Tsev Cov Ntawv, Cov Cai, thiab Cov Ntawv Tshaj Tawm  Cov Ntawv Cov Ntawv Qhia Txog Tus Nqi thiab Cov Ntaub Ntawv ​​ 

Daim Ntawv Qhia Tus Nqi thiab Cov Ntaub Ntawv​​ 

Rov qab mus rau Kev Tshawb Xyuas Nyiaj Txiag Inpatient Division Homepage​​ 
Rov qab mus rau Kev Tshawb Fawb Txog Nyiaj Txiag Sab Nraud thiab Tus Cwj Pwm Kev Noj Qab Haus Huv Hauv Tsev​​ 

Cov ntawv qhia txog tus nqi ntawm Lub Chaw Haujlwm Saib Xyuas Kev Noj Qab Haus Huv (DHCS) muaj rau rub tawm. Lub Chaw Tshawb Xyuas Daim Ntawv Qhia Txog Tus Nqi (CRTS) tau txais cov ntawv qhia txog tus nqi uas tau xa tuaj. CRTS yuav hloov kho cov ntawv thiab cov ntaub ntawv thaum lawv muaj.​​ 

The forms are Adobe Acrobat PDF files and Microsoft Excel files. If you are unable to access a form and would like to request a copy, please send an email to FRDaudits.Questions@dhcs.ca.gov or contact CRTS at (916) 650-6696.​​ 

Ceev faj - Txhua daim ntawv yuav raug kho dua. Thaum npaj Daim Ntawv Qhia Tus Nqi Tshiab, nkag mus rau cov ntaub ntawv los ntawm lub vev xaib no kom ntseeg tau tias siv cov qauv tam sim no. Kev xa tawm ntawm cov ntaub ntawv dhau los yuav raug tsis lees paub los ntawm CRTS thiab yuav xav tau kev xa rov qab nrog cov ntaub ntawv tshiab.​​ 

Nco tseg - Koj yuav tsum xa daim ntawv pov thawj DocuSign sib thooj nrog txhua Daim Ntawv Qhia Tus Nqi kom tsis txhob raug tso tseg.​​ 

Kev Pabcuam Tus Neeg Mob​​ 

Cov Ntawv thiab Cov Ntaub Ntawv Txog Kev Saib Xyuas Mus Ntev​​ 

Chaw Saib Xyuas Tus Kheej Nruab Nrab - Tus Muab Kev Pabcuam​​ 

Cov chaw saib xyuas tus kheej rau cov neeg xiam oob qhab hauv kev loj hlob (ICF-DDH/N) yuav tsum ua kom tiav thiab xa daim ntawv qhia txog tus nqi DHCS 3076 txhua xyoo. Daim Ntawv Qhia Txog Tus Nqi yuav tsum tau muaj cov ntaub ntawv qhia txog tus nqi thiab tus nqi khiav lag luam rau lub chaw thiab qhov kev pab cuam Medi-Cal.​​ 

Chaw Saib Xyuas Tus Kheej Qib Nruab Nrab - Chaw Ua Haujlwm Hauv Tsev​​ 

ICF-DDH/N Cov Chaw Ua Haujlwm Hauv Tsev yuav tsum ua kom tiav thiab xa DHCS 3099 Daim Ntawv Qhia Tus Nqi Hauv Tsev nyob rau ib xyoos. Daim Ntawv Qhia Tus Nqi yog rau cov koom haum saw hlau ua haujlwm lossis tswj ob (2) lossis ntau dua ICF-DDH/N cov chaw. Daim Ntawv Qhia Tus Nqi yuav tsum muaj qee cov ntaub ntawv nthuav tawm ntawm Lub Tsev Haujlwm Hauv Tsev thiab kev faib cov nqi tsev hauv tsev rau ntau yam ICF-DDH/N cov chaw.​​ 

If you have any questions regarding these forms, please send an email to ICFDDHN.Questions@dhcs.ca.gov or contact CRTS at (916) 650-6696.​​ 

Qhov Kev Pab Kho Mob Sab Nraud​​ 

Federally Qualified Health Center/Rural Health Clinic (FQHC/RHC) Cov ntawv thiab cov ntaub ntawv​​ 

