Attachment 5 - Interpreter Billing Document revised 2.3.20.xlsx
XLSX spreadsheet 52 KB Posted
- 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 invoices from contracted interpreters and translation service providers. The form captures comprehensive service delivery information including interpreter details, client information, and service type categorization across in-person interpretation, telephonic interpretation, and translation services. Interpreters must document the date, start time, finish time, and total hours for each service delivery method, with specific rounding requirements applied based on service type. The form requires calculation of service charges and any applicable cancellation fees, with the example provided demonstrating how charges are calculated and rounded to the nearest quarter hour for in-person services. The document serves as the official billing mechanism for DHHS to verify service delivery accuracy and process payments, with completed forms requiring submission to dhhs.interpreterbilling@nebraska.gov within sixty calendar days following the last day of the month in which services were provided to avoid non-payment.
The billing document establishes clear approval and verification requirements, including signatures from both the service provider and an approving DHHS worker, along with printed names, phone numbers, and dates. The form includes certification language stating that signatories attest to the truthfulness, completeness, and accuracy of the information provided and compliance with contract terms, with explicit warnings regarding potential fraud prosecution for false claims. The document does not specify hourly rates or pricing structures directly but references the contract terms governing rate calculations, indicating that payment amounts vary based on service type and duration. This billing form is a critical component of the DHHS interpreter and translation services procurement framework, which utilizes a prequalified contractor pool model with performance-based compensation tied exclusively to actual services rendered, with no guaranteed minimum service volumes.
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Text version
Sheet1
| Department of Health and Human Services | Date: | ||
| ATTACHMENT 5 | |||
| INTERPRETER BILLING DOCUMENT | Interpreter Name: |
| Interpreter Language: | ||
| DHHS Staff Name or Authorized Representative: | ||
| DHHS Office Location: | ||
| Interpreter Street Address: |
| DHHS Staff Name or Auth Rep Phone Number: | |
| DHHS Division: | |
| Interpreter Phone Number: |
| CASE INFORMATION | |
| Client Name: | |
| Client Street Address: |
Phone Number:
Client ID Number: Client Phone Number:
| DATE | SERVICE DELIVERY TIME | ||
| START | FINISH | **SUB-TOTAL HOURS |
Cancellation Fee (if applicable)
| In Person: Total Service Hours | |
| In Person: Amount to be paid | $ |
| Phone: Total Minutes |
Phone: Amount to be paid $ Latifa Elbergame: Latifa Elbergame:
How this amount was calculated:
$1.40 * 30min = $42.00
43 min - 30min = 13min We round the 13min to the nearest 15min $40.00 * 0.25 (15min) =$10.00
$42.00+$10.00=$52.00
Translation: Total Hours
| Translation: Amount to be paid | $ | ||
| Total Hour Payment: | $ | Total Invoice Payment Amount | $ |
| Statement: | Provider's Signature | Date of Signature |
| 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 Printed Name | Provider's Phone Number |
| Instructions: | Approving Worker's Signature | 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).
Approving Worker's Printed Name and Division Worker's Phone Number
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.
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