Table of Contents 1 OVERVIEW..................................................................................................................................................1-1 1.1 FILING DEADLINE AND CERTIFICATION...................................................................................................1-1 2 CLAIM CALCULATION INSTRUCTIONS..............................................................................................2-1 2.1 CLAIM HEADER INFORMATION (APPENDIX C, SECTION C.1)..................................................................2-1 2.2 QUARTERLY CLAIM CALCULATION SUMMARY (APPENDIX C, SECTION C.2)..........................................2-1 2.3 QUARTERLY CLAIM CALCULATION DETAIL (APPENDIX C, SECTION C.3)...............................................2-3 2.4 QUARTERLY SPECIALIZED TRANSPORTATION CALCULATION (APPENDIX C, SECTION C.4)....................2-4 2.5 ANNUAL CAPITAL CALCULATION (APPENDIX C, SECTION C.5)..............................................................2-5 2.6 QUARTERLY DETAILED EXPENDITURE REPORT (APPENDIX C, SECTION C.6).........................................2-7 2.7 QUARTERLY OUT-OF-DISTRICT TUITION (APPENDIX C, SECTION C.7)...................................................2-9 2.8 SAMPLE QUARTERLY CERTIFICATION OF PUBLIC EXPENDITURES.........................................................2-10 2.9 SAMPLE QUARTERLY AMENDED CERTIFICATION OF PUBLIC EXPENDITURES.......................................2-11 3 ADMINISTRATIVE CLAIM UPLOAD SYSTEM....................................................................................3-1 3.1 INTRODUCTION.......................................................................................................................................3-1 3.2 GLOSSARY OF TERMS.............................................................................................................................3-2 3.3 DESIGNATING AN “UPLOADER”...............................................................................................................3-2 3.4 OBTAINING A USERNAME AND PASSWORD..............................................................................................3-2 3.5 LOGGING IN............................................................................................................................................3-3 3.6 NAVIGATING THE WELCOME SCREEN AND VIEWING UPDATES...............................................................3-8 3.7 UPLOADING A FILE.................................................................................................................................3-9 3.8 CLAIM ID NUMBERS............................................................................................................................3-17 3.9 VIEWING UPLOAD STATUS/FILE STATISTICS AND ERROR REPORTS......................................................3-17 3.10 AMENDING A CLAIM............................................................................................................................3-20 3.11 UNDERSTANDING BENCHMARK VALIDATIONS......................................................................................3-20 3.12 CLAIM ACCEPTANCE OR DENIAL NOTIFICATION...................................................................................3-20 3.13 TECHNICAL NOTES/SYSTEM SPECIFICATIONS.......................................................................................3-22 3.14 FILE FORMATTING................................................................................................................................3-23 3.15 CLAIM DEADLINES...............................................................................................................................3-23 3.16 CONTACT INFORMATION......................................................................................................................3-23 4 SCHOOL BASED MEDICAID PROGRAM ADMINISTRATIVE ACTIVITY CLAIMING PROGRAM CLAIM UPLOAD....................................................................................................................4-1 5 SCHOOL-BASED MEDICAID PROGRAM ADMINISTRATIVE ACTIVITY CLAIMING PROGRAM CLAIM FILE FORMAT SPECIFICATION FOR DATA FILE.........................................5-1 5.1 OVERVIEW.............................................................................................................................................5-1 5.2 FILE FORMAT.........................................................................................................................................5-1 5.3 FIELD FORMATS.....................................................................................................................................5-2 5.4 FILE RECORD DESCRIPTIONS...................................................................................................................5-3 5.5 CLAIM DATA FILE FORMAT.....................................................................................................................5-4 5.6 RECORDS AND FIELD DEFINITIONS..........................................................................................................5-4 6 SCHOOL-BASED MEDICAID PROGRAM ADMINISTRATIVE ACTIVITY CLAIMING PROGRAM CLAIM FILE FORMAT SPECIFICATION FOR EXCEL FILE......................................6-1 6.1 CLAIM HEADER INFORMATION................................................................................................................6-1 6.2 QUARTERLY CLAIM CALCULATION SUMMARY.......................................................................................6-2 6.3 QUARTERLY CLAIM CALCULATION DETAIL............................................................................................6-2 6.4 QUARTERLY SPECIALIZED TRANSPORTATION CALCULATION.................................................................6-4 6.5 ANNUAL CAPITAL CALCULATION...........................................................................................................6-4 6.6 QUARTERLY DETAILED EXPENDITURE REPORT......................................................................................6-5 6.7 QUARTERLY OUT-OF-DISTRICT TUITION................................................................................................6-6 7 JOB DESCRIPTION TITLES......................................................................................................................7-1 1 Overview This document describes how to complete and submit the Massachusetts School-Based Medicaid Administrative Activity Claiming cost report. 1.1 Filing Deadline and Certification Claims should be submitted electronically through the Administrative Claim Upload System. Details regarding the submission process, file formats and submission deadlines are available in Part III of this guide, Administrative Claim Upload System.. Effective for claims with date of service July 1, 2009, and all subsequent quarters, all quarterly claims for a fiscal year must be uploaded by midnight on October 15th. Positively amended claims are also due by October 15th. However, there is no deadline for negatively amended claims. This deadline will hold regardless of holidays and weekends. Claims for a fiscal year received after October 15th will not be processed for payment. Claims will still be processed quarterly. Deadlines for including claims in a quarterly submission are January 15th, April 15th, and July 15th, respectively, regardless of holidays and weekends. Claims with dates of service prior to July 1, 2009, are due within two years of the date of service. (Exception regarding deadline for submission of retroactive claims that are at the two-year deadline: All claims that are being submitted under the last allowable quarter are due 15 days prior to the close of that quarter. For example, if you plan to submit a claim for the September 2007 quarter, it is due by September 15, 2009.) The Certification of Public Expenditure (Refer to Sections 2.8 and 2.9) must be signed by an officer of the government agency, such as the school superintendent or the business manager of the regional school district or charter school. Signed original Certifications of Public Expenditure must be submitted by midnight on October 20th, and be returned to the University of Massachusetts Medical School (UMMS) at the address below, on school district letterhead.. Original Certifications of Public Expenditure for claims processed during the December, March and June quarters must be received by January 20th, April 20th, and July 20th respectively. University of Massachusetts Medical School Commonwealth Medicine Center for Health Care Financing School-Based Medicaid Program 333 South Street Shrewsbury, MA 01545 1-800-535-6741 Schoolbasedclaiming@umassmed.edu 2 Claim Calculation Instructions The claim upload template has seven sections. Complete shaded areas or sections below shaded headings only. The template can be found in Appendix C of this document. Restricted federal funding should be deducted from the actual expenses, such that only state/local funding sources are included in the expenditure data. 2.1 Claim Header Information (Appendix C, Section C.1) Line 1 Enter the year for the claiming period. Line 2 Enter the quarter for the claiming period (Example: Jan-Mar). Line 3 Enter the School District Medicaid Provider Identification Number. Line 4 This line will be prepopulated with “MA.” No entry is needed. Line 5 Enter the School District name. Line 6 Enter the name of the vendor/collaborative who is submitting the claim, if applicable. Line 7 Enter the claim type, “original” for an original/initial submission or “amendment” for an amended submission. Line 8 Enter the gross claim expenses from the Quarterly Claim Calculation Summary (Appendix III, Section 2, Row 10). Line 9 Enter the net claim expenses from the Quarterly Claim Calculation Summary (Appendix III, Section 2, Row 11). Line 10 Enter the amended claim number, if applicable. If the claim is an amendment to a claim previously uploaded, enter the claim number of the original claim. 