FQHC/RHC/Indian Health Services Memorandum of Agreement (IHS-MOA) cov chaw muab kev pab thiab FQHC/RHC Cov Chaw Ua Haujlwm Hauv Tsev yuav tsum ua kom tiav thiab xa DHCS 3088 Medi-Cal Worksheets Electronic Submission Protocol.​​ 

Home Office – Six (6) or Less​​ 

Freestanding FQHC/RHC cov chaw muab kev pab uas muaj rau (6) lossis tsawg dua FQHC/RHC cov chaw kho mob yuav tsum ua kom tiav thiab xa DHCS 3089 Daim Ntawv Qhia Txog Tus Nqi Hauv Tsev rau Kev Npaj Them Nqi (PPS) Rate Setting (xav txog lossis qhov tseeb) thiab Hloov Hauv Kev Thov Kev Pabcuam (CSOSR). Cov chaw zov me nyuam no yog ib feem ntawm lub koom haum saw lossis ntau lub koom haum kho mob uas ua haujlwm tsawg kawg yog ob (2) lossis ntau lub tsev kho mob lossis ib qho (1) FQHC/RHC thiab ib lub koom haum tsis yog kev kho mob/kev lag luam.​​ 

Home Office – Seven (7) or More​​ 

Cov kws kho mob FQHC/RHC uas muaj xya (7) lossis ntau dua FQHC/RHC cov chaw kho mob yuav tsum ua kom tiav thiab xa daim ntawv qhia txog tus nqi ntawm DHCS 3089.1 Home Office Cost Report rau PPS Rate Setting (kwv yees lossis tiag tiag) thiab CSOSR. Cov chaw muab kev pab no yog ib feem ntawm ib lub koom haum sib txuas lossis ntau lub koom haum kho mob uas khiav tsawg kawg yog ob (2) lossis ntau lub chaw kho mob lossis ib (1) FQHC/RHC thiab ib lub koom haum/lag luam uas tsis yog kev kho mob.​​ 

Rate Setting ua ntej Lub Ib Hlis 1, 2021​​ 

FQHC thiab RHC cov chaw muab kev pabcuam nrog Lub Sijhawm Kawg (FPE) hnub ua ntej Lub Ib Hlis 1, 2021 yuav tsum ua kom tiav thiab xa DHCS 3090 Tus Nqi Tshaj Tawm los txiav txim siab nws tus nqi PPS.​​ 

Rate Setting tom qab Lub Ib Hlis 1, 2021​​ 

FQHC thiab RHC cov chaw muab kev pabcuam nrog FPE hnub tom qab Lub Ib Hlis 1, 2021 yuav tsum ua kom tiav thiab xa DHCS 3090 (Post FPE Lub Ib Hlis 1, 2021) Daim Ntawv Qhia Tus Nqi los txiav txim nws tus nqi PPS.​​ 

Kev Hloov Pauv ntawm Daim Ntawv Thov Kev Pabcuam ua ntej Lub Ib Hlis Ntuj hnub tim 1, 2021​​ 

FQHC thiab RHC cov chaw muab kev pabcuam nrog FPE hnub ua ntej Lub Ib Hlis 1, 2021 yuav tsum ua kom tiav thiab xa DHCS 3096 CSOSR Daim Ntawv Thov kom hloov PPS tus nqi yog tias muaj cov qauv tshwj xeeb.​​ 

Hloov hauv Scope-of-Service Thov tom qab Lub Ib Hlis 1, 2021​​ 

Cov neeg muab kev pab FQHC thiab RHC uas muaj hnub FPE tom qab Lub Ib Hlis 1, 2021 yuav tsum ua kom tiav thiab xa daim ntawv DHCS 3096 (Tom qab FPE Lub Ib Hlis 1, 2021) CSOSR los thov kom hloov tus nqi PPS yog tias ua tau raws li cov qauv tshwj xeeb.​​ 

Kev Thov Kev Pom Zoo (hloov kho Lub Kaum Hli 31, 2024)​​ 

Cov kws kho mob FQHC thiab RHC yuav tsum ua kom tiav thiab xa daim ntawv thov kev sib haum xeeb DHCS 3097 txhua xyoo rau DHCS ua qhov kev sib haum xeeb rau Managed Care Plans (MCPs) thiab Medicare crossover mus ntsib kom ntseeg tau tias cov chaw kho mob tau txais nyