si yo no puedo proveer la informaci n Permitir que toda la informaci n que yo le provea al HSD se compare mediante computadora con la de otras agencias federales estatales o locales El personal del HSD utilizar la informaci n que yo facilito para tomar la decisi n si yo tengo derecho de recibir los beneficios asi es que la informaci n debe ser la m s correcta posible Si la informaci n que yo facilite es falsa incorrecta o incompleta me pueden negar terminar los beneficios Siyo con conocimiento e intencionalmenta facilito informaci n falsa incorrecta o incompleta me pueden enjuiciar por motivo de ese delito Entiendo que yo tengo la obligaci n de reembolsar la suma de todos los beneficios que yo no tenga derecho de recibir DERECHOS DE AUDIENCIA IMPARCIAL Entiendo que
43. announced cash counts will be made by designated district staff or by auditors PLEASE ALSO NOTE THAT A CHANGE FUND AND A PETTY CASH FUND ARE UTILIZED IN TWO DIFFERENT WAYS FAMILY PLANNING CHANGE FUNDS SHALL NOT BE USED FOR ANY PURPOSE OTHER THAN FOR GIVING CHANGE PETTY CASH FUNDS ARE UTILIZED BY DESIGNATED STAFF TO PURCHASE OFFICE NECESSITIES b Payments Payments by cash check or money order may be accepted at any time from clients When a client pays by check the back of the check must immediately be stamped with a Family Planning For Deposit Only stamp If a client wishes to make a payment in cash the payment must be made to the Change Fund Custodian or the designated back up person The cash will then be kept in the locked change funds box until a deposit is made at the end of the day Percent pay patient will be asked to pay their fees and any outstanding balances at the time of services No person shall be denied services because of inability to pay Family Planning Program Protocol FPP 4 06 Appendix B 25 OF 50 Each District Director may designate specific hours when cash payments may be accepted by each Local Health Office If cash payments cannot be accepted at any time during normal office hours the specific hours in which cash payments may be accepted must be clearly posted in the Health Office c Receipt A receipt must be issued to Pay Percent clients for every visit and must be offered to all 0 clients A copy of
44. ards and INPHORM may not match In cases when there are charges and or payments not found on you ledger card INPHORM governs as itis possible there are additional charges and or payments made at another Local Public Health Office To check look up the encounters in question and see if they were done at another site Correcting a ledger card error use a pen to draw a line through the error and initial it then enter the correct information on the next line Do not use white out erase or alter the error Each component of the Family Planning Fee Collection System is designed to satisfy the requirements for a good accounting system Used according to the instructions contained in this manual this system will provide an effective means of assessing receipting posting and reporting fee charges and collections Declaration Of Family Size And Income Verification a Income Worksheet and Income Affidavit Exhibit 1 Pages 8 On the first encounter of the Initial visit and thereafter at the time of the Annual visit the client will be asked to provide information to complete the Income Worksheet All persons living under one roof are not necessarily counted as members of the family household The family household is defined for the purpose of family planning as an economic unit If the client is unable to provide proof of income the Income Affidavit can be filled out and signed in place of or in addition to the Income worksheet and is considered su
45. atient Initial Visit Problem Focused Brief 10 minutes CPT Code 99201 or Expanded Problem Focused 20 minutes CPT Code 99202 or Detailed 30 minutes CPT Code 99203 or Comprehensive Moderate 45 minutes CPT Code 99204 or Comprehensive High 60 minutes CPT Code 99205 Established Patient Annual Visit Expanded Problem Focused 15 minutes CPT Code 99213 or Detailed 25 Minutes CPT Code 99214 or Comprehensive 40 minutes CPT Code 99215 a Initial Annual Exam This service includes all required care components COUNSELING LABORATORY MEDICAL Post exam contraceptive Pap Smear Weight education Medical History Hematoi Blood Pressure Pressure RPR if indicated Thyroid Palpation Pregnancy Test if applic Abdominal Exam Extremities Check Pelvic Exam Recto Vaginal Exam Testes Exam Prostate Check Other services which may be included in the Initial Annual immunizations vaginal smear and wet mount screening test for urine infection glucometer blood glucose screen additional counseling services and any other necessary medications as ordered by clinician b New Patient Problem Focused Brief 10 minutes CPT Code 99201 This covers visits for pregnancy tests ECP Quickstart blood pressure check for new clients Ifthe pregnancy test is positive a Medicaid Presumptive Eligibility application needs to be done at the time of the visit if the client qualifies and the clerk nee
46. button c Go to the Select Transaction Type Always select the Spread Patient Payment radio button Note Spread Patient Payment ONLY posts to client Payor 6 charges The system posts payment to the oldest charge including Beginning Balance first Once the oldest charge is paid the system automatically rolls to the next oldest client charge with any remaining balance d Enter the Amount of the payment in the Amount Box Choose cash or check in the Type box and press the Post button e Close the Payments Adjustments box The payment will record in the grid as a Payment Spread Payment Exceeds Charges a If a payment is greater than the total amount owed the INPHORM system will display a pop up window with a message stating Payment more than patient owes The INPHORM system will Family Planning Program Protocol FPP 4 06 Appendix B 40 OF 50 NOT allow the payment to be posted Close the pop up window Close the Payments Adjustments box In the right hand corner locate the Payor 6 display field and the balance for Payor 6 Using the Amount from the Payor 6 balance field repeat steps listed under Simple Client Payment f Refer to the General Instructions for Adjusting Payments section to post the remaining amount Use Adjustment Code 58 Overpayment as the adjustment code If this procedure does not work and you continue to get an error message call the Help Desk 3 Client Prepayment
47. centage of actual costs that a client will be assessed No one will be denied services because of the inability to pay Disposition of Fee Revenues Fees collected by the program will be used to meet the increasing costs of providing family planning services and to expand services in order to more adequately meet the needs of those who are not receiving care in the community These revenues will be budgeted in the manner prescribed by the State and Federal policies covering government related income ALL STATE LAWS AND DOH PHD ACCOUNTING PROCEDURES MUST BE FOLLOWED WHEN COLLECTING FEES FOR THE FAMILY PLANNING PROGRAM Financial Management System Maintaining an effective financial management system for a family planning project involves the needs of the agency the requirements to adhere to federal guidelines and especially the needs of the clients served Financial responsibility is an important matter for all employees in a family planning project it cannot be left only to the clerks in order to be effective but must be supported by the clinical staff as well A team approach in maintaining effective financial management is as important as a team approach in providing professional health services Confidentiality Since it is the responsibility of the staff to insure confidentiality it is recommended that a private space be provided to make appointments obtain proof of income and fill out laboratory slips Confidential Client must have a Red
