Exhibit F ADCS Psychiatric and Psychological Services Invoice.xlsx
XLSX spreadsheet 29 KB Posted
- Attached to
- Master Agreement AZ|CTR064201
- Contract number
- CTR064201
- Issued by
- Arizona
About this file
This document is an invoice user guide for the Arizona Department of Child Safety (DCS) related to Psychiatric and Psychological Services. The invoice template is designed for providers who offer mental health services across five Arizona regions: Central (Region 10), Pima (Region 20), Northern (Region 30), Southeast (Region 40), and Southwest (Region 50). The guide provides detailed instructions for completing invoices, specifying requirements for documentation, billing, and service reporting.
The invoice supports multiple service types including psychiatric consultations, psychological evaluations, group and individual counseling, home-based services, and psychiatric assessments. Providers must document specific details for each service, including participant ID, client name, date of service, service type, billed units, and unit rates. The template requires providers to submit a signed certification statement affirming the accuracy of services, with each invoice representing services for a single month and region. Providers must use the specific contract number and provider identification when submitting invoices, and the document emphasizes the importance of accuracy and non-discrimination in service delivery.
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Invoice User Guide
| EXHIBIT F |
| DEPARTMENT OF CHILD SAFETY PSYCHIATRIC AND PSYCHOLOGICAL SERVICES INVOICE |
Psychiatric and Psychological Services Invoice User Notes
This guide is intended to provide some useful tips in using the standard Psychiatric and Psychological Services Invoice. Please note throughout that the cells have a summary of the information being requested to help describe required information. The following information provides quick tips to help you navigate the tool.
| Invoice |
| This tab is the summary of services by service type and includes Participant name, PID, dates of service, # of billed units, and the billed rate. Please fill out this template electronically. Do not handwrite. |
| Please indicate if the invoice is an Original, Amendment, Supplimental or Re-Bill by marking the appropriate line. Any change to an original invoice is considered an amended invoice. Place an X next to the invoice type. |
| - an original invoice is the first invoice that has been submitted for the service month |
| - an amended invoice changes something that was submitted on the original |
| - a supplemental invoice is an invoice for services provided that were not included on the original (this should be rare) |
| - a re-bill is an invoice for services already billed that have not been paid |
| Complete the Region, Invoice Number and Service Month. | |
| Region - each region that you provide services for must be billed separately. Indicate the appropriate region number: | |
| - Region 10 - Central Region (includes Pinal County and the eastern part of Maricopa County) | |
| - Region 20 - Pima Region | |
| - Region 30 - Norther Region (includes Mohave, Yavapai, Coconino, Navajo and Apache counties) | |
| - Region 40 - Southeast Region (includes Gila, Graham, Greenlee, Cochise and Santa Cruz counties) | |
| - Region 50 - Southwest Region (includes Yuma and La Paz counties and the western part of Maricopa County) | |
| Invoice Number - This is a number that you assign to your invoices that can be used as a reference number. | |
| A common format is a number that identifies the service month and region for example Invoice number. | |
| For example, 201501SW would mean that the invoice is for January 2015 for the SW region. | |
| Service Month - enter the month and year for the invoice. Each month must be billed separately. | |
| Complete your Provider Name, Provider Number and the Contract Number. | |
| - Provider Name - enter the name of your company as it appears on your contract | |
| - Provider Number - enter the FEIN associated with your company | |
| - Contract Number - enter the contract number associated with the claims submitted | |
| Enter the Rates and Units | |
| - Enter the contracted rates and units for each service type in the "Rates" and "Billed Units"column. Please verify for accuracy. |
Read the certification statement, then complete the bottom of the invoice; signature, date, printed name and title and your e-mail address.
&8Revised 6-30-15
Invoice
| EXHIBIT F |
| DEPARTMENT OF CHILD SAFETY PSYCHIATRIC AND PSYCHOLOGICAL SERVICES INVOICE |
| Provider Name: | Invoice #: | Original Invoice: |
| Provider ID #: | Page #: (example: 1 of 5) | Amended Invoice: |
| Contact Phone #: | Service Month/Year: | · Supplemental Invoice: |
| Re-Bill Invoice: | ||
| Contract Number: | ||
| Region: | Date Submitted: | |
| Provider Signature: | ||
| DATE: | ||
| “This invoice is a true and accurate account of the services listed on this statement for the time period specified; this invoice constitutes the full and complete charge for the services described above; that no further invoices | ||
| for payment of these services will be made; these services have been provided without discrimination based on age, race, color, creed, gender, religion or national origin and that this statement is subject to | ||
| federal and state audit review.” |
| Participant ID # | Client Name | Date of Service | Service Type | COMMENTS: Type of Consultation for example: CPS Staffing, Court Testimony, Telephone Consult (as applicable) | Billed Units | Unit Rate | Total Due |
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| 0.00 | |||||||
| 0.00 | |||||||
| 0.00 | |||||||
| Total: | 0.00 | 0.00 |
Serv Types
| EXHIBIT F | |
| DEPARTMENT OF CHILD SAFETY PSYCHIATRIC AND PSYCHOLOGICAL SERVICES INVOICE | |
| Note: | Please verify Contract for approved Service Types |
| Services types claimed will NOT be paid if not contractually approved. |
Please insert lines as needed on Invoice.
| Name | Service Unit of Measure |
| PSYC CONS HOUR | HOURS |
| PSYC CONS HR RU | HOURS |
| PSYC EVAL HOUR | HOURS |
| PSYC EVAL HR RU | HOURS |
| PSYC GROUP PERS | PERSON |
| PSYC GRP PER RU | PERSON |
| PSYC HM BASED | HOURS |
| PSYC HM BASEDRU | HOURS |
| PSYC IND CSL HR | HOURS |
| PSYC INDC HR RU | HOURS |
| PSYC UNT CLT HR | HOURS |
| PSYC UNTCL HRRU | HOURS |
| PSYCHIAT ASSESS | HOURS |
| PSYCHIAT PA | REVIEW |
| PSYCHIAT PA RUR | REVIEW |
| PSYCHIAT-ASSERU | HOURS |
| PSYCHIAT-CNSTRU | HOURS |
| PSYCHIAT-CONSLT | HOURS |
| PSYCHIAT-MEDREV | REVIEW |
| PSYCHIAT-MEDRVR | REVIEW |
| Note: Service Types will be updated as necessary. |
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