2.2 Quarterly Claim Calculation Summary (Appendix C, Section C.2) Refer to the chart at the end of this section for a list of personnel contained in each cost pool. Line 1 Enter the capital percentage rate from Appendix III, Section 5 – Annual Capital Calculation, Column C, Row 6. Line 2 Enter the school district’s unrestricted indirect cost rate, as calculated by the Department of Education. Line 3 Enter the direct service provider’s gross claim amounts from Appendix III, Section 3 – Quarterly Claim Calculation Detail for Cost Pool 1. This is completed by adding the total gross claim amounts (Column G) for activity codes B, D, F, H, J, and N. Line 4 Enter the administrative only providers gross claim amounts from Appendix III, Section 3- Claim Calculation Detail for cost pool 2. This is completed by adding the total gross claim amounts (Column G) for activity codes B, D, F, H, J, and N. Line 5 Enter the gross claim amount for Specialized Transportation from Appendix III, Section 4 – Quarterly Specialized Transportation Calculation Column E, Row 1. Line 6 Enter the gross claim subtotal 1 amount by adding Lines 3, 4, and 5. Line 7 Enter the capital costs by multiplying Line 6 by Line 1. Line 8 Enter the gross claim subtotal 2 amount adding Line 6 and Line 7. Line 9 Enter the indirect costs by multiplying Line 8 by Line 2. Line 10 Enter the total gross claim amount by adding Line 8 and Line 9. Line 11 Enter the total net claim amount by multiplying Line 10 by 50%. Direct Service Practitioners (Providers must meet the provider qualifications and perform direct services.) • Speech/Language Therapist - Medicaid Definition (130 CMR 432.404(C) or 432.405) • Speech/Language Assistant - Medicaid Definition (260 CMR 10.02) • Occupational Therapist - Medicaid Definition (130 CMR 432.404(B) or 432.405) • Occupational Therapy Assistant – Medicaid Definition (259 CMR 3.02(1) through (3)) • Physical Therapist - Medicaid Definition (130 CMR 432.404 (A) or 432.405) • Physical Therapy Assistant - Medicaid Definition (259 CMR 5.02(1) through (3)) • Registered Nurse – Medicaid Definition (130 CMR 414.404(A) • Licensed Practical Nurse – Medicaid Definition (130 CMR 414.404 (A) • Audiologist - Medicaid Definition (130 CMR 426.404) • Audiologist Assistant - Medicaid Definition (260 CMR 10.02) • Hearing Instrument Specialist - Medicaid Definition (130 CMR 416.404) • Counselor - Medicaid Definition (130 CMR 429.424(E)(2)) • Psychologist 1 - Medicaid Definition (130 CMR 429.424.(B)(1) or 429.424(B)(2)) • Psychologist 2 - Medicaid Definition (130 CMR 429.424.(B)(1) or 429.424(B)(2)) • Social Worker 1 - Medicaid Definition (130 CMR 429.424 (C)(1) or 429.424(C)(2)) • Social Worker 2 - Medicaid Definition (130 CMR 429.424 (C)(1) or 429.424(C)(2)) • Personal Care Service Provider - Medicaid Definition (42 CFR 440.167) • Medicaid Billing Personnel • Psychiatrist - Medicaid Definition (130 CMR 429.424(A)(1) or 429.424(A)(2)) Administrative Only Staff • Speech/Language Aide, Assistant • Speech/Language Therapist • Occupational Therapist • Occupational Therapist Aide, Assistant • Physical Therapist Aide, Assistant • Physical Therapist • Audiologist • Audiologist Assistant or Aide • School Psychologist • Hearing Instrument Specialist • School Psychologist Intern • Case Manager • Counselor • School Adjustment Counselor • School Guidance Counselor • Nurse • Nurse’s Aide • Psychiatrist • Psychologist • Social Worker • Personal Care Service Provider • Direct Support Personnel • Vision Specialist • Physician Note: If personnel perform direct services related to the categories listed in Cost Pool 1, but do not meet the provider qualifications, they should be included in Cost Pool 2. 2.3 Quarterly Claim Calculation Detail (Appendix C, Section C.3) There are two claim calculation pages, one for the Direct Service cost pool and one for the Administrative Only cost pool. Column A Enter the cost pool number. Column B Activity codes. No entry required. Column C Enter the statewide percentage of time spent on each activity code, as provided by MassHealth. Column D Enter the total cost pool amount from Appendix III, Section 6 – Quarterly Detailed Expenditure Report. Column E Enter the Medicaid eligibility percentage for activity codes F, H, and J. No entry is required for activity codes A, B, C, D, E, G, I, K, L, M, and N. Medicaid Eligibility Percentage Calculation Step 1: Gather quarterly school district enrollment information as of the following dates: January 5th, April 5th, July 5th, and October 5th. This list should include those students who are enrolled in the LEA and those attending out of district schools when the LEA is financially responsible for the student except for regional schools and charter schools. If a student is attending a charter or regional school, only the charter or regional school is eligible to include that student in their Medicaid Eligibility Percentage calculation, and the public school district should not include any such student in their count. Step 2: Access the School-Based Medicaid Web-based matching system being offered by MassHealth. Complete a direct match as of the following dates: January 5th, April 5th, July 5th and October 5th. The system will only include people in reimbursable aide categories who are eligible on the given date. • MassHealth Standard • MassHealth CommonHealth • MassHealth Family Assistance • MassHealth Basic • MassHealth Essential Students in the following aide categories will not be included. • MassHealth Standard (16, 41, 44, 45, VX) • MassHealth CommonHealth (51, 54, 55, ED, EH, EN) • MassHealth Family Assistance (58, 73, 85, 87, 90. 91, 95, 96, AC) • MassHealth Basic (64) • MassHealth Essential (AR, AS, AT, AU, TT, TV) Step 3. Using the result of the data match, calculate the quarterly ratio of Medicaid eligible students in the school district to the total number of students registered in the school district served in the participating LEA. The resulting percentage is the Medicaid Eligibility Percentage. Column F Enter the general administrative factor for activity code N. The general administrative factor is calculated to allocate the amount of time spent performing general administrative activities to the amount of time spent performing Medicaid administrative activities. A separate factor is calculated for Cost Pool 1 and Cost Pool 2. The formula for calculating each cost pool’s factor is as follows. The letters correspond to the RMTS activity codes. [B% + D% + (F% * Medicaid Eligibility Percentage) + (H% * Medicaid Eligibility Percentage) + (J%* Medicaid Eligibility Percentage)] (A% + B% + C% + D% + E% + F% + G% + H% + I% + J% + K% + L% + M%) Column G Enter the total gross claim amount for each activity code by multiplying column C x column D x column E (where applicable) x column F (where applicable). 2.4 Quarterly Specialized Transportation Calculation (Appendix C, Section C.4) Column A Enter the school district’s quarterly specialized transportation expenditures for special education students. Column B Enter the specialized transportation percentage. Specialized Transportation Percentage Calculation Step 1: Gather quarterly school district special education enrollment information as of the following dates: January 5th, April 5th, July 5th, and October 5th. This list should include those students who are enrolled in the LEA and those attending out of district schools when the LEA is financially responsible for the student except for regional schools and charter schools. If a student is attending a charter or regional school, only the charter or regional school is eligible to include that student in their Medicaid Transportation calculation and the public school district should not include any such student in their count. Step 2: From the special education enrollment information, identify the number of students who have specialized transportation in their IEP. Step 3: From the special education students identified in Step 2, identify the number of students who have specialized transportation in their IEP for a medical reason. Step 4. Using the totals from Step 2 and Step 3, calculate the quarterly ratio of Special Education Medicaid eligible students with transportation in their IEP for a medical reason to the total number of Special Education students with specialized transportation in their IEP. The resulting percentage is the Specialized Transportation Percentage. Column C Enter the Special Education Medicaid Eligibility percentage. Special Education Medicaid Eligibility Percentage Calculation Step 1: Gather quarterly school district special education enrollment information as of the following dates: January 5th, April 5th, July 5th, and October 5th. This list should include those students who are enrolled in the LEA and those attending out of district schools when the LEA is financially responsible for the student except for regional schools and charter schools. If a student is attending a charter or regional school, only the charter or regional school is eligible to include that student in their Medicaid Eligibility calculation and the public school district should not include any such student in their count. Step 2: Access the School-Based Medicaid Web-based matching system being offered by MassHealth. Complete a direct match as of the following dates: January 5th, April 5th, July 5th, and October 5th. The system will only include people in reimbursable aide categories who are eligible on the given date. • MassHealth Standard • MassHealth CommonHealth • MassHealth Family Assistance • MassHealth Basic • MassHealth Essential Students in the following aide categories will not be included: • MassHealth Standard (16, 41, 44, 45, VX) • MassHealth CommonHealth (51, 54, 55, ED, EH, EN) • MassHealth Family Assistance (58, 73, 85, 87, 90. 91, 95, 96, AC) • MassHealth Basic (64) • MassHealth Essential (AR, AS, AT, AU, TT, TV) Step 3. Using the result of the data match, calculate the quarterly ratio of Special Education Medicaid eligible students in the school district to the total number of Special Education students registered in the school district served in the participating LEA. The resulting percentage is the Special Education Medicaid Eligibility Percentage. Column D The statewide average of time spent receiving Medicaid covered services. This percentage is provided by MassHealth. No entry is required. Column E Calculate the gross claim amount for specialized transportation by multiplying column A x column B x column C x column. 2.5 Annual Capital Calculation (Appendix C, Section C.5) Note: This is an annual calculation. Complete this calculation once per fiscal year and apply the calculation to all quarterly claims within that fiscal year. Column A, Row 1 Enter acquisition cost of buildings and fixed assets. Acquisition costs of buildings and fixed assets include costs related to • the acquisition of building; • the acquisition of fixed assets; • land improvements, such as paved parking areas, fences and sidewalks; and • any of the buildings’ components, such as plumbing system, heating system, and air conditioning system. Acquisition costs of buildings and fixed assets do not include costs related to: • Any equipment that is merely attached or fastened to the building, but not permanently fixed to it, which is used as furnishing or decoration or for specialized purposes. Column B, Row 1 Annual use allowance = 2%. This percentage is provided by MassHealth. No entry is required. Column C, Row 1 Enter the total building and fixed valuation by multiplying column A, Row 1 x column B, row 1. Column A, Row 2 Enter the major moveable valuation. The major moveable valuation includes: • the acquisition costs of the school districts equipment that is not included in the value of buildings and fixed assets. The major movable valuation does not include • the cost of land; • any portion of the cost of buildings and equipment borne or donated by the federal government irrespective of where title was originally vested or where it presently resides; and • any portion of the cost of buildings and equipment contributed in satisfaction of a federal matching requirement. Column B, Row 2 Annual use allowance = 6.67%. This percentage is provided by MassHealth. No entry is required. Column C, Row 2 Multiply column A, row 2 x column B, row 2. Column A, Row 3 Enter the net interest expense. The net interest expense is the school district’s budgeted interest expenses for the year for the claim associated with land, equipment, and school building acquisition, construction, fabrication, reconstruction, and remodeling. Allowable interest costs incurred must meet all of the following conditions. • The financing is provided (from other than tax or user fee sources) by a bona fide third party external to the municipality or school district; • The assets are used in support of the Medicaid program. • Earnings on debt service reserve funds or interest earned on borrowed funds pending payments of the construction or acquisition costs are used to offset the current period’s cost or the capitalized interest, as appropriate. Earnings subject to being reported to the federal Internal Revenue Service under arbitrage requirements are excludable. • For debt arrangements over $1 million, unless the municipality or school district makes an initial equity contribution to the asset purchase of 25% or more, the municipality or school district must reduce claims for interest cost by an amount equal to imputed interest earning on excess cash flow, which is to be calculated as follows. Annually, non-federal entities shall prepare a cumulative (from the inception of the project) report of monthly cash flows that includes inflows and outflows, regardless of the funding source. Inflows consist of depreciation expense, amortization of capitalized construction interest, and annual interest cost. For cash flow calculations, the annual inflow figures are divided by the number of months in the year (i.e., usually 12) that the building is in service for monthly amounts. Outflows consist of initial equity contributions, debt principal payments (less the pro rata share attributable to the unallowable costs of land) and interest payments. Where cumulative inflows exceed cumulative outflows, interest is calculated on the excess inflows for that period and be treated as a reduction to allowable interest cost. The rate of interest to be used to compute earnings on excess cash flows is the three-month Treasury bill closing rate as of the last business day of that month. • Interest attributable to fully depreciated assets is unallowable. (See A-87(B) at 23(b).) Column C, Row 3 Enter net interest expense. Column C, Row 4 Enter the subtotal capital by adding column C, rows 1, 2, 3. Column C, Row 5 Enter the sum of the total annual budgeted school district wide salaries and total annual budgeted district wide fringe benefits. Column C: Row 6 Enter the capital percentage rate by dividing column C, row 4 by column C, row 5. 2.6 Quarterly Detailed Expenditure Report (Appendix C, Section C.6) Complete the following sections for Cost Pool 1 and Cost Pool 2. Note: Include personnel information and salary costs for all individuals who were eligible to participate in the RMTS for that quarter and who were included on the participant list submitted for that quarter. If an individual started working for the LEA after the date the template was due, their costs may be included in the claim and they must be included on the RMTS participant list for the following quarter. For claims for the quarter July 1 to September 30, include all participants for whom you have costs and who were included on the participant list for any of the three prior quarter’s RMTS. If an individual started working for the LEA after the last RMTS, their costs may be included in the claim and they must be included on the RMTS list for the following quarter. A. Personnel Information Column A Enter the employee’s/contractor’s last name. Column B Enter the employee’s/contractor’s first name. Column C Enter the employee ID number. Column D Enter the job code, indicating if the individual is an “employee” or “contractor.” Column E Enter employee’s/contractor’s job description title. Refer to Appendix IV for a list of titles. Column F Enter Y or N, indicating if the individual is providing medical services. Column G Enter the employee’s cost pool number. “1” for “direct service providers,” “2” for “administrative only providers.” B. Salary and Benefits Only actual fringe benefit costs may be included. The use of a fringe benefit percentage is no longer allowed. Column H Enter the individual’s actual quarterly salary or contractual payment before the federally funded percentage is applied. Column I Enter the percentage of the individual’s salary or contractual payment that is paid with federal funds. Column J Enter the individual’s actual quarterly salary or contractual payment without federal funds. Column K Enter actual amount of employer paid unemployment contribution for each employee. Column L Enter actual amount of employer paid group health insurance for each employee. Column M Enter actual amount of employer paid Medicare tax for each employee. Column N Enter actual amount of employer paid worker’s compensation or injury payments for each employee. Column O Enter actual amount of employer paid retirement for each employee. Column P Enter actual amount of employer paid other benefits for each employee. Column Q Enter total of columns J, K, L, M, N, O, and P. C. Other Related Costs Materials - Enter actual quarterly material and supply expenditures attributed to each cost pool. Include only material and supply costs funded by state/local revenue that are used to assist in the performance of reimbursable Medicaid administrative activities. Do not include the cost of materials and supplies used in the delivery of health-related services. Out of district tuition - Enter actual quarterly out of district tuition expenditure attributed to each cost pool from the Quarterly Out-of-District Tuition worksheet. (Section 7, column I). Purchased Services (Cost Pool 2 only) - Enter actual quarterly purchased services expenditures attributed to cost pool 2 that are related to the delivery of Medicaid administrative activities do not include the cost of purchased services used in the delivery of health-related services. Total Salary - Enter sum of salary + benefits for each cost pool (from column Q). Total Cost Pool - Enter sum of salary/benefits + materials + out of district tuition + purchased services for each cost pool. Purchased services costs are only included for Cost Pool 2. 2.7 Quarterly Out-of-District Tuition (Appendix C, Section C.7) Column A Enter the cost pool number. Column B Enter the total quarterly tuition expenditures for day schools for each cost pool. Column C Percent of health-related services for day schools. These percentages are provided by MassHealth. No entry is required. Column D Enter the sum of column B x column C. Column E Enter the total quarterly tuition expenditures for residential schools for each cost pool. Column F Room and board discount. This percentage is provided by MassHealth. No entry is required. Column G Percent of health-related services for residential schools. These percentages are provided by MassHealth. No entry is required. Column H Enter the sum of column E x column F x column G. Column I Enter the sum of column D + column H. 2.8 Sample Quarterly Certification of Public Expenditures I hereby certify that 1. I have examined this statement, the accompanying Supporting Schedules, the allocation of allowable expenditures and the attached Worksheets for the period from ___________(date) to _________________(date) and that to the best of my knowledge and belief they are true and correct statements prepared from the books and records of the public agency in accordance with applicable cost report instructions. 2. The expenditures included in this statement are based on the actual cost of allowable expenditures for activities that support the implementation of the Medicaid state plan. 3. The required amount of public funds were available and used to pay for the total allowable expenditures included in this statement, and such public funds are not federal funds, or are federal funds authorized by federal law to be used to match other federal funds. 4. I understand that federal matching funds are being claimed on the expenditures identified in this report. 5. I am the officer authorized by the referenced public agency to submit this form to the single state Medicaid agency and I have made a good faith effort to ensure that all information reported is true and accurate. 6. I understand that this information will be used by the single state Medicaid agency as a basis for claims for federal funds and that falsification or concealment of a material fact by me may result in my prosecution under federal or state civil or criminal law. Administrative Activity Gross Claim Expenses $_________________________ Administrative Activity Net Claim Expenses $_________________________ ______________________________ ______________________________ Signature/Title School District Name _______________________________ Date The Quarterly Certification of Public Expenditure statement must be submitted to the Office of Medicaid on your school district letterhead. 2.9 Sample Quarterly Amended Certification of Public Expenditures I hereby certify that 1. I have examined this statement, the accompanying Supporting Schedules, the allocation of allowable expenditures and the attached Worksheets for the period from ___________(date) to _________________(date) and that to the best of my knowledge and belief they are true and correct statements prepared from the books and records of the public agency in accordance with applicable cost report instructions. 2. The expenditures included in this statement are based on the actual cost of allowable expenditures for activities that support the implementation of the Medicaid state plan. 3. The required amount of public funds were available and used to pay for the total allowable expenditures included in this statement, and such public funds are not Federal funds, or are federal funds authorized by federal law to be used to match other federal funds. 4. I understand that Federal matching funds are being claimed on the expenditures identified in this report. 5. I am the officer authorized by the referenced public agency to submit this form to the single state Medicaid agency and I have made a good faith effort to ensure that all information reported is true and accurate. 6. I understand that this information will be used by the single state Medicaid agency as a basis for claims for federal funds and that falsification or concealment of a material fact by me may result in my prosecution under federal or state civil or criminal law. Original Administrative Activity Gross Claim Expenses $_________________________ Original Administrative Activity Net Claim Expenses $_________________________ Amended Administrative Activity Gross Claim Expenses $_________________________ Amended Administrative Activity Net Claim Expenses $_________________________ Difference Administrative Activity Gross Claim Expenses $_________________________ Difference Administrative Activity Net Claim Expenses $_________________________ ______________________________ ______________________________ Signature/Title School District Name _______________________________ Date The Quarterly Certification of Public Expenditure statement must be submitted to the Office of Medicaid on your school district letterhead. 3 Administrative Claim Upload System 3.1 Introduction This section provides step-by-step instructions for uploading Medicaid Administrative Activity Claims into the Administrative Claim Upload System in order to submit claims electronically. Included in this section is the following information. • Designating an individual responsible for uploading files for your school district (an “Uploader”); • Obtaining and updating a username and password; • Logging in; • Uploading a file; • Viewing the claims file status, including file statistics and error reports; • Understanding the electronic claims validations; • Formatting files for electronic submissions; • Understanding the claims deadlines; and • Contacting the University of Massachusetts for systems help. Feedback on the File Status Once claims are uploaded into the system, the uploader will receive immediate feedback on screen if there are errors in the file format or if the claim has been accepted for processing. Once a claim has been accepted by the system, the claim calculations will be validated. The uploader will receive a system-generated e-mail indicating claim acceptance. Electronic Validation of Claims If certain expenses exceed benchmarks, the claim will be flagged for review and an e-mail will be sent to the uploader to provide additional information for those expenses. If additional information is requested, this must be received before the claim submission deadline in order for the claim to be included in the submission. All claims will be checked through the upload system. (See Section 3.9 – Viewing Upload Status/File Statistics and Error Reports for more information on claims processing and validations.) Benefits of the Administrative Claims Upload System Through the Upload system, claims can be uploaded and kept in an electronic format. This will enable claims to be processed more efficiently. Claim errors can be identified quickly, allowing claims to be corrected and resubmitted in a timely manner. Additionally, electronic claim submission will enable EHS to identify trends in data, and efficiently gather claim information. 3.2 Glossary of Terms Benchmark Guidelines – Guidelines used to determine possible claim errors upon claim submission. Claim ID number – A unique system generated number assigned to successfully uploaded claims for a specified quarter. This number is necessary to upload future amendments and can be used to search for the status of a claim. Data File – Specific file format using the .dat extension. See Appendix B for specifications. EHS – Executive Office of Health and Human Services. Excel File – Specified template format using .xls extension. Live Claim – Claim for submission. This claim will be processed for payment. Test Claim – Claim for testing purposes only. This claim will not be used for submission. UMMS – University of Massachusetts Medical School, Center for Health Care Financing. Uploader – Medicaid provider designee responsible for uploading the school district’s claims. The designee can be a vendor or a school district employee. Only this person will receive a username and password to the upload site. 3.3 Designating an “Uploader” Each Medicaid provider must designate an individual or a vendor/billing agent, known as an uploader, in order to submit claims through the Administrative Claim Upload System. To do this, Medicaid providers must complete the claim upload form, found in Appendix A. The form must be signed by the authorized official for the Medicaid provider, and submitted on their letterhead before a username and password will be assigned for the upload system. 3.4 Obtaining a Username and Password The previously designated uploader will receive an e-mail containing a username, temporary password, and a link to the upload login page. Sample Email Text 3.5 Logging In Step 1: Click on the link provided in the following e-mail notification. www.schoolbasedclaiming.net/eohhsweb Step 2: Your designated username, composed of parts of your last and first name, will prepopulate in the username field. The username is only prepopulated when the Web site link is used. If the link was not used, you must also type in your username. Step 3: Type in, or copy and paste your temporary password. Click “Submit.” You will be prompted to select a new password upon your first login. Step 4: Enter a new password when prompted to do so. Click “Submit” to create your password or “Clear” if you wish to clear fields and retype information. Your password must be at least eight characters in length. It must be a combination of both letters and numbers. It is case sensitive (upper and lower-case letters chosen must be used exactly as indicated.) Your password will expire every 90 days, at which time the system will prompt you to create a new one when you login. Forgotten Password If you have forgotten your password, you may have your password reset using the login screen. To do this: Step 1: Click on the “Forgot Password?” link under the username and password section. Step 2: Provide the username and the e-mail address that the upload system has on record for the user. If your e-mail address has changed, e-mail UMMS at schoolbasedclaiming@umassmed.edu or call 1-800-535-6741, option #2, to update your information. Step 3: Click “Submit.” A message stating that the password has been successfully reset will appear on the screen. A system-generated e-mail will be sent to you with the same username and new temporary password. Failed Login If an error was made when logging in, the upload system will display “Invalid Username or Password.” After three failed attempts, the system will suspend the password. E-mail UMMS at schoolbasedclaiming@umassmed.edu or call 1-800-535-6741, option # 2, for assistance. 3.6 Navigating the Welcome Screen and Viewing Updates Once you have successfully logged onto the site, you will reach the welcome screen. Any new information about administrative activity claiming will be posted here. If the system will be unavailable for maintenance, the scheduled times will be listed. From this screen, you can proceed to the upload tab at the top of the screen to submit your claims. Click on the tabs at the top of the screen to navigate through the administrative activity claim upload site. • Home The welcome screen displays helpful information and important announcements. • Upload Test claims and subsequent live claims can be uploaded into the system. • Status The uploader is able to view the upload status of a specific claim. 3.7 Uploading a File Test Upload Each provider must complete a test upload prior to uploading actual claims to be submitted and paid. The test upload ensures that data is submitted in the correct format. Test files are not submitted for payment. A test upload may be done as many times as necessary to ensure a successful submission upload. To upload a test file: Step 1 After logging into the system with your username and password, go to the “Upload” tab and click on the applicable TEST file upload type. A pop-up occurs when a test upload is selected. Being a test site, claims will not be paid. Press OK. You must upload a “TEST” file prior to submitting live claims. Step 2 Click “Browse” to select the test file to be uploaded. Step 3 Select your corresponding formatted file (either Excel or Data.) The upload claim file must be in the specified Excel or Data format (refer to Section 3.15 – Claim Deadlines) or the file will not upload. Click “Browse.” Excel Format Data Format Step 4 Click “Submit” to submit your selected file. The submission process takes a few moments. Please do not hit “Submit” more than one time. Choose the Excel file with the .xls extension. Choose the Data file format with the .dat extension. To choose a file, double click on the file or click “Open” after selecting the file. To choose a file, double click on the file or click “Open” after selecting the file. Click “Submit.” Confirming Test Upload After test submission, the upload results page will display automatically. This page indicates whether the test upload was successful or failed (see examples below). If an upload attempt fails, the upload results page will display an error list, which indicates the reason for the upload failure. The file will need to be corrected and re-uploaded. Example: Test upload successful (Excel) Example: Test upload failure (Excel) Error Listing Successful Upload Failed Upload Live Claim Upload A test file of the same type must have been uploaded successfully before a live file may be uploaded. To upload a live claim: Step 1 After logging into the system with your Username and password, click on the “Upload” tab at the top of your screen. Click on either “Excel File Upload” or “DAT File Upload,” dependent on your chosen format. Choose Excel or Data File Upload Step 2 Click “Browse” to select the live claim file to be uploaded. Step 3 Select your corresponding formatted file (either Excel or Data). The upload claim file must be in the specified Excel (.xls) or Data (.DAT) format (refer to Section 3.14 – File Formatting) or the file will not be upload. Excel Format Click “Browse” to select your claim file. Choose the file to upload from your system. Choose the Excel file with the .xls extension. To choose a file, double click on the file or click “Open” after selecting the fil Data Format Step 4 Click “Submit” to submit your selected file. The submission process takes a few moments. Please do not hit “Submit” more than once. Submission Validation Process/Confirmation Uploaded files are checked for file formatting errors (file formats are outlined in Appendix B). Upload is Successful. The file upload successful page will display. Example 1: Upload Successful (Excel) Choose the Data file format withthe.datextension. To choose a file, double click on the file or click “Open” after selecting the file. Click “Submit.” Upload file contains file formatting errors. If an upload attempt fails for file formatting reasons, the upload results page will display an error list, which indicates the reason for the upload failure. The file will need to be corrected and re-uploaded for submission. Example 2: Upload failure – File formatting errors (Excel) Example 3: Upload file contains validation errors. Validation errors are general or data specific errors found in the data itself that need correction prior to successful upload. If an upload fails due to validation errors, a validation error screen will display with errors needing correction prior to successful upload. You can correct the error immediately, and re-upload your file. General File Validation Error Examples • If a claim for the same quarter is approved or pending in the system and an uploader is attempting to reupload, the uploader will receive an error message indicating they need to contact schoolbasedclaiming@umassmed.edu in order to re-upload claim information. • If the claim exists but is not approved or is pending, the uploader will receive a validation message saying “Claim exists, do you want to overwrite the current claim?” Example 3A: General Data Validation Error Validation error details Specific data element validation error examples • If any statewide percentages are incorrect, the uploader will receive an error in their file statistics report showing error location. • If the indirect rate is incorrect, the uploader will receive an error in their file statistics report showing the error location. • If a claim specific value, such as Medicaid Eligibility Rate, is different throughout the claim, the uploader will receive an error in their file statistics report showing error locations. Example 3B: Specific Data Validation Error 3.8 Claim ID Numbers Once a claim is successfully uploaded, it will be assigned a claim ID number. This number can be used when searching claims in the “Status” tab (see below.) The claim ID number is also necessary when uploading an amended claim (Section 3.12 – Claim Acceptance or Denial Notification). 3.9 Viewing Upload Status/File Statistics and Error Reports The status tab allows the uploader to search for processed, approved, and denied claims that have been uploaded. This feature also shows the date the claim was uploaded and the net claim amount. Additional report data is provided under the File Statistics link in the Details section. See screen shot below at dialogue box that says “Click “File Statistics” or “Error Report” to see details for a specific claim.” A specific error is detected and this notification allows you to see where the error occurred. You can correct this error immediately, and re-upload your file. These reports are helpful in determining if the claim has been uploaded successfully. If there are errors in the claim that need to be corrected, the report will help determine the location of these errors. These reports are helpful in determining if the claim has been uploaded successfully or if there is an error that prevented a successful upload. Step 1: Click on “Status” tab at the top of the page. Step 2: Click on “File Statistics” or “Error Report” under Details section. Example: Status Page Click “File Statistics” or “Error Report” to see details for a specific claim. Click on “Status” Tab Example: File Statistics Details Example: Error Report Details Claim upload successful Failed upload error message 3.10 Amending a Claim The process for uploading an amended claim is the same as the process for uploading an original claim. The upload system recognizes amended claims through the claim type and amended claim number data fields in the header of the claim file being uploaded. The location of these data fields is specific to the type of file you are uploading. An example of an Excel file is shown below. For specific data file specifications see Appendix B of this document. Example: Excel File Amendment Header Fiscal Year 2004 Fiscal Quarter Jan-Mar District ID 1959999 State MA District Sample Public Vendor /Collaborative Name Vendor A ClaimType Amendment Gross Claim Expenses 4500.76 Net Claim Expenses 2250.38 Amended Claim No 747899 3.11 Understanding Benchmark Validations Once a claim has been successfully uploaded, the data in the claim is checked against benchmark validations. Benchmark validations are used to help identify potential errors in a claim. Claims containing data elements that fall outside the benchmark validations will be analyzed to determine if additional information is required. If it is determined that additional information is needed, the uploader will be contacted via e-mail. Once any outstanding questions have been resolved, the claim will be approved for submission and the uploader will be notified of approval through a system-generated e-mail. 3.12 Claim Acceptance or Denial Notification The uploader will receive notification of claim processing acceptance or denial via system- generated e-mail. Notification will include net claim amount, claim number assigned, contact information, etc., and a link for viewing the claim status. Example: Claim acceptance e-mail Dear School-Based Medicaid Provider, This message is to notify you that the following Medicaid Administrative Activity Claim has been accepted for processing: Claim # 1087 for Sample Charter School for the quarter ending 09/30/2005 Total Net $10,612.16. Please note: We require your certification form before this claim can be submitted for reimbursement. If you have any questions concerning this claim please contact: University of Massachusetts Medical School The Center for Health Care Financing 333 South Street Shrewsbury, MA 01545 800 535 6741 SchoolBasedClaiming@umassmed.edu You may view the status of your claim online at: https://www.schoolbasedclaiming.net/eohhsweb Example: Claim denial e-mail Dear School-Based Medicaid Provider, Your Medicaid Administrative Activity Claim is being returned to your school district for the reasons listed below. Salaries submitted are exactly the same as last date-of service quarter. Please adjust your claim accordingly and resubmit it to the University of Massachusetts Medical School, Center for Health Care Financing. Claim # 1087 for Sample Charter School for the quarter ending 09/30/2005 Total Net $10,612.16. If you have any questions concerning this claim