48. conomic unit unless there is absolutely no concern regarding confidentiality Inform adolescents that discussion of their visit with their parents will not change their ability to be assessed on their own income This is to stress that discussion with parents is encouraged at all times by the clinic Adolescents who are legally emancipated should be assessed on the basis of their own economic unit and income c Students Students who are age 19 are treated as adolescents until their 20 birthday see above Students 20 and above should be treated as adult clients and assessed on the basis of their own economic unit Local Health Office staff should ask students for proof of income since some students do work Family Planning Program Protocol FPP 4 06 Appendix B 7 OF 50 d Sterilizations When a client decides to apply for sterilization the procedure is entered into INPHORM and the client pays if there is a percent due before the procedure It is important to explain to the client that we are unable to give a refund if they do not have the procedure done but that the payment will be applied as a credit for future Family Planning services Family Planning Program Protocol FPP 4 06 Appendix B 8 OF 50 Client label here or print name EXHIBIT 1 INCOME WORKSHEET Name Teens Are you here with your parent s consent Adolescentes Est s aqu con el consentimiento de tus padres Yes Si No Date of Birt
49. day s visit and Visit Option gt Page 1 Contra Service Contra Method after today s visit and Provider In the case of special circumstances enter as follows 1 If the client has a positive pregnancy test at today s visit History Option gt Maternal tab select Pregnancy Intendedness and enter EDC 2 If ECP andior Quickstart are dispensed at today s visit see the INPHORM Procedures Manual or Training Bulletin 2003 07 for specifics 3 If a Family Planning referral is made Visit Option gt Page 1 Contra Referral select Sterilization or Method Complication 4 If today s visit includes counseling andier a repeat pap to fellow up an abnermal pap Visit Option gt Paga 1 Other select Follow up Abnormal Pap EXHIBIT 3 ENCOUNTER FORM PAGE 4 Family Planning Program Protocol FPP 4 06 Appendix B 20 OF 50 EXHIBIT 3 ENCOUNTER FORM PAGE 5 Family Planning Program Protocol FPP 4 06 Appendix B 21 OF 50 Name DOB DRUGS 2006 MEDICATIONS CODE COST UNITS Date MEDICATIONS CODE COST UNITS lucose Beverage 100mg Ferrous Sulfate E C Tab 5GRS 100 0058 4 76 Fluconazole Tab 150mg ea P0162 5 12 Acetomino Tylenol Chew 80mg 30 P0024 4 36 Acetomino Tylenol Drop 100mg 15ml P0025 445 Histofreezer Acetomino Tylenol Susp 160mg 120ml P0026 3 89 Acyclovir 400mg 21 P0027 5 38 Acyclovir 400mg 35 P0028 6 50 Isoniazid Syrup 50mgq 5ml 500ml P0061 5 03 P0063 7 66 P0121 9
50. dential services will be considered as a separate economic unit and have only their own income assessed Inform the caller that they can be assessed on their own income and not their parent s income This is meant to reduce any barrier to service for the adolescent concerning family planning services 3 Number in the Household Economic Unit 4 High Risk Factors Examples are adolescents women over 35 history of pregnancy difficulties pregnancies spaced less than two 2 years and income at or below 185 of poverty 5 Current Family Planning balance due If the client has a current balance a payment to reduce the balance should be requested before services are provided or supplies dispensed If the client cannot make a payment review their account card remind them of the date the charges were incurred and the date of any payments made Also emphasize that the family planning clinic prioritizes scheduling the zero pay clients and that there may be a possibility that a zero pay client may be scheduled before them and they may be put on a waiting list Exceptions will be made only for documentation of hardship Although not directly related to fees the complete telephone information to be related to each client is given in Section 1 4 Clinic Services of the Family Planning Protocols 6 Medicaid Coverage New Mexico Public Health Department NMPHD is an assigned Medicaid Provider However if the office has a waiting list be sur
51. ds to be informed that today s visit should be billed to Medicaid Family Planning Program Protocol FPP 4 06 Appendix B 13 OF 50 Established Patient Visit Minimal 5 minutes CPT Code 99211 or Problem Focused 10 minutes CPT Code 99212 This covers visits for re supply blood pressure check Depo Provera injection ORTHO EVRA Quickstart ECP and pregnancy test If the pregnancy test is positive a Medicaid Presumptive Eligibility application needs to be done at the time of the visit if the client qualifies and the clerk needs to be informed that today s visit should be billed to Medicaid Established Patients Medical Problem Visit Problem Focused 10 minute CPT Code 99212 or Expanded 15 minutes CPT Code 99213 or Detailed 25 Minutes CPT Code 99214 or Comprehensive 40 minutes CPT Code 99215 This covers visits made as a result of a complication involving a client s contraceptive method such as IUD removal due to health problems visits made to follow up results or repeat of a suspicious or abnormal Pap smear visits made to change contraceptive methods at other than the annual exam or visits to apply for sterilization tubal or vasectomy Extended counseling sessions or complicated referrals which take a lot of staff time may be charged to this code The medical staff depending on time spent with client should make this determination No Charge Visit CPT Code 99211NC This category should be used for NO CHARGE visits ONLY
52. e Bankruptcy Notice The form on which the client legally declared that they were unable to pay their debts Billing A set of activities using CPT4 codes and ICD9 codes approved by the American Medical Association required to determine the client s fee s and the reconciliation of those fees due in accordance with DOH HIPPA policies Cashier The staff person responsible for obtaining proof of income requesting and accepting payment and documenting the transactions This individual is usually the custodian of the cash fund Charges The true full costs of services and supplies received by the client determined by relative value scales and Federal guidelines Charge Statement Receipt The record of all charges for the type of visit or itemized costs of services and supplies received by the client during the current visit Checkout The last stop in the client s visit where the client learns of the charges and adjustments to the bill and pays the fees if any Client Patient Any person who is requesting services Collection The act of receiving money from the client or third party payor Cost The true expense of an item or service Discounts Adjustments the dollar amount deducted from the client s charges based on the client s Percentage Pay Rate Economic Unit Consists of the individuals and their dependents living in a household who provide food and shelter for the family unit Eligibility Determination of a client
