Get the free Supplement 10 To Attachment 4.19-B - dhcs ca
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This document outlines the supplemental reimbursement procedures for publicly owned or operated clinics that provide services to Medi-Cal beneficiaries in California.
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How to fill out supplement 10 to attachment
How to fill out Supplement 10 To Attachment 4.19-B
01
Begin by gathering the required information, including patient data and provider details.
02
Enter the patient's full name, date of birth, and Medicaid ID number at the top of the form.
03
Fill out the provider's name, address, and NPI (National Provider Identifier) in the designated section.
04
Record the type of services provided, ensuring to be specific and clear.
05
Indicate the dates of service in the appropriate fields.
06
Provide detailed descriptions of the services rendered, including procedure codes.
07
Calculate the total cost for services and enter the amount in the cost section.
08
Review all information for accuracy before submission.
09
Sign and date the form where indicated.
Who needs Supplement 10 To Attachment 4.19-B?
01
Healthcare providers submitting claims for Medicaid reimbursement.
02
Facilities that provide services covered under Attachment 4.19-B.
03
Mental health professionals seeking reimbursement for eligible services.
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What is Supplement 10 To Attachment 4.19-B?
Supplement 10 To Attachment 4.19-B is a specific document used for reporting certain data related to Medicaid programs, often involving financial aspects of provider reimbursements.
Who is required to file Supplement 10 To Attachment 4.19-B?
States that participate in Medicaid are required to file Supplement 10 To Attachment 4.19-B as part of their state plan amendments.
How to fill out Supplement 10 To Attachment 4.19-B?
To fill out Supplement 10 To Attachment 4.19-B, users must provide required financial data, adhere to specified formats, and ensure that all information is accurate and in compliance with CMS guidelines.
What is the purpose of Supplement 10 To Attachment 4.19-B?
The purpose of Supplement 10 To Attachment 4.19-B is to collect detailed financial information on Medicaid provider payments to ensure compliance and proper reimbursement processes.
What information must be reported on Supplement 10 To Attachment 4.19-B?
Information that must be reported includes total expenditures, provider-specific payment rates, and other relevant financial data pertaining to Medicaid services.
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