please contact: University of Massachusetts Medical School The Center for Health Care Financing 333 South Street Shrewsbury, MA 01545 800 535 6741 SchoolBasedClaiming@umassmed.edu You may view the status of your claim online at: https://www.schoolbasedclaiming.net/eohhsweb 3.13 Technical Notes/System Specifications Workstation Requirements Operating Systems Win 98 or higher Macintosh Web Browsers Internet Explorer 5.0 to 6.0; 7.0 with MS Windows XP or Vista Mozilla Firefox 2.0 or higher Netscape 7.1 or higher Safari The Web browser, Internet Explorer, is not supported on the Macintosh operating system. Use Netscape or Safari instead. Cookies Workstations should enable cookies in the browser. Web Filters Workstations should allow access to URL https://www.schoolbasedclaiming.net/eohhsweb. E-mail E-mail should allow delivery from schoolbasedclaiming@umassmed.edu in large quantities on a single day. Online Training Application Flash Player is needed to run the online training program. The following link, http://macromedia.com/software/flash/about, has a connection to the Player download center, which will walk you through the process of downloading the most recent version of Player. System Administration Requirements Cookies System administrator: If there is a proxy server, set the proxy not to cache the www.schoolbasedclaiming.net domain. The actual Web site URL is https://www.schoolbasedclaiming.net/eohhsweb. www.schoolbasedclaiming.net cookies (sessions) are tied to the URL and IP address. Routers If the SBC IP address needs to be explicitly defined on routers, the SBC IP address is 146.189.111.50 E-mail Servers E-mail servers should allow e-mail delivery from schoolbasedclaiming@umassmed.edu. E-mail Server IP E-mails may be sent through the following three mail gateways. • 146.189.194.27 • 146.189.194.30 • 146.189.194.28 Web Filters Web filters allow access to the production site secure connection URL https://chcf.net/chcfweb. 3.14 File Formatting Claims can be uploaded only in a specified data file format (.dat) or Excel template (.xls). • The data file specifications are provided in Appendix B of this document. • The pre-formatted Excel template may be downloaded from www.schoolbasedclaiming.net/eohhsweb or obtained by e-mailing a request to schoolbasedclaiming@umassmed.edu. 3.15 Claim Deadlines The deadline to upload a correct claim into the system is midnight on the 15th of the month after the close of the quarter. This deadline will hold regardless of holidays and weekends. Claims received after the 15th will be processed for the next quarterly submission. Deadlines are listed below. Quarter Ending Deadline for Receipt of Claims September 30th October 15th December 31st January 15th March 31st April 15th June 30th July 15th 3.16 Contact Information University of Massachusetts Medical School School-Based Medicaid Program 333 South Street Shrewsbury, MA 01545 1-800-535-6741 Schoolbasedclaiming@umassmed.edu 4 School Based Medicaid Program Administrative Activity Claiming Program Claim Upload The purpose of this form is to identify the individual designated by a school-based Medicaid provider to upload administrative activity claims. This form must be completed by the provider and submitted on letterhead. You must inform us within 14 days if this information changes. Any time you make a change in Uploader information you must submit a new form. Provider Information MassHealth Provider Name: MassHealth Provider Number: NPI No.: Contact Name: Title: Address: Tel. No.: Fax No.: E-Mail: Uploader Information: Name of person or vendor/billing agent who will upload claims Name: Upload Start Date: Contact Name: Title: Address: Tel. No.: Fax No.: E-Mail ____________________________________________ Signature ____________________________________________ Date Please submit completed form to: University of Massachusetts Medical School School-Based Medicaid Program 333 South Street Shrewsbury, MA 01545 Fax: (508) 856-7643 Phone: (800) 535-6741 5 School-Based Medicaid Program Administrative Activity Claiming Program Claim File Format Specification for Data file 5.1 Overview The "Administrative Activity Claiming Upload" (AAC) file is encoded as a plain text file. Individual claim files may be assigned any file name. Within the file, AAC data is organized into "records" and record "fields." There are nine defined record types, each with a different set of defined fields. Every record type corresponds to a report within the AAC claim, while record fields correspond to a collection of values from that report. Example: The record type "Claim Summary" corresponds to the "Quarterly Claim Calculation Summary" report and includes the fields "50% Direct Personnel Costs,” "50% Direct Support Personnel Costs,” "Total Gross Claim Amount," and "Total Net Claim Amount," etc. Each line of the data file contains one record. The record type is identified by a special text code at the beginning of the line, and the values that follow are assigned to specific record fields by the order in which they are listed. The file format defines the order in which records are recorded. A special "Header" record type contains claim overview information, such as school district name, ID, claim date of service, etc. Data from claim reports, which are organized by job position, group number, and/or activity code, are split into detail and summary records. Detail records contain information specific to one job group, or job group activity code. Summary records contain subtotals by job group and/or report totals. Detail records define fields for indicating the job position, group number, and/or activity code, so the same structure may be used for data for all job groups and activities. Example: "HP Expenditures Detail (for Job Group 1)," "HP Expenditures Summary (for Job Group 1)," "HP Expenditures (for Job Group 2),” "HP Expenditures Summary (for Job Group 2.)" 5.2 File Format Each line of the file represents one data record, which contains a record identifier and the values for one or more fields. Each record identifier and field value is separated by delimiting and separating characters. Double quote marks (") are used as delimiters around the field value, and a tilde character (~) is used as a separator between field values. A carriage return ends the line and serves as the record delimiter. The record identifier and each field value is delimited left and right by a set of " and separated from the next field by a ~. Each line of the file format contains information for one record type, specified by the record ID. The fields defined for each record type have a defined order. The general format for each record in the file is as follows. "RecordIdentifier"~"Field1Value"~"Field2Value"~"Field3Value"~"Field4Value" The following example illustrates a cost pool record based on the following data. Record Type – CP, Job Group – 1, Activity Code – G, Percent of time spent on activity – 51.8800%, Total Cost Pool – $35738.44655848, Medicaid Penetration Factor – N/A, General Administration Overhead Factor – N/A, Total Gross Claim Amount - $18541.106074539424 "CP"~"1.0"~"G"~"51.8800"~"35738.44655848"~""~""~"18541.106074539424" In general, a record is required for every record type, job group and activity code even if there are no data for a specific category. Using the example record above, if there is no cost pool record for Job Group 1 and activity code D, the Cost Pool record would be formatted as follows. "CP"~"1.0"~"G"~"0.0"~"0.0"~""~""~"0.0" Note that any “N/A” values are represented as "", rather than "0", as in the following cost pool record example. Record Type = CP, Job Group = 1, Activity Code = A, % Time Spent = 23.46%, Total Cost Pool = $100,000, Medicaid Eligibility Factor = N/A (for activity A), General Admin Overhead Factor = N/A (for activity A), Total Gross Claim Amount = $23,460 "CP"~"1"~"A"~"23.46"~"100000.00"~""~""~"23460.00" 5.3 Field Formats Submitted values will be formatted according to the field's defined data type. The following sections detail the expected format of data for each data type. Date Values Date field values are submitted in YYYYMMDD format. For example, 12/31/2006 would be formatted as "20061231." Currency Values Currency field values do not include comma or dollar sign symbols. For example, $1,250.01 would be formatted as "1250.01." To indicate "N/A", use an empty string (""). Percentage Values Percent field values may be submitted with any amount of precision. Percent values are formatted with a whole number and fractional component, but do not include a % sign. For example, 16.67 % would be formatted as "16.67." To indicate "N/A", use an empty string (""). String Values String values are formatted as plain text and should not include any special formatting characters, such as tabs, carriage return characters, or single or double quotes. For example, the last name field for health care professional, Amy Amaral, would be formatted as "Amaral." Any omitted or "N/A" string values will be represented using empty quotes (""). Since the order of values in a record determines which data is mapped to which field, empty quotes ensure that the omitted field receives a null value. Job Position Group Numbers Job position group number values may include or exclude leading zeros. Valid job position group number values are "1" or “01” and "2" or “02.” Activity Codes Activity code values may be submitted as either upper or lowercase letters. Valid activity code values are ”A”, ”B”, ”C”, ”D”, ”E” , ”F”, ”G”, ”H”, ”I”, “J”, “K”, “L”, “M”, “N”, and ”a”, ”b”, ”c”, ”d”, ”e”, ”f”, ”g”, ”h”, ”i” “j”, “k”, “l”, “m”, “n”. 