53. e Ud tenga si tiene otro seguro de salud Lalecha que Ud ve a dar a iuz Si Ud necesita ayuda para rellenar esta solicitud para obtener la informaci n que Ud necesita comuniquese con la oficina de JSD Despu s de que recibamos su solicitud reexaminaremos todos los documentos Si los documentos no est n completos le pediremos que nos facilite la informaci n necesaria La decisi n con base en su solicitud se tomar deniro de 45 d as que Ud pida m s tiempo para obtener informaci n Le enviaremos carta tocante a su solicitud SOLICITANTE Favor de guardar esta hoja para su expediente 51 Ud es una persona que tiene discapacidad y Ud requiere esta informaci n en un formato sltemativo o requiera un acomedaci n especial pare poder participar en cualquier audiencia p blica programa o servicio comuniquese con el personal del Departernento de Servicios Humanos de NM gratis y llame n mero 1 800 432 6217 al 1 800 608 4TDDD o trav s del sistema de relais de Nuevo M xico TOD 1 800 658 8331 El departamento solicite la comunicaci n previa por lo menos 19 dias por anticipado para poder proporcionar los formatos alternativos a y acorodaci nas especiales que Ud solicite 10 2 02 MADSP 048 Reexaminado 10 3 02 Replaces MAD 049 amp MAD 050 SEE MAD 023 Engilsh Family Pl
54. e that clients with Medicaid coverage are Family Planning Program Protocol FPP 4 06 Appendix B 5 OF 50 aware of other Medicaid providers in your area Clients who are enrolled in a Medicaid MCO can be seen at the health office without a referral from their Primary Care Provider Family Planning staff are encouraged to offer a Medicaid application to all non Medicaid clients for the Family Planning Medicaid 35F 1115 Waiver Explanation of Benefits EOB or correspondence will not go to the client s home A Copy of Medicaid application is on page 41 and 44 of this section 7 Private Medical Insurance Any client with private medical insurance should submit bills receipts of PHD services to their private insurance company DOH Federal Tax ID number is necessary for billing purposes Give this Tax 85 6000 565 to the client so they can submit it to their insurance company Responsibility for paying Family Planning charges remains with the client instead of PHD D SYSTEM COMPONENTS AND POLICIES 1 The Family Planning Fee Collection system is made up of the following components a b o Declaration of Family Size and Income Verification Income Worksheet Exhibit 1 Actual Costs and Charges for Family Planning Services FP Charge for Services Exhibit 2 PHD Individual Services Encounter Form Accounting System Computer System INPHORM Patient Account Module Patient Account Cards McBee ledger cards under certain circumstances c
55. ear 87207 Epi Pertussis Culture 87070 Epi Pertussis DFA N GTT post glucose 1 2 3 hr spec post 100gm N MSAFP3 Estriol Epi Plague culture and FA N MSAFP3 hCG Epi Plague FA Rubella titer Epi Rubella Immune Status titer Epi Rubeola Serological Diagnosis N Sensitivity Studies Group B or urine TB Chem 7 Basic Metabolic Panel SED Epi Varicella Zoster Virus Immune Status TB Comprehensive Metabolic Panel SED Epi Vibrio culture TB Culture Fungus and ID SLD Epi Viral Culture Lab Blood Glucose Office machine 82962 15 79 Lab CBC wrdifferential SED 85025 18 08 Lab DFA for T Pallidum TB DNA Fingerprinting CDC LAB TB Hepatic Function Panel SED TB Mycobacteriology amp ID SLD TB Mycobacteriology DNA Probe 106 59 Lab GC Chlamydia urine swab 35 79 TB Mycobacteriology MTB Susceptibility Studies 111 58 Lab GC culture 35 78 TB Mycobacteriolgy RNAamp 216 59 Lab Gram Stain 87205 29 69 Lab Hemoglobin if nn 1984 EXHIBIT 3 ENCOUNTER FORM PAGE 2 Family Planning Program Protocol FPP 4 06 TB Sputum Induction 106 59 TB Therapeutic Drug Level NJ 80299 283 59 Appendix B 17 OF 50 DIAGNOSIS 2006 CH Child Health VVell Check CH Newborn Metabolic Screen Diabetes Diabetes Mellitus Diabetes Mellitus w o compl tp Il or unspec type uncontrolled Diabetes mellitus w o compl type uncontrolled DIA Diabet
56. ease encourage the use of the Norplant Foundation Assistance Network as the certificate provides full payment rather than the smaller sliding scale amount Does the woman have to bring the certificate at the time of her scheduled appointment YES the certificate must be presented before the removal can take place If the implants have already been removed a certificate cannot be signed and accepted after the fact What if a certificate holder wants to schedule a removal but is not an established client Follow your local health office s regular scheduling procedures This may mean a birth control class and or a new client intake appointment The woman may also wish to choose alternate birth control method after having her implants removed These additional services will be charged using the sliding fee scale What if a new client complains about a long wait to schedule a removal appointment Every certificate holder has received a list of at least three providers suggest that she contact another provider who may be able to schedule her sooner No one should be denied services but do stick to your local health office s regular scheduling procedures in prioritizing appointments What if a question that is not answered here Please keep us informed of any other questions that arise Call the Help Desk at 800 280 1618 We want to be sure that the Norplant Removal Assistance Network works for both you and the clients u Famil
57. entar en la oficina principal del Departamanto de Servicios Humanos la oficina local de Asistencia Econ mica en el Departamento de Servicios Humanos y Salud de lo Estados Unidos el Departamento de Justicia de los Estados Unidos o en la Oficina de Derechos Civiles Sala 326W Edf ic Whitten 1400 Independence Avenue S W Washington D C 20250 8410 o favor de llamar ai 202 720 5964 voz y 430 02 Family Planning Program Protocol FPP 4 06 Appendix B 54 OF 50 MADSP 048 Reexaminado 11 12 04 Pagina 3 PE MOSAA AGENCY USE ONLY egundo Nombre CALLE N mero Calle o Camino Casilla de Correo Tel fono en Su Casa o para Mensajes Ciudad Estado Zona Postal Estado Zona Postal Direcci n Postal Si es distinta la de su casa Ciudad Ha usado Ud otro nombre si Sicontesta Si escriba el otro nombre s y fecha s cuando lo s us FAMILIARES Escriba el nombre de todos los ni os y otras personas que viven con Ud en su casa Conteste por parte de todas las personas en la lista Se requiere esta informaci n de los que solicitan Medicaid NECESIDADES M DICAS Hay mujer embarazada en su hogar Osi Sicontesta Si qui n Fecha de espera de nacimiento Dentro de los ltimos 3 meses alguna de las persona s que vive en su hogar ha recibido servicios m dicos que no se han pagado si No Si contesta Si Qui n tiene cuenta sin pagar y por qu meses SEGURO D
58. eparate MAD O08 for absent parents or TPL document 150 160 What Yau O NM residency rent receipt statement etc O Rights and responsibilities explained Social Security cards if awazlgnla Tot Te Teen EPSDT explained Immigration cards of INS letters O Use of Medicaid cad and SALUD explained Age for children birth certificate baptiamal ota D PHESURAPTIVE FOR PRENATAL CARE O income for the four di weeks prior to MOSAA APPROVED interview Meno ond ddr of Agency FOR 150 USE ONLY DISPOSITION Data processed reason Tor denial certification dates retroactive coverage elc Family Planning Program Protocol FPP 4 06 Appendix B 60 OF 50
59. ephone or Message Number STREET ADDRESS Number Street or Road P O Box Number Work Telephone Number City State Zip Code MAILING ADDRESS if it is different from your home address City State Have you ever used another name C ves C If Yes list other name s and date s they were used T 2 3 HOUSEHOLD MEMBERS List all children and other people living in the home Answer all the questions for everyone listed Social Security Sex Date of Birth Relatio TOM ERES Number Race M F ship uy Day Ye ves No vos No SELF a This information is required only for those who are applying for Medicaid MEDICAL NEEDS ls anyone In the household pregnant ves Lino Yes whol Haz anyones in the household rescaled medica serves within the last thras 3 months which have not been Cives i Yes Who has the unpaid bils and tor which months HEALTHINSURANCE 2 Does anyone in your household have health insurance Lives M Yes list personis below MAD OUO must be completed AL 8 3 Has insurance fcr a child or children been dropped within the last sfx months Di yes a 22 Wes provide name s of child or children and dete s the Insurance was dropped 4 2 ER s s Family Planning Program Protocol FPP 4 06 AppendixB 50 OF 50 MAD 023 Revised 11 12 04 Page 4
