Solano County Mental Health Payor Financial Information (PFI) Instructions

Transcription

1 Purpose: Policy: Open a fiscal account to bill for Mental Health Services This form must be completed at the time of intake and annually thereafter. A new PFI must be completed at the time of any significant change of information. Client Information 1 Annual UMDAP Period Begins / Ends Complete for all clients who access services Fiscal Account Period. New client: begins on the first day of the month of the first service provided to the client and ends on the last day of the month that completes one year. Existing client: use InSyst to determine UMDAP Period. The UMDAP Period does not change once it is established. 2 Client Name Last Name, First Name and Middle Initial 3 DOB (MM/DD/YYYY) Date of Birth of client using 2-digit month, 2-digit day and 4- digit year format. (MM/DD/YYYY) 4 Account # New client: leave blank - Billing & Collections Unit will add after account is established Existing client: obtain number from InSyst Client Status Summary Report screen. This is not the client medical record chart number. 5 Social Security Number (SSN) Social Security Number using format Marital Status Check one only 7 Insurance Information Complete if client has insurance. Mark and complete all that apply to the client. Also complete the Assignment of Benefits and Authorization to Release Information section # Medi-Cal CMSP Healthy Families Healthy Kids Medicare Private Ins. Check if client has Medi-Cal. Attach printout of the POS, Medi-Cal verification sheet or InSyst screen. Check if client has CMSP. Attach printout of the POS, Medi- Cal verification sheet or InSyst screen. Check if client is enrolled in Healthy Families. Attach POS or InSyst screen. Check if client is enrolled in Healthy Kids. Attach copy of Insurance card. Check if client has Medicare. If client is capitated to private insurance, as listed on the POS, Medi-Cal verification sheet or InSyst screen, complete #14-15 Check if client has private insurance or capitated Medicare and complete # Share of Cost Check if client has a Share of Cost (SOC) according to the Medi-Cal information obtained from InSyst or POS.

2 9 SOC Amt Enter the SOC amount obtained from InSyst or POS. Obtain a signature on the Share of Cost Obligation Agreement form before services are provided. If client refuses to sign, client will be billed the full cost of the service. 10 Medi-Cal or Healthy Families CIN # Medi-Cal or Healthy Families CIN (account) number. 11 Responsible County County Code listed on the POS, Medi-Cal verification sheet or InSyst screen (i.e. Solano is 48). Watch for Partnership capitation in body of message. 12 Medi-Cal Aid Code Aid Code on the Medi-Cal verification sheet. 13 Check if No insurance Check this box if the client has no insurance and complete all applicable boxes in this section. 14 Provider of Financial Information Enter information if other than the client or responsible person is providing this information. Medi-Cal Pending Date Referred Referred for Eligibility SSI Pending SSI Application Date If Medi-Cal / SSI eligible but not referred, state reason Check if client has a pending Medi-Cal application. Indicate date the client was referred to the Employment and Eligibility (E&E) Division. Check whether the client is referred to E&E to complete a Medi-Cal application. If client is not referred state the reason, i.e. hospitalized, in the appropriate box. Check if client has Social Security Income application pending thru Social Security Administration. Indicate the date of the application, if known. If client is not referred to E&E or Social Security, state the reason(s). 15 Name of Insurance Company Name of client s private insurance company including name of capitated Medicare insurance company. Group / Policy / ID# Name of Insured Insurance Mailing Address Insurance Phone Number 16 Client or Responsible Person Information (row 1) Name of Responsible Party (Payor References Relationship to Client DOB (of Client of Responsible Party) Insured SSN Number that identifies the policy or client ID with the insurance company. Name of the person who is the primary insured under the policy. Mailing address including City, State and Zip Code. Phone number of the insurance company. Information refers to client and/or client s spouse or other responsible person, i.e. parent, family member, Public

