Exhibit_D2_-_DAAS_Monthly_Activity_Detail.xlsx

XLSX spreadsheet 35 KB Posted Aug 1, 2024

Attached to: Master Agreement AZ|CTR072894
Contract number: CTR072894
Issued by: Arizona

About this file

Written by GovTribe AI · Oct 3, 2025

The document is a Transportation Invoice User Guide for a Department of Aging and Adult Services (DAAS) monthly activity detail spreadsheet. It appears to be an invoice template and instructions for transportation service providers, specifically for medical and non-medical transportation services across multiple counties. The guide provides detailed instructions for completing invoices, including specific requirements for documenting transportation services such as trip logs, client information, mileage tracking, and billing procedures.

The contract covers transportation services categorized into local and distant ambulatory and non-ambulatory trips, with specific billing requirements for each service type. The invoice template includes fields for tracking service dates, number of passengers, client details, pickup and drop-off information, mileage, wait times, and additional charges such as flag drops and attendant services. The document outlines precise documentation standards, including unique driver numbering, odometer or GPS mileage verification, and specific time tracking protocols. The invoice supports different invoice types including original, amended, supplemental, and re-bill submissions, with strict guidelines that each service month must be billed separately and with comprehensive trip-level detail.

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INSTRUCTIONS

This User Guide is intended to provide some helpful tips for completing the Invoice. Please note the bottom of this Excel document contains multiple worksheet tabs to accommodate the services in the awarded contract.

Invoice Tab -

The provider should verify the accuracy of the information on the summary Invoice Tab before printing, signing, scanning and, submitting.

INVOICE TYPE: Select X in the drop down menu next to the invoice type (defined below)

Original: The first submission of an invoice to the Department

Amended: An invoice that changes items on a previously submitted invoice

Supplemental: An invoice for items that were not billed on the original invoice

Re-Bill: An invoice for items that were previously billed, but not paid. Usually the items were denied and could be rebilled after a deficiency was remedied.

Complete the County, Invoice Number and Service Month (defined below)

County - Each county that you provide services for must have a separate invoice

Invoice Number - This is a number that you assign to your invoices that can be used as a reference number and for auditing purposes.

Service Month - Enter the month and year for the invoice. Do not include invoices for more than one month on the same invoice. *Each month must be billed separately.

Service Log Tab (AMBULATORY TRIP LOG / NON AMBULATORY TRIP LOG)

Service Date: Enter the date that service was provided for each individual service line

Subcontractor Name: Enter the name of the subcontracted transportation company you are utlizing to complete this service

Driver Name / Number: Complete the Driver Name / Number (Driver Numbers must be unique to each driver, the format required is John Doe / 12345) Each driver for the duration of the contract shall have a unique driver number and that number must not be reassigned to another driver in the event the driver is separated from the provider (this number could be an employee number)

Number of passengers: Enter the total number of passengers included in the trip only on the client line of the first pickup location

Case Number: Must contain the case number for each client being transported

Client Name: Must be filled in with the Client's last name first and first name last in the two provided columns, every client transported shall be entered on an individual line

Reason for Transport: Type in the reason for transport from the referral form

Pick up and drop off information: Fill in the addresses and times of both pickup and drop off for each client

Flag Drop, Mileage, No Show and, Cancel: Fill these cells in with the requested information (Flag Drop is (1) for each flag drop (per location as stated in the contract), Mileage is the actual mileage driven to at least one decimal point, No Show and cancel require only an X be placed in the appropriate cell) Total mileage for any complete trip is required to be entered on a single line corresponding to the first pickup, the total miles must be for the entire trip to the final destination of the last passenger in the vehicle taken from an odometer reading, in vehicle GPS reading or, taximeter (internet map searches will not be accepted)

Wait Time and Attendant: Enter the actual amount of times in minutes only. All times will begin after the required wait time per the contract, if the wait time or attendant time is 85 minutes past the contractually required wait time enter 85. These items will be automatically rounded up to the nearest 15 minute interval and applied to the invoice sheet

Additional Passengers Same Trip: Enter any additional Flag Drops per the contract (one per pickup location) and only enter the total trip mileage on the line with the first passenger picked up. (the actual mileage driven will be from the start to end of the trip and only entered on one line)

TRANSPORTATION INVOICE USER GUIDE REV. 09/09/2019

INVOICE DETAIL

DAAS Monthly Activity Detail
Contractor Name:	Division Name:
Month & Year:

SERVICE DATE

# OF PASSENGERS

AUTHORIZATION NUMBER/ MEMBER ID #

REASON FOR TRANSPORT

CLIENT LAST NAME

CLIENT FIRST NAME

PICK UP ADDRESS

PICK UP TIME

DROP OFF ADDRESS

DROP OFF TIME

FLAG DROP (s)

DESCRIPTION

RATE

UNIT(S)

CHARGE

(Units x Rate)

Column3

Column4

FOR TOTAL2

FOR TOTAL3

FOR TOTAL4

#REF!

TRANSPORTATION TRIP LOG

Page &P of

Descriptions

Ambulatory Transportation - Local

Ambulatory (Passenger Van 8+ Passengers) Transportation - Local

Non-Ambulatory (Wheelchair Van) Transportation - Local

Attendant - Local

Wait Time - Local

No Show Fee - Local

Ambulatory Transportation - Distant

Ambulatory (Passenger Van 8+ Passengers) Transportation - Distant

Non-Ambulatory (Wheelchair Van) Transportation - Distant

Attendant - Distant

Wait Time - Distant

No Show Fee - Distant

DAAS/APS

DAAS/RRP

OTHER:

File details come from the government source that posted it. Updated Oct 3, 2025.