60. es mellitus w o comp type Il not stated as uncontrolled 250 00 DIA Diabetes mellitus w o complications 250 0 DIA Gestation Diabetes 648 8 EPLCampylobacter 008 43 EPLContact to communicable diseases V01 8 EPLE Coli 008 00 EPL Giardia EPLHepatitis A Acute EPLHepatitis A Past history EPL Hepatitis B Acute EPLHepatitis B Carrier EPL Hepatitis B Past history EPLHepatitis C Acute EPI Hepatitis C Chronic EPI Hepatitis E EPLHepatitis Unexplained EPLLice Head EPLLice Pubic EPLMeningococcal H Flu EPLNeed for gamma globulin EPLOther Communicable Disease EPLParasites EPLPenussis EPLSalmonella EPLShigella FP Abnormal Pap ASCUS FP Abnormal Pap Mild or Moderate Dysplasia of Cervix FP Abnormal Pap Severe Dysplasia or CIS of Cervix CIN III FP Emergency Contraception FP Fibrocystic Breast Disease FP Galactorrhea not assoc wichildbirth FF Initial Sterilization FP Initiation of Other Contraceptive Measures FP IUD checkfremoval FP IUD Insertion FP Other FP Advice FP Postpartum visit Routine Family Planning Program Protocol FPP 4 06 Appendix B 18 OF 50 Test Negative or Equivocal FP PN Pregnancy Supervision normal 1st FP PN Pregnancy Supervision normal other FP Prescription of Oral Contraceptive FP Sterilization desired FP Surveill of Previously Prescr Methods Subdermal Contracept FP Surveill of Previously Prescribed Methods Oral Contracepti
61. fficient proof of income Note The General Consent for Services form needs to be signed by each new client and by each returning client if it can not be found in the client s chart Note The clerk needs to speak with Family Planning clients in a private area or in a low tone of voice in order to ensure the client s privacy The clerk may even need to ask any person standing close enough to overhear the conversation to take a seat and wait to be called b Examples of acceptable proof of income include i Apay check stub showing wages for all members of the economic unit who are gainfully employed Or ii A federal income tax return from the previous year for all members of the economic unit who filed federal income tax returns or iii A letter from an employer stating wages earned and the time period in which the wages were earned or iv If the client is self employed a statement or letter showing amount of money earned or net profit for the past month v If the client has a WIC Income Worksheet dated within the last twelve 12 months it may be Family Planning Program Protocol FPP 4 06 Appendix B 6 OF 50 used as proof of income Income documentation must be requested from the participant at the initial annual visit It is the clerk s responsibility to review income documentation verify the income sign the income worksheet and return the documentation to the client It is not necessary to keep copies of the income documen
62. formation I understand that if I do I may be prosecuted taken off the program or made to pay back the benefits I receive He dicho la verdad en cuanto todos los ingresos de mi familia Seg n mi entender no he mentido ni retenido informaci n Comprendo que si miento puedo ser proseguido tenminado del programa o tener que reponer los beneficios que he recibido Client initial X R A Family Planning Program Protocol FPP 4 06 Appendix 11 OF 50 EXHIBIT 2 Consent CONSENT for FAMILY PLANNING SERVICES CONSENTIMIENTO PARA SERVICIOS DE PLANIFICACI N FAMILIAR 1 lam voluntarily requesting family planning services from the New Mexico Department of Health Public Health Office understand that have the right to accept or refuse these services without being denied other services from this agency Solicito voluntariamente los servicios de Planificaci n Familiar del Departamento de Salud de Nuevo M xico Entiendo que tengo el derecho de aceptar o negar estos servicios sin que se me nieguen otros servicios de esta agencia 2 lunderstand that my records will be kept confidential and will be released only as permitted or required by law and that my health information will not be released to an outside agency or person except as specified in Notice of Privacy Practices which have received a copy of understand that in cases of abuse or neglect of minors or medical emergencies such as risk for suicide or hurting someone else a
63. ga LLENE ESTA SECCI N SI ESTA ES SOLICITUD DE CALIFICACI N PRESUNTA Presumptive Eligibili Ud o su s ni o s est n recibiendo beneficios de Medicaid 51 No Si contesta Si digale a la agencia o al m dico que ya Ud o su s ni o s recibe n Medicaid y mu strele su tarjeta de Medicaid Si Ud o una de las personas que vive en su hogar con Ud est embarazada le han concedido derechos de calificaci n presuntos por este embarazo O 51 O No Si contesta Si Ud no tiene derechos presuntos por el resto del plazo de este embarazo Han recibido su s nifio s derechos de calificaci n presunta presumptive eligibility dentro de los ltimos seis meses O Si O No Si contesta Si su s no tiene n derechos presuntos He le do toda la informaci n que consta en esta solicitud me la han leido Esta solicitud es nicamente para recibir los beneficios de Medicaid Juro bajo pena de ley que la informaci n que he inclu do en esta solicitud es cierta completa y correcta a mi mejor saber y entender Otorgo permiso al HSD que se comunique con personas o agencias con el fin de obtener la informaci n necesaria acerca de m Me han informado cu les son mis derechos y obligaciones con respecto a Medicaid Firma del Solicitante Firma de la Persona que Ayud a Rellener esta Solicitud Testigo si el solicitante firm con una X Family Planning Program Protocol FPP 4 06 AppendixB 56 OF 50 Family Planni
64. h INCOME WORKSHEET Please write down any money you AND anybody else in your family or household received Amount weekly bi weekly semi monthly monthly or annually Favor de idicar TODO el dinero que se recibi entre la familia por semana quincena mensual semi mensual o anualmente Working at a job or business before taxes Salario de empleo o negocio ante de inpuestos Check Stub Letter from Employer Other Any other sources Qualquier otro ingreso Number in household supported by this income Numero de personas en la casa sostenida por estos ingresos Weekly Por semana MULTIPLY BY 52 Bi Weekly Quincena MULTIPLY BY 26 Semi Monthly 2 veces mes MULTIPLY BY 24 Monthly Mensual MULTIPLY BY 12 Annual Annual MULTIPLY BY 1 PF go Con cn STAFF USE Client is at Percent Pay I have seen this document and witness client signatures STAFF SIGNATURE amp TITLE INCOME AFFIDAVIT DECLARACION DE INGRESO On the following lines please tell how much you provide for your basic needs Who pays rent utilities food etc If you receive cash how much and from whom Is this full time part time or seasonal employment las siguiente l neas por favor d ganos como provees por sus necesidades b sicas Qui n paga el alquiler las utilidades la comida etc Si usted recibe el dinero en efectivo cuanto y de quien Este trabajo e
65. he Amount box Post button Close the payments adjustment box CORRECTIONS Medicaid SALUD Client Deemed No Longer Eligible For clients who are listed as Medicaid eligible in the INPHORM system then later determined to have been not eligible the correction is as follows Registration Financial a b Go to the Financial Information summary screen and select the Third Party option Double click the row of the Third Party entry that need to be changed Enter the End Date for Medicaid eligibility and save and close the record Encounters Search for the correct encounter Search List Encounters Double click on correct encounter Select the Procedure Details tab Highlight the procedure that needs to be corrected Change the Payor field entry to Patient Pay Save the record This process needs to be done for EACH procedure detail The Patient Account automatically reflects the transfer from a Medicaid responsibility to a client responsibility Family Planning Program Protocol FPP 4 06 Appendix B 43 OF 50 7 SPECIAL CIRCUMSTANCES REGARDING NORPLANT REMOVAL CERTIFICATES Client with a Norplant Removal Certificate 9 Create a new financial record under Registration Financial Information Third Party radio button On the Payor Info tab choose Other Payor for Payor Class field and Norplant Foundation for Insurance field Make sure both the Beginning and End Effective Dates fro