3 17 Client or Responsible Person Information (row 2) Address City State Zip Code Telephone # 18 Client or Responsible Person Information (row 3) Source of Income 19 Client or Responsible Person Information (row 4) If Not Employed, Date Last Worked 20 Client or Responsible Person Information (row 5) Employer Position Telephone # Information refers to client and/or client s spouse or other responsible person, i.e. parent, family member, Public Main source of income of client and/or client s spouse or other responsible person, i.e. parent, family member, Public Refers to client and/or client s spouse or other responsible person, i.e. parent, family member, Public Guardian, private conservator, payee, etc. who is financially responsible or whose insurance policy the client is covered Refers to client and/or client s spouse or other responsible person, i.e. parent, family member, Public Guardian, private conservator, payee, etc. who is financially responsible or whose insurance policy the client is covered 21 Spouse, etc. Provide information, if available, for client s spouse if not collected as client s Responsible Party 22 Nearest Relative / Relationship, Address and Telephone # of person identified Name and contact information of nearest relative 23 Print Client s Name Last Name, First Name and Middle Initial repeat on second page necessary in case document is copied 24 Annual UMDAP period (from page 1) Repeat on second page necessary in case document is copied UMDAP Liability Determination Liquid Assets Proof of information should be requested but do not hold up completing or submitting the PFI 25 Savings Accounts Enter amount client reports as current savings account balance. 26 Checking Accounts Enter amount client reports as current checking account balance. 27 IRA, CD, Market Value of stocks, bonds and mutual funds 28 Total Liquid Assets Add lines #25 thru #27. Enter total value of all stocks, bonds and mutual funds client reports owning.

4 29 Less: Asset Allowance Based on the number of dependent(s) reported on line #46 use one of the following amounts: 1=$2000 2=$3000 3=$3150 4=$3300 5=$3450 See Uniform Patient Fee Schedule chart for additional amounts 30 Net Asset Valuation Subtract #29 from #28 31 Monthly Asset Valuation If line #30 is greater than zero, divide the amount by 12. If line #30 is less than zero, write zero (-0-) Copy this amount in line #42 Allowable expenses 32 Court ordered obligations paid monthly Include all amounts the client is paying due to a court order. 33 Monthly child care payments Include all amounts paid for child care where receipts can be provided if requested. 34 Monthly dependent support payments Amount(s) paid for dependent support, i.e. alimony, where receipts can be provided if requested. 35 Monthly medical expenses payments Amount(s) paid for medical bills/payments where receipts can be provided if requested. 36 Monthly mandated deductions from gross income for retirement plans. (Do not include Social Security Income) Amount(s) paid for retirement plans other than Social Security, i.e. employee portion of retirement plans, 37 Total Allowable Expenses Add lines #32 thru #36. Write this amount on line #44. Adjusted Monthly Income 38 Self / Payor Amount of gross monthly income that client receives from all sources. 39 Spouse Amount of client s spouse s gross monthly income from all sources. 40 Other List total of additional client or family income. 41 Sub-Total Add line #38 thru Add monthly asset valuation Amount from line #31 43 Sub-Total Add lines #41 and #42 44 Subtract total expenses Amount from line #37 45 Adjusted Monthly Income Subtract line #44 from #43 46 Number of Dependents on Adjusted Monthly Income Number of people dependent upon income reported on line # Annual Liability Using the Uniform Patient Fee Schedule chart, determine the Annual liability of the client using the Adjusted Monthly

5 Income from line #45 and the Number of Dependents from line #46. [handout] 48 Number of Months in UMDAP Period Enter number of month span from line #24. E.g. if UMDAP period is 12 months write 12, however if the UMDAP period is shorter write that number of months. 49 Monthly Payment Plan Divide line #47 by number of months reported on line # Signature of Client or Responsible Person [for Client s where a fee was set] Signature of the client or responsible person. 51 Date Date when the client or responsible person signs the form. 52 Signature of Client of Responsible Person [for Client s with Insurance] Signature of the client or person listed on the insurance policy or Medi-Cal. If insurance is later granted a new PFI must be completed. 53 Date Date when the client or responsible person signs the form. 54 Check [box] if unable to provide explanation to client and provide reason explanation wasn t provided (required if checked): Check the box if staff was unable to explain the fee or form to the client. Requires a reason why no explanation was given, i.e. client in crisis and unable to understand, parent provided information over the phone. 55 Print Name Print the name of the staff person who completed the PFI. 56 Staff Signature Signature of the staff person who completed the PFI. 57 Office or Program Phone Number Personal office or program reception phone number of person listed on line # Date Date the staff person completed the form Note: if client or responsible person refuses to sign either line the client could be held responsible for full cost of service(s) provided.