5.4 File Record Descriptions File Header The header record contains basic claim identifying information and select details from the certification sheet. For example, the submitting school district name and ID, type of claim, date of service, claim amounts, etc. Claim Summary The claim summary record contains the net and gross claim totals and subtotals from the "Quarterly Claim Calculation Summary" report. Cost Pool The cost pool record contains information from the "Quarterly Claim Calculation" report. There is one record per job group per activity code, for a total of 28 records. Specialized Transportation The specialized transportation records contain data from the "Quarterly Specialized Transportation" report. Capital Costs The capital costs records contain data from the "Capital Calculation" claim report. Detailed Expenditures/Expenditures Totals The "Detailed Expenditures" and "Detail Expenditures Totals" records correspond to the "Detailed Expenditures" reports. There is one record for each HP within a Job Group, and one summary/total record for each Job position group number. Material costs, Chapter 766 expenses, purchased services, and the total cost pool for the job position group number are included in the job position group number summary records. A summary record is required for each job position group number. However, there may not be any corresponding detail records if there are no health personnel resources for a specific job position group number. Out-of-District Schools (OOD) Totals (Chapter 766 Schools) OOD information is separated into detail and summary records, which contain expenses by job group and expense totals, respectively. 5.5 Claim Data File Format Each data file contains information for one school district, for a specific quarter of a school year. The data file is a plain text file using double quotes to delineate fields, tilde characters to separate fields, and a return character to separate records. Each defined record type is expected in the file even if there is no data for that record, job group, or activity code (with the exception of health professional (HP) detail records, if there are no resources for a specific Job position group number.) Special Formatting Characters Character ASCII Code Use Double Quote (Straight Quotes 2 ) 2 Delimit field values using one set of double quotes before, and one after each value. Tilde (Tilde ) 126 Separate one record indicator or field value from the next, using a tilde character between the trailing double quote of the first field and the leading double-quote of the next field. This is used only between fields; the last field value in a record does not have a following tilde. (Carriage Return) 10 Indicate the end of a record with the carriage return character after the trailing double-quote of the last field value. 5.6 Records and Field Definitions Records must appear in the file in the order in which they are listed below. Every record is required, and a record for each job and activity code must be submitted. Header Record 1 Record Name Type Details Record Type Identifier String Always "HD" Year Integer Year of the claiming period (actual, not fiscal year). For example, for a claim covering dates of service from July 1st, 2006, through September 30th 2006, the fiscal school year would be "2006." Quarter String Quarter of the claiming period; a seven-character keyword: "Jan-Mar" "Apr-Jun" "Jul-Sep" "Oct-Dec" District ID Integer School district identifier; the "School-Based Medicaid Provider Number" assigned by the Executive Office of Health and Human Services State String State Abbreviation: "MA" District Name String School district name Vendor Name String Vendor Name (Optional) Claim Type String Keyword; either "Original" or "Amendment," depending upon the type of the claim Total Gross Claim Expenses Currency Total gross claim expense from the "Quarterly Claim Calculation Summary" report Total Net Claim Expenses Currency Total net claim expense from the "Quarterly Claim Calculation Summary" report Amended Claim Number Integer For a claim of type "Amendment," the number of the claim that is to be amended (Optional) Claim Summary Data from the "Quarterly Claim Calculation Summary" report 1 Record Name Type Details Record Type Identifier String Always "CS" 50% Direct Service Providers Currency 50% Administrative Only Providers Currency 50% Specialized Transportation Costs Currency 50% Gross Claim Subtotal 1 Currency Capital Percentage Rate Percent 50% Capital Costs Currency 50% Gross Claim Subtotal 2 Currency Indirect Cost Rate Percent 50% Indirect Costs Currency 50% FPP Cost Rate Percent Always "50.0" 50% Total Gross Claim Amount Currency 50% Total Net Claim Amount Currency Cost Pool Data from the "Quarterly Claim Calculation" report 828 Records: 1 record per Job Group + Activity Code Record Order: (by Job Group - Activity Code) Job Code 1: Activities A-N, Job Code 2: Activities A-N Name Type Details Record Type Identifier String Always "CP" Job Position Group Number Integer Activity Code String Percent of Time Spent on Activity Percent Total Cost Pool Currency Medicaid Eligibility Factor Percent (Use "" to indicate N/A.) General Administrative Overhead Factor Percent (Use "" to indicate N/A.) Total Gross Claim Amount Currency Specialized Transportation Data from the "Quarterly Claim Specialized Transportation" report 1 Record Name Type Details Record Type Identifier String Always "ST" Quarterly Specialized Transportation Expenditures for Special Education Students Currency Number of Special Education Students with Medically Necessary Transportation in Their IEP/Number of Special Education Students Who Receive Specialized Transportation Percent Medicaid Eligibility Factor of Special Education Population Percent State Wide Average of Time Spent Receiving Medicaid Covered Services Percent Gross Claim Amount for Specialized Transportation Currency Capital Costs Data from the "Capital Calculation" report 1 Record Name Type Details Record Type Identifier String Always "CC" Building and Fixed Assets Acquisition Cost Currency Fixed Asset Annual Use Allowance Percent Building and Fixed Asset Total Currency Major Movable Equipment Acquisition Cost Currency Major Movable Equipment Annual Use Allowance Percent Major Movable Equipment Total Currency Net Interest Expense Currency Total Capital Currency Total Annual District Wide Salary + Fringe Benefits Currency Capital Percentage Rate Percent HP Expenditures Detail Data Data from the "Detailed Expenditures" report N Records: One record per Healthcare Professional Record Order: (by Job Group) All HP records for Job Group 1, All HP records for Job Group 2 Name Type Details Record Type Identifier String Always "HP" Staff Last Name String Staff First Name String Employee ID String HP Type String Keyword; either "Employee" or "Contractor." Note: Employees must have benefit $ amounts specified. Contractors will have 0 benefit $ amounts. Job Description String Must be identical to state mandated job descriptions (spelling dashes, spaces etc.). Job Position Group Number Integer Salary Before Federally Funded % Applied Currency Federally Funded % Percent Quarterly Salary without Federal Funds Currency Quarterly Unemployment Benefits Currency Quarterly Insurance Benefits Currency health, life, etc. Quarterly Medicare Benefits Currency Quarterly Workers Compensation Benefits Currency Quarterly Pension Benefits Currency Other Benefits Currency Total Salary and Fringe Benefits Currency HP Expenditures Summary Data (Job Group Subtotals) Data from the "Detailed Expenditures" report 2 Records: 1 record per Job Group Required: Summary Data for each job group is required, even if there are no health professionals associated with a particular job group. Record Order: (by Job Group) 1, 2 Name Type Details Record Type Identifier String Always "JP" Job Position Group Number Integer Materials and Supplies Expense Currency Chapter 766 Expense Currency Purchased Services (for group 2 only) Currency Quarterly Salaries Subtotal Currency Total Cost Pool Currency Out-of-District Schools Detail Data Data from the "State-Wide Summary Worksheet for Out-of -District Schools" report 2 Records: 1 record per Job Group Record Order: (by Job Group) 1, 2 Name Type Details Record Type Identifier String Always "OJ" Job Position Group Number Integer Total Quarterly Tuition Expenditures for Day Schools Currency Percentage of Health Related Services for Day Schools Percent Health Related Portion of Quarterly Day School Tuition Currency Total Quarterly Tuition Expenditures for Residential Schools Currency Room and Board Discount Factor Percent 100% - Discount % Ex: "86.36” (100% - 13.64%) Percentage of Health Related Services for Residential Schools Percent Health Related Portion of Quarterly Residential School Tuition Currency Total Health Related Portion of Quarterly Day and Residential Tuition Currency Out-of-District Schools Summary Data (Chapter 766 Expense Totals) Data from the "State-Wide Summary Worksheet for Out-of-District Schools" report 1 Record (Total of All Job Group Detail Records) Name Type Details Record Type Identifier String Always "OD" Total Health Related Portion of Quarterly Day School Tuition Currency Total Health Related Portion of Quarterly Residential School Tuition Currency Total Health Related Portion of Quarterly Day and Residential Tuition Currency Sample DAT File Note that the "CS" record is wrapped across multiple lines due to page size limitations. "HD"~"2007.0"~"Jan-Mar"~"121111.0"~"MA"~"ATest Public Schools"~"ATest Vendor"~"Original"~"14686.198722297631"~"7505.43892670043"~"" "CS"~"10593.407306637959"~"405.8489138790418"~"10999.256220517"~"1340.3703521045677"~"0.0"~"1340.3703521045677"~"510.2766656"~""~"510.2766656~"50.0"~"~"365.2640224911376"~"7505.43892670043" "ST"~"36808.0"~"13.00"~"43.00"~"24.800"~"510.2766656" "OJ"~"1.0"~"52178.0"~"2.9700"~"1549.6866"~"25638.0"~"86.3600"~"0.6100"~"135.05995848"~"1684.74655848" "OJ"~"2.0"~"52178.0"~"2.1800"~"1137.4804"~"25638.0"~"86.3600"~"0.4500"~"9643.00”~”99.63439559999999"~"1237.1147956" "OD"~"19290.2066"~"5333.761311120001"~"24623.967911120002" "CC"~"27800852"~"2.00"~"556017.04"~"91282.0"~"6.6700"~"6088.51"~"185785.0"~"747890.55"~"15625235" ~"4.78642753212991700" "CP"~"1.0"~"A"~"0.0"~"35738.44655848"~""~""~"0.0" "CP"~"1.0"~"B"~"0.0"~"35738.44655848"~""~""~"0.0" "CP"~"1.0"~"C"~"0.0"~"35738.44655848"~""~""~"0.0" "CP"~"1.0"~"D"~"13.3400"~"35738.44655848"~"~"~""~"1031.2121471459363" "CP"~"1.0"~"E"~"2.8400"~"35738.44655848"~"~"~""~"219.53841813301796" "CP"~"1.0"~"F"~"4.500"~"35738.44655848"~"21.6300"~""~"347.86016957696506" "CP"~"1.0"~"G"~"51.8800"~"35738.44655848"~""~""~"18541.106074539424" "CP"~"1.0"~"H"~"23.4600"~"35738.44655848"~""21.6300"5.84411288215312200"~"489.9844243496194" "CP"~"1.0"~"I"~"3.9800"~"35738.44655848"~""~""~"1422.390173027504" "CP"~"1.0"~"J"~"0.0"~"35738.44655848"~""21.6300""~"0.0" "CP"~"1.0"~"K"~"0.0"~"35738.44655848"~""~""~"0.0" "CP"~"1.0"~"L"~"0.0"~"35738.44655848"~""~""~"0.0" "CP"~"1.0"~"M"~"0.0"~"35738.44655848"~""~""~"0.0" "CP"~"1.0"~"N"~"0.0"~"35738.44655848"~""5.84411288215312200""~"0.0" "CP"~"2.0"~"A"~"0.0"~"35738.44655848"~""~""~"0.0" "CP"~"2.0"~"B"~"0.0"~"35738.44655848"~""~""~"0.0" "CP"~"2.0"~"C"~"0.0"~"35738.44655848"~""~""~"0.0" "CP"~"2.0"~"D"~"13.3400"~"35738.44655848"~"~"~""~"1031.2121471459363" "CP"~"2.0"~"E"~"2.8400"~"35738.44655848"~"~"~""~"219.53841813301796" "CP"~"2.0"~"F"~"4.500"~"35738.44655848"~"21.6300"~""~"347.86016957696506" "CP"~"2.0"~"G"~"51.8800"~"35738.44655848"~""~""~"18541.106074539424" "CP"~"2.0"~"H"~"23.4600"~"35738.44655848"~""21.6300"5.84411288215312200"~"489.9844243496194" "CP"~"2.0"~"I"~"3.9800"~"35738.44655848"~""~""~"1422.390173027504" "CP"~"2.0"~"J"~"0.0"~"35738.44655848"~""21.6300""~"0.0" "CP"~"2.0"~"K"~"0.0"~"35738.44655848"~""~""~"0.0" "CP"~"2.0"~"L"~"0.0"~"35738.44655848"~""~""~"0.0" "CP"~"2.0"~"M"~"0.0"~"35738.44655848"~""~""~"0.0" "CP"~"2.0"~"N"~"0.0"~"35738.44655848"~""5.84411288215312200""~"0.0" "HP"~"Wycslezski"~"Andy"~"12344”~"Employee"~"Nurse"~"Y"~"1.0"~"2604.0"~"2604.0"~".50"~"2.54"~"238.63"~"29.23"~"11.7"~"23.2"~"0.0"~"2909.3" "HP"~"Smith"~"Amy"~”6549"~"Employee"~"Psychiatrist"~"Y"~"1.0"~"12636.0"~"2604.0"~".50"~"12.34"~"1157.98"~"141.84"~"56.79"~"112.59"~"0.0"~"14117.54" "HP"~"West"~"John"~"3455116"~"Employee"~"Speech"~"Y"~"1.0"~"15223.0"~"2604.0"~".50"~"14.87"~"1395.06"~"170.88"~"68.41"~"135.64"~"0.0"~"17007.86" "JP"~"1.0"~"19.0"~"1684.74655848"~"30463.0"~"35738.44655848" "HP"~"Garza"~"Achmed"~"9874"~"Employee"~"Therapist"~"N"~"2.0"~"6130.0"~"2604.0"~".50"5.99"~"561.76"~"68.81"~"27.55"~"54.62"~"0.0"~"6848.73" "HP"~"Ivanov"~"Agram"~"9699314"~"Employee"~"NurseAide"~"N"~"2.0"~"8456.0"~"2604.0"~".50"8.26"~"774.92"~"94.92"~"38.0"~"75.34"~"0.0"~"9447.44" "HP"~"West"~"Rich"~"3354"~"Employee"~"GuidanceCounselor"~"N"~"2.0"~"6782.0"~""~"2604.0"~".50"6.62"~"621.51"~"76.13"~"30.48"~"60.43"~"0.0"~"7577.17" "JP"~"2.0"~"3.0"~"1237.1147956"~"21368.0"~"25113.4547956" 6 School-Based Medicaid Program Administrative Activity Claiming Program Claim File Format Specification for Excel File The available Excel file layout is a predefined template that may be downloaded at www.schoolbasedclaiming.net/eohhsweb or via email request to schoolbasedclaiming@umassmed.edu. When prompted to open or save the template, choose to “save” the template to the location of choice. Claim data may then be entered directly into the template in corresponding fields and saved with an Excel file name of choice. The available Excel file layout is a predefined template that may be downloaded at www.schoolbasedclaiming.net/eohhsweb or via email request to schoolbasedclaiming@umassmed.edu. When prompted to open or save the template, choose to “save” the template to the location of choice. Claim data may then be entered directly into the template in corresponding fields and saved with an Excel file name of choice. 6.1 Claim Header Information Claim Year Claim Quarter District ID State District Name Vendor/Collaborative Name Claim Type Gross Claim Expenses Net Claim Expenses Amended Claim # 6.2 Quarterly Claim Calculation Summary 1 Capital % Rate % 2 Indirect Cost Rate % Gross Claim Amounts Costs for Which the FFP = 50% 3 Direct Service Personnel $ 4 Administrative Only Personnel $ 5 Specialized Transportation $ 6 Gross Claim Subtotal 1 $ 7 Capital Costs $ 8 Gross Claim Subtotal 2 $ 9 Indirect Costs $ 10 Total Gross Claim $ 11 Total Net Claim $ 6.3 Quarterly Claim Calculation Detail Cost Pool A B Percent of Time Spent on Activity C Total Cost Pool D Medicaid Eligibility Percentage E General Administrative Overhead Factor F Total Gross Claim Amount G 1 A % $ N/A N/A $ 1 B % $ N/A N/A $ 1 C % $ N/A N/A $ 1 D % $ N/A N/A $ 1 E % $ N/A N/A $ 1 F % $ % N/A $ 1 G % $ N/A N/A $ 1 H % $ % N/A $ 1 I % $ N/A N/A $ 1 J % $ % N/A $ 1 K % $ N/A N/A $ 1 L % $ N/A N/A $ 1 M % $ N/A N/A $ 1 N % $ N/A % $ % $ 2 A % $ N/A N/A $ 2 B % $ N/A N/A $ 2 C % $ N/A N/A $ 2 D % $ N/A N/A $ 2 E % $ N/A N/A $ 2 F % $ % N/A $ 2 G % $ N/A N/A $ 2 H % $ % N/A $ 2 I % $ N/A N/A $ 2 J % $ % N/A $ 2 K % $ N/A N/A $ 2 L % $ N/A N/A $ 2 M % $ N/A N/A $ 2 N % $ N/A % $ 6.4 Quarterly Specialized Transportation Calculation Quarterly Specialized Transportation Expenditures for Special Education Students Specialized Transportation Percentage: # of Special Education Students with Medically Necessary Specialized Transportation in Their IEP/# of Special Education Students Who Have Specialized Transportation in Their IEP Special Education Medicaid Eligibility Percentage State Wide Average of Time Spent Receiving Medicaid Covered Services Gross Claim Amount for Specialized Transportation A B C D E 1 $ % % 24.80% $ 6.5 Annual Capital Calculation Type of School-Based Cost School-Based Cost A Use Allowance B Total C Building And Fixed Valuation 1 $ 2% $ Major Moveable Valuation 2 $ 6.67% $ School Wide Interest Expense 3 $ $ Subtotal Capital 4 $ Total District Salary + Fringe Benefit 5 $ Capital Percentage Rate 6 % 6.6 Quarterly Detailed Expenditure Report Detailed Expenditures Report Materials $0.00 Total Salary Cost Pool 1 Out of District Tuition $0.00 Total Cost Pool Direct Service Personnel Staff Last Name Staff First Name Employee ID Job Code Job Description Medical Y or N Job Position Group # Salary Before Federally Funded % Applied Federally Funded % Quarterly Salary Without Federal Funds Unemployment K Health, Life Ins, etc. L Medicare M WC / Injury Pmts N Pension O Other P TSaBe A B C D E F G H I J Detailed Expenditures Report Materials $0.00 Total Salary Cost Pool 2 Out of District Tuition $0.00 Total Cost Pool Administrative Only Personnel Purchased Service $0.00 Staff Last Name Staff First Name Employee ID Job Code Job Description Medical Y or N Job Position Group # Salary Before Federally Funded % Applied Federally Funded % Quarterly Salary Without Federal Funds Unemployment K Health, Life Ins, Etc. L Medicare M WC / Injury Pmts N Pension O Other P TSaBe A B C D E F G H I J 6.7 Quarterly Out-of-District Tuition Day Schools Residential Schools Cost Pool Number Total Quarterly Tuition Expenditures for Day Schools Percentage of Health Related Services for Day Schools Health Related Portion of Quarterly Day School Tuition Total Quarterly Tuition Expenditures for Residential Schools 13.64% Room & Board Discount Percentage of Health Related Services for Residential Schools Health Related Portion of Quarterly Residential School Tuition Total Health Related Portion of Quarterly Day & Residential Tuition A B C D E F G H I 1 $ 25.09% $ $ 86.36% 17.34% $ $ 2 $ 11.88% $ $ 86.36% 6.75% $ $ $ $ $ 7 Job Description Titles Job Description Providing Medical Services Group Audiologist - Medicaid Definition Yes 1 Audiologist - Medicaid Definition No 2 Audiologist Yes or No 2 Audiologist Assistant - Medicaid Definition Yes 1 Audiologist Assistant - Medicaid Definition No 2 Audiologist Assistant or Aide Yes or No 2 Counselor - Medicaid Definition Yes 1 Counselor - Medicaid Definition No 2 Counselor Yes or No 2 Case Manager Yes or No 2 Direct Support Personnel Yes or No 2 Hearing Instrument Specialist - Medicaid Definition Yes 1 Hearing Instrument Specialist - Medicaid Definition No 2 Hearing Instrument Specialist Yes or No 2 Medicaid Billing Personnel Yes or No 1 Nurse Licensed -RN - Medicaid Definition Yes 1 Nurse Licensed - RN - Medicaid Definition No 2 Nurse Licensed - LPN - Medicaid Definition Yes 1 Nurse Licensed -LPN - Medicaid Definition No 2 Nurse Yes or No 2 Nurse's Aide Yes or No 2 Occupational Therapist - Medicaid Definition Yes 1 Occupational Therapist - Medicaid Definition No 2 Occupational Therapist Yes or No 2 Occupational Therapist Aide Yes or No 2 Occupational Therapy Assistant - Medicaid Definition Yes 1 Occupational Therapy Assistant - Medicaid Definition No 2 Occupational Therapy Assistant Yes or No 2 Job Description Providing Medical Services Group Personal Care Service Provider- Medicaid Definition Yes 1 Personal Care Service Provider- Medicaid Definition No 2 Personal Care Service Provider Yes or No 2 Physical Therapist - Medicaid Definition Yes 1 Physical Therapist - Medicaid Definition No 2 Physical Therapist Yes or No 2 Physical Therapy Assistant - Medicaid Definition Yes 1 Physical Therapy Assistant - Medicaid Definition No 2 Physical Therapy Assistant Yes or No 2 Physical Therapist Aide Yes or No 2 Physician Yes or No 2 Psychiatrist - Medicaid Definition Yes 1 Psychiatrist - Medicaid Definition No 2 Psychiatrist Yes or No 2 Psychologist 1 - Medicaid Definition Yes 1 Psychologist 1 - Medicaid Definition No 2 Psychologist 2 - Medicaid Definition Yes 1 Psychologist 2 - Medicaid Definition No 2 Psychologist Yes or No 2 School Adjustment Counselor Yes or No 2 School Guidance Counselor Yes or No 2 School Psychologist Yes or No 2 School Psychologist Intern Yes or No 2 Social Worker 1 - Medicaid Definition Yes 1 Social Worker 1- Medicaid Definition No 2 Social Worker 2- Medicaid Definition Yes 1 Social Worker 2 - Medicaid Definition No 2 Social Worker Yes or No 2 Speech/Language Therapist - Medicaid Definition Yes 1 Speech/Language Therapist - Medicaid Definition No 2 Speech/Language Therapist Yes or No 2 Speech/Language Aide Yes or No 2 Speech/Language Assistant - Medicaid Definition Yes 1 Speech/Language Assistant - Medicaid Definition No 2 Speech/Language Assistant Yes or No 2 Vision Specialist Yes or No 2