66. ing are allowable h Depositing Checks and cash must be deposited daily at the designated bank within twenty four 24 hours of receipt per ADM 01 15 01 There are NO exceptions to this policy A designated staff member can be given time at the end of the day to make the deposit in a timely manner It is imperative that the individual who is preparing the deposit not be the individual who makes the deposit this is for quality assurance purposes In cases of small one two person offices there may be no choice and the person who prepared the deposit also makes the deposit The Fee Deposit Register should be used to record information about each deposit made by the health office The original validated deposit slips are kept in the LPHO Copies are sent in the Monthly report due on the 5 of each month i Bank Withdrawals On or about the fifteenth day and the last day of each month authorized personnel Kathy Tall Bear Family Planning Program Protocol FPP 4 06 Appendix B 26 OF 50 of the Administrative Services Division of DOH will draw checks against your respective bank balances The amount of the withdrawal will be based on the deposit slips and the Family Planning Fee Deposit Register which you send to State Office It is important that you let Kathy Tall Bear 827 2692 know of any bounced checks to avoid negative balance charges to your account j Billing and Fee Collection Any BALANCE DUE should be brought to the client s atten
67. local health office s NO the certificate for assistance can only be obtained by calling 1 800 760 9030 HOWEVER all local health office s can accept the certificate as payment for removing the Norplant implants How does a woman obtain the certificate Any Norplant user may call the Norplant Removal Foundation Assistance Network at 1 800 760 9030 She will be asked a few questions to determine eligibility and if eligible will be mailed the certificate in about a week What assistance does the Foundation give an eligible Norplant user The Foundation will mail her the following 1 a list of health care professionals in her area who participate in the program 2 the Certificate that enables her to get her Norplant System removed at no charge 3 an eligibility requirements fact sheet 4 a postage paid envelope to be given to the clinician who removes the device clerk will mail it in Can only Family Planning clients apply for the certificate NO any Norplant user may apply by calling 1 800 760 9030 This number may be given to anyone who inquires about removal services Established clients who call inquiring about removal should always be referred to talk to a nurse for counseling before scheduling a removal Review FP Protocol section 5 p p 21 amp 22 with all staff Can a Norplant be removed by Family Planning without using the certificate as payment YES by charging the Norplant user under the sliding fee scale HOWEVER pl
68. m the certificate are entered Save the record and create an encounter for the date of service Ensure that Payor Class and Insurance on the Encounter Procedure Details tab also have Other Payor and Norplant Foundation displayed In the Procedure field select the new CPT Code 11976NC This is the code to be used for Norplant Removal with a certificate Complete the rest of the required fields and save the record Norplant Payment Access the Patient Account Screen Highlight the Payor Z7 line in the Blue Grid in the upper right hand corner of the screen In the Light colored grid highlight the correct Norplant Procedure Hit the Pay Adj Button From the Select Transaction Type select the Pay Specific Charge radio button The Selected Payor field should display Z7 Enter the Amount in the Amount box Insert the Check in the Check Card box select Check under the Type box and press the Post button Close the Payments Adjustments box The payment will record as a Simple Payment NOTE If the amount posted pays the procedure in full it will NOT show in the light colored grid UNLESS the Show Zero Balance checkbox is marked For further INPHORM Questions please refer to the INPHORM User Manual and or contact the Help Desk at 800 280 1618 Family Planning Program Protocol FPP 4 06 Appendix B 44 OF 50 EXHIBIT 9 Billing Letter English 1 Example Print on letterhe
69. ney sends a Bankruptcy Notice stamp the date received on it Attach the Bankruptcy notice the back of the McBee Ledger card enter a note in the chart McBee card and enter a green alert in the computer Stop sending billing letters at this point Follow the instructions on Hardship Case to enter the Bankruptcy Notice Do not send it to the Fee Collection Liaison f Overpayment If a client sends you an overpayment contact the client by phone immediately and try to ascertain the reason for overpayment If the client meant the overpayment as a donation handle it as such However if she he wishes to have the overpayment applied as a credit to their account you must do so The account will then show a credit balance which will remain until the client comes in for their next visit The credit balance can only be applied to future services rendered and is not a cash refund Refunds will not be issued to clients If the client does not return for a visit the credit amount may be credited to donations after there has been no activity on the account for eighteen 18 months g Donations Occasionally clients may wish to make a donation Voluntary donations from clients are permissible Donations must not be a condition for the receipt of services or supplies The Title X policy regarding the solicitation of donations from clients is that general solicitations such as posters in the waiting room or announcements in public presentations or in advertis
70. ng Program Protocol FPP 4 06 Appendix B 57 OF 50 Family Planning Program Protocol FPP 4 06 Appendix B 58 OF 50 MEDICAID ON SITE APPLICATION ASSISTANCE MOSAA NARRATIVE Catepory s applied for 036 Pregnancy Aland os amp F Family Pisnring Appen Dura Cl 032 chitiren under age 18 x Firzb ctae imeni D nta MAILING ADDRESS Stars Np O Box Re Code HOUSEHOLD COMPOSITION List all HH mambeg relatonshin mes and verification infarenation How Verified ABSENT PARENT INFORMATION List vy chidiren above who hse one ar loth i iF parents Esing outside 1h hold Let ther absant parent and information regarding hither wheregeouts Complete the AP antur of i a N RETADAG List individuals who List individuae who need S upra2a monthis needed presi of incom fer i THIRD PARTY List a HH mcberg who ha add i beth sidos of the insurance card vn agen Insurance Completa DOG and attach a pi 4 a MAD 71 pra Family Planning Program Protocol FPP 4 06 Appendix 59 OF 50 MAD O71 bed Page 2 VERIFICATION CHECKLIST PRESUMPTIVE FOR CHILDREN APPROVED Health inaurance card Maarification af dapanmdant onra l naeded for O Pregnancy initialed nn opel of s
