Attachment 5 - Interpreter Billing Document revised 2.3.20.pdf
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- Attached to
- Interpreting & Translation Services
- Solicitation number
- 103325-O3
- Issued by
- Blaine County, Nebraska
About this file
This is an interpreter billing document form used by the Nebraska Department of Health and Human Services (DHHS) to process payment claims for interpreting and translation services rendered by contracted interpreters. The form captures essential service delivery information including the interpreter's name, language, contact information, client details, and DHHS staff authorization. It accommodates multiple service delivery methods—in-person interpretation, telephonic interpretation, and translation services—with separate line items for hours and associated payment amounts. Providers must specify the date of service, start and finish times, and round total service hours to the nearest quarter hour, except where contract terms specify otherwise (such as for Medicaid-funded services or telephonic interpretation). The completed billing document must be submitted to the DHHS Interpreter Billing Email Address at dhhs.interpreterbilling@nebraska.gov within sixty calendar days following the last day of the month in which services were provided to qualify for payment consideration.
The billing form includes fields for applicable cancellation fees and requires signature certification from both the DHHS approving worker and the service provider, with each party attesting to the accuracy and compliance of the submitted information. The form explicitly warns that false claims may result in fraud prosecution. Payment amounts are calculated based on the specific service types provided, with the total invoice payment amount clearly identified for processing. This standardized billing document serves as the official mechanism for interpreters contracted under the DHHS interpreting and translation services prequalification pool to request reimbursement for services delivered across DHHS divisions and client locations throughout Nebraska.
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Text version
Total Hour Payment: $
Translation: Total Hours
Phone: Total Minutes
START FINISH **SUB-TOTAL HOURS
In Person: Total Service Hours
In Person: Amount to be paid $
Cancellation Fee (if applicable)
Approving Worker's Printed Name and Division
Provider's Printed Name Provider's Phone Number
Date of Signature
Approving Worker's Signature
Total Invoice Payment Amount $
The completed billing document should be submitted to the DHHS Interpreter Billing Email Address at: dhhs.interpreterbilling@nebraska.gov.
DHHS reserves the right to not pay any initial request for payment that is submitted later than sixty (60) calendar days past the last day of the month for which services were provided.
Instructions: Date of Signature
*Please identify whether the interpreting included in-person, over phone, and/or translation services.
**Please round total service hours to the nearest quarter hour except where not allowed per contract (medicaid funds and/or over phone).
Worker's Phone Number
Statement:
By signing this form, the signor certifies that the information contained in this document is true, complete and accurate, and in compliance with the terms of the contract. Anyone filing a false claim may be prosecuted for fraud.
Provider's Signature
$Phone: Amount to be paid
Translation: Amount to be paid $
Date:
ATTACHMENT 5
INTERPRETER BILLING DOCUMENT
Department of Health and Human Services
Interpreter Language:
Interpreter Name:
Interpreter Phone Number:
Interpreter Street Address:
DATE
DHHS Staff Name or Authorized Representative:
DHHS Staff Name or Auth Rep Phone Number:
DHHS Office Location:
DHHS Division:
CASE INFORMATION
Client Name: Client Street Address:
Client ID Number:
Client Phone Number:
SERVICE DELIVERY TIME
File details come from the government source that posted it. Updated .