71. ntial clients who owe a balance Monthly is preferable s Record Retention Retain all records appointment books monthly reports encounter forms billing letters and Medical Records if inactive for 3 years for 3 years Family Planning encounter forms and all copies of billing letters sent are to be kept in a locked alphabetical file separated from the client charts Monthly Reports and Ledger Cards are also to be kept in a locked file Monthly reports can be shredded after 3 years If a client has not been in for 3 years and owes no balance archive the Medical Record and shred the ledger card encounter forms and billing letters If the client owes a balance keep the account card and encounter forms and billing letters active until the balance is paid Family Planning Program Protocol FPP 4 06 Appendix B 38 OF 50 t Use of Norplant Certificate Call the Help Desk if you are not familiar with the procedure All Local Health Offices are now listed as providers in the Norplant Foundation Removal Assistance Network We hope the following Questions and Answers will help you in giving services to women who have certificates from the Foundation What is the certificate The certificate is a document mailed to eligible Norplant users anywhere in the USA to pay for the removal of their implants The assistance is provided by The Norplant Foundation Removal Assistance Network Is this assistance certificate provided through the
72. o Fee Deposit Register form 4 Two Calculator Tape Tallies on the following items Please label each clearly and staple to the payment ledger a Monthly totals of all client charges after the sliding scale adjustment for the month b Monthly totals of all payments of check or cash for the month THE MONTHLY REPORT IS NOT GENERATED BY INPHORM Continue to maintain a file of the report packets by month in each local health office A copy of actual billing letter goes in the financial record Family Planning will reference these files when conducting audits in each local health office Include any corrections and or adjustments made to the Monthly Report in this file Family Planning Program Protocol FPP 4 06 Appendix B 28 OF 50 EXHIBIT 7 FAMILY PLANNING PAYMENT LEDGER Example FAMILY PLANNING PAYMENT LEDGER 2006 Month January Name of Health Office S anta FePublic Health Office Region 2 Site Code 026A Date Deposi Patient Name Birth Date File Today s Previous Amount t Charges Balance Paid after adj 01 03 0 cor mee 11 22 76 0001230 17 89 6 01 05 0 con Candy Cane 01 06 73 0101010 45 76 6 01 11 0 Ruby 01 05 75 97 12 216 27 6 A ppl ebee 01117 0 02 2417 6 6 Donations Payment Balance Type Due 17 89 Cash 100 27 Cash Page Totals Family Planning Program Protocol FPP 4 06 Appendix 29 OF 50 Total Checks 67 31 Lucille Duran Clerk S pecialist Month Total Cash amp Checks 2
73. ount number It also should include date of bill health office phone number and if paying by check or money order please make it to Family Planning Title X health office name address and attention Family Planning Clerk Example of billing letters are in the last 4 pages of this protocol A copy of each billing letter sent should be kept in the client s financial file alphabetize folder System by client and chronological order along with the encounter forms Encounter forms do not go in the clinical chart This will aid you in reviewing the client s balance when you are requesting a payment the next time they come into the clinic When the client comes in the clerk should mention that a balance is due and state the amount to the client see C Tele Appt Screen for appropriate language Also the nurse should be made aware of the balance due The nurse can then reiterate that the account needs to be brought up to date Clinician support in the area of fee collections is imperative to the clerks If the client has confidential status do not attempt to contact them or send them letters You should have a current listing of confidential clients on file Ask the confidential clients for payment when they are in the office If a confidential client cannot pay at the time of service give them a bill to take with them and an envelope addressed to the office k Write offs Are No Longer Be Done Write offs and reinstatements are no longer be done
74. rtment toll free at 1 890 432 6217 or TOD 1 860 609 4TDD or through the Mew Mexloo Relay System TOD at 1 800 869 8331 The Department requests at least 10 days advance notica to provide requested alternative formate and spacial accommonations 14 23 01 MAD 023 Revised 9 27 02 replaces MAD 049 jrg Family Planning Program Protocol FPP 4 06 Appendix B 48 OF 50 TESTE RTT Ml AY MAD 023 Revised 9 27 02 Page 2 MY RIGHTS AND RESPONSIBILITIES Read carefully before completing the application BY SIGNING THIS APPLICATION AGREE TO THE FOLLOWING To provide all information and proof needed to determine eligibility e To provide a Social Security Number for every household member who is applying for benefits To permit the Human Services Department HSD to contact persons or agencies to verify needed information if am not able to provide the information To allow all information give to HSD to be matched by computer with other federal state and local agencies HSD will use the information give to decide on my eligibility so the information must be as correct as possible the information report is false incorrect or incomplete my benefits may be denied or ended f i knowingly give false incorrect or incomplete information may be prosecuted Tor that crime understand that must pay back any benefits am not eligible to receive FAIR HEARIN
75. s All accounting will now be maintained through INPHORM fee collection program in conjunction with account cards a Family Planning Change Funds Twenty five dollars 25 00 will be issued as change funds to each office to be used for giving change A Change Funds Custodian and a back up person someone usually in the office should be assigned and the names documented with the Family Planning STATE Office and with the District Director Family Planning change funds shall be the responsibility of the assigned Custodian and shall be kept in a locked strong box in a secure place per ADM 01 12 Documented reconciliation of the change funds should occur both before and after transfer to the back up person If a client needs change to make a payment and neither the Custodian nor the back up person is in the office the client will have to come back at a later time Under no circumstances is anyone other than the Custodian or the back up person to have access to the funds Monies collected daily should be kept in the locked change funds box until their deposit Deposits are to be done by someone other than the custodian in order to ensure the integrity of the deposit process This procedure can be waived for small one or two person offices when only one staff person is in for the day and performing all clerical duties 1 To establish a change fund i Contact Ferm Najera State Office at 505 476 8877 if a change fund needs to be established or the
76. s de tiempo completo medio tiempo o por temporadas Staff The client should answer the above questions for this affidavit to be considered complete I have told the truth about ALL sources of my family s income To the best of my knowledge I have not given false or Family Planning Program Protocol FPP 4 06 Appendix B 9 OF 50 withheld information I understand that if I do I may be prosecuted taken off the program or made to pay back the benefits I receive He dicho la verdad en cuanto todos los ingresos de mi familia Seg n mi entender no he mentido ni retenido informaci n Comprendo que si miento puedo ser proseguido tenminado del programa o tener que reponer los beneficios que he recibido Client initial Client label here or print name EXHIBIT 1 INCOME WORKSHEET Name RU by A ppl ebee Teens Are you here with your parent s consent Adolescentes Est s aqu con el consentimiento de tus padres Yes Si No Date of Birth 01 05 7 5 INCOME WORKSHEET Please write down any money you AND anybody else in your family or household received Amount weekly bi weekly semi monthly monthly or annually Favor de idicar TODO el dinero que se recibi entre la familia por semana quincena mensual semi mensual o anualmente Working at a job or business before taxes Salario de empleo o negocio ante de inpuestos Check Stub Letter from Employer Other V 1
77. s entitlement to services by the evaluation of client s age gross income economic unit and special circumstances Emancipated minor A person who is sixteen 16 years of age or older who 1 Is or has been validly married annulment or marriage of 15 year old will not count 2 1 active duty with the armed forces or 3 Has obtained a declaration of emancipation from district court NOTE No one under sixteen 16 can be emancipated A person at least sixteen years old may apply for and obtain a declaration of emancipation if s he is 1 Willingly living separate and apart from parents or guardian and 2 Managing her his own financial affairs Full Pay The designation for clients who receive no adjustment to their incurred charges Family Planning Program Protocol FPP 4 06 Appendix B 3 OF 50 Fee Adjustment Schedule See Family Planning Program Poverty Guidelines Percent Pay Rate Schedule Fees The amount due from the client which reflects the charges after any adjustment Financial Record Folder for each percent pay client It should contain client s encounter forms receipts billing letters and sometimes returned billing letters It could also have copies of the proof of income such as a pay sub letter from employer federal income tax return etc It should be filed with the most recent form generated on top and filed in alphabetic order by last name Gross Income Earned income before deductions used in calculating
78. s female eech 7 Po123 465 RifaterTab6O 0103 4545 Condoms male esech 7 00081 04041 Special Order TB Azithromycin 500mg 30 0168 2779 Contraceptive Film v CF Ipoo23 9565 Special Order TB Azithromycin 500mg 3 s 31 96 Contraceptive foam wiapp Special Order TB Levaquin 750mg 20 126 75 Contraceptive jelly Special Order TB Levaquin Tab 500mg 50 4970 CycleBeads Special Order TB Streptomwycin Inj 400mg ml 1 s 1123 Depo P Generic Progesterone 150 mg TCA 80 in alcohol 70 3641 Lo Ovral 28 Terconazole vaginal cream04 0107 1892 Micronor28 0131 376 TMP SMX Susp 200mg 40mg 180m Po108 491 winatin Pot4d4 S 4067O0 TMP SMXDS Tab 160mg 800mg 20 7 Po122 451 Nordete283 0141 4 475 TMP SMDXDS Tab 160mg 800mg 28 Po143 482 28 1 17 531 TMP SMXDS Tab 160mg 800 mg6 Po109 394 Ortho Diaphragm AllFlex_____________ Poo2o0 2990 Triamcinalone AcetCr 1 15 0111 39 Ortho Evra singlepatch 0150 1634 Vagifem Tabs 18 tabs 147 4930 148 4935 OO Q j onmonsNoum4i25 EAN OrtneNovm7 7 7 09 376 fommoTricycento 015 692 1 OuuatonThernometer Digta 0004 1083
79. s full name current full address telephone number social security number and a statement of why copies of the records need to be obtained The letter must be submitted to the local health office to the attention of the nurse manager If the nurse manager declines to send the information or has any questions regarding the adequacy of the release the nurse manager should contact the Department s Office of General Counsel 827 2993 for assistance INPHORM FEE COLLECTION The Family Planning Program has evaluated its current Protocols regarding patient accounts billing and has determined the following practices will be applied by Family Planning Billing Clerks upon completion of INPHORM System Training See the INPHORM Training Bulletin 2005 01 All Family Planning payment information is entered into the Patient Accounts module All procedures that are entered through the Encounter Module Procedure Details Tab with a charge associated with them will be brought forward to the Patient Accounts screen by the INPHORM system NOTE Do NOT try to correct a transaction or try to reverse the entry Should an error occur contact the Help Desk at 1 800 1618 or 476 8526 Remember to enter the Call Ticket number on the McBee card for the percent pay clients for documentation PAYMENT TRANSACTIONS 1 Simple Client Payment a If the client has a charge associated with a procedure access the Patient Accounts screen b Press the
80. sits and pays at more than one site In such cases INPHORM governs Payment The amount received from a client or third party payor other than a donation Percentage Pay Rate That percentage of the actual charges incurred that the client is required to pay based on their family size and gross income and Federal Poverty Guidelines Percentage Pay Rate Schedule The client s percentage pay will be calculated by INPHORM once an encounter is generated in the INPHORM system This schedule will be updated on a yearly basis and automatically entered into INPHORM Issued by the Federal Government annually Notice of changes to the Percentage Pay Rate schedule will be issued to the LPHO s prior to the system change being implemented Receivable Accounts awaiting or requiring payment Salud A word used to represent the three Managed Care Organizations contracted by Medicaid to provide medical coverage for financially eligible individuals Presently they include 1 Presbyterian 2 Lovelace 3 Molina Services Those clinical activities performed for a client Sliding Fee Scale of Billing The fee schedule of the facility establishing adjustments on the basis of ability to pay and the resultant actual charge to the client for services rendered based on Federal Poverty Guidelines Supplies Those items delivered to a client Family Planning Program Protocol FPP 4 06 Appendix B 4 OF 50 Un collectible Accounts The amount owed but which for pr
81. tation but you can if you choose to It can be kept in the financial record The charge for services is based on a sliding scale fee schedule which follows current Federal Poverty Guidelines If proof of income is not provided ask the client to fill out the Income Affidavit to the best of their knowledge and sign it You can accept this as proof of income Under no circumstances should income documentation become a barrier to a client receiving services A new income declaration may also be made at the request of the client whenever their financial situation changes significantly Re verification of Income and Family Size must be documented on the new Income worksheet or Income Affidavit Itis recommended that clients be screened for Medicaid eligibility This will improve access to the federally funded Family Planning Waiver Program DETERMINATION OF CLIENT INCOME IS A MAJOR FACTOR IN PRIORITIZING CLIENT SERVICES Remember that all income worksheets must be kept for three years Archiving Purposes 3 Special Circumstances a Documented Hardship A client can document hardship Occasionally clients may experience problems beyond their control which constitute a temporary financial hardship like death or illness in the family fire theft high medical bills drug abuse bankruptcy etc An explanation should be noted briefly on the back of the Income Worksheet The nurse may determine that past services should have been documented under fin
82. the receipt must be filed in the client s Financial record Follow the Computer procedures for issuing receipts Receipts must also be issued to any client who comes into the clinic at a later date to make payment on their balance due A manual receipt book should be kept on hand in the event that the INPHORM system is not functioning Receipts can be generated by the INPHORM system for Pay Percent clients only clients who have no charges can receive a receipt which is handwritten from the receipt book d Bad Checks If a client S check is returned by the bank for non sufficient funds let Kathy Tall Bear in General Accounting know ASAP The individual who made the check must be charged an additional amount to their account in the INPHORM system see Adjustments on page 37 Attempt to contact the client by phone immediately Oftentimes she he will want to pick up the check and just make the payment in cash If the client wants you to redeposit the check you may do so at once If you redeposit at that time the client should be recharged for the visit and then given credit for the payment In the event that the check is returned a second time recharge the client and send the check back to them A notice of NSF charges for bad checks should be visibly posted in each office The individual who made the check must be charged an additional 25 00 amount to their account in the INPHORM system see Adjustments on page 37 e Bankrupt If a client s attor
83. tion It is important for all clerks to do this It is a requirement of our Federal Grant that we collect at least 8596 of the fees charged to our percent pay clients Billing Letters should be sent to all accounts with a balance at a minimum of every other month Even if a client s balance is very old a bill should be sent If the bill is returned because the address is not correct try to obtain the correct address by calling the client or other means If you are not able to find the client s correct address stop sending bills until you have an updated address Enter a low level alert in INPHORM so any other office will see that the client s address needs to be updated and you need to be contacted with the update It is also helpful to contact the WIC clerk in your office to see if the client has an updated address in their system Stop sending billing letters to client with outstanding balances after 18 billing letters have been mailed or if the billing letter was returned by the United States postal service Document each time a billing letter is sent on the McBee Ledger Card and when it was returned Enter a green alert in INPHORM stating that the client has a balance and you have stopped sending billing letter Billing letters should include the current letterhead header with new governor and staff names and footer your health office name address and phone number with client s name address date of birth balance overdue since and INPHORM acc
84. udit purposes it is essential that each health office keep its appointment books logs for three 3 years p Satellite Offices If your office provides services at a satellite office the completed encounter forms and income worksheets should be taken back to the main office for data input You may issue a temporary receipt for any client paying in cash q Family Planning Fee Collection Committee The Fee Collection committee consists of experienced FP clerks from each Region They assist the Fee Collection Liaison in updating the fee collection protocol and policies and act as a resource for other clerks in their area who need fee collection training Fee Collection Liaison Monthly Report Packet Lucille Duran Family Planning 476 8869 Fax 505 476 8898 Financial Accounting Monthly Report Packet Kathy Tall Bear Financial Control 827 2692 Fax 505 827 2693 r Calendar Monthly Monthly Reports Packet due at State Office by the 5th of each month If for some reason you are unable to send the reports in it is necessary to call the Family Planning Fee Collection Liaison at 476 8869 Please also let the Fee Collection Liaison know if you are behind in your Family Planning data entry If your Monthly Report is late please let Financial Accounting know the amount of your deposits for the month And Monthly billing is preferable to every other month Bimonthly Every Other Month Billing Letters must be sent to any non confide
85. ust help HSD Identify the father of a child who gets Medicaid and who was born outside of marriage and identify any third parties who may have to pay far medical care and services lunderstand thatif do not help HSD may not get Medicaid benefits ar may lose my benefits unless can show a good reason fornot helping HSD RELEASE OF MEDICAL INFORMATION By signing this application allow HSD to examine medical records needed for eligibility decisions and or Tor payment of benefits CIVIL RIGHTS STATEMENT All pragrams administered by HSD are equal opportunity programs Itis unlawful for HSD to discriminate against an applicant for or recipient of any program due to race color national origin sex age religion political beliefs or disability Complaints of discrimination may be filed with the New Mexico Human Services Department central office the loca Income Support Division County office the U S Department of Health and Human Services the U S Department of Justice or tha Offica of Civil Rights Room 326 W Whitten Bullding 1400 Independence Avenue S W Washington D C 20250 8410 or call 202 720 5964 voice and TDD Family Planning Program Protocol FPP 4 06 Appendix B 49 OF 50 MAD 023 Revised 11 12 04 Page 3 PE MOSAA AGENCY USE ONLY Application Former Recipient Q ves Application Date Date Mailed Date Received 1 Redetermination ENS HEADOFTHEHOUSEHOLD NAME Last First Middle Home Tel
86. ve FP Surveillance other FP Unspecified Contraceptive Management GEN Abnormal Breast Exam GEN Abnormal Mammogram GEN Adverse Drug Reaction GEN Anemia unspecified GEN Breast Mass GEN Breast Pain in Mastalgia GEN Cellulitis Abscess unspecified site GEN Dental Caries GEN Drug use abuse GEN Elevated Blood Pressure GEN Elevated Blood Sugar GEN General Medical Exam GEN Gynecological Exam GEN Hypertension GEN Mastitis GEN MOSAA GEN Non compliance with medical treatment GEN Obesity GEN Ovenweight GEN Tobacco disorder GEN Urinary Tract Infection RH Refugee Medical Exam STD Bacterial Vaginosis STD Balanitis STD Bartholin Gland Abscess D Bartholin Gland or Duct Cyst STD Candidal Vaginitis STD Chlamydia Cervix STD Chlamydia contact to STD Chlamydia Urethra STD CystSebaceous STD Dysuria STD Epididymitis STD Folliculitis unspecifi ed STD Gonorrhea Anus Family Planning Program Protocol FPP 4 06 Appendix B 19 OF 50 DIAGNOSIS 2006 FAMILY PLANNING SUPPLEMENTAL Check if Check if Check if Pte ES ee CODE Family Planning Contraceptive service E Family Planning Contraceptive service STD Gonorrhea Cervix Family Planning contraceptive before today s visit Family Planning Contraceptive Method STD Gonorrhea Contact to
87. y Planning Services in STD Clinic On occasion a person seen in STD clinic may require Family Planning supplies or tests This may include pregnancy testing packs of OCP s Emergency Contraceptive Pills ORTHO EVRA or a Depo Provera injection In these cases ask the client to complete an income affidavit and Family Planning Program Protocol FPP 4 06 Appendix 39 OF 50 calculate the percent pay The client is responsible for any charges for contraceptive or pregnancy tests Document all Services on the clinical encounter form for both an STD visit and a Family Planning visit Some clinics streamline this procedure by keeping the needed forms in the exam rooms If client falls into a percent pay category and paying for these services creates a barrier to service see Special Circumstances page 6 for Hardship Case criteria REQUESTS FOR INFORMATION FRAUD At no time is information about a client and or client record s to be given out to any non Public Health Division employees without signed written authorization from the client The Confidentiality of the client is to be observed both in the office setting and on the telephone If someone requests information or copies of records inform them that they need to submit a letter for any information along with a signed release from the client authorizing the release of the requested information to the person organization or facility seeking the information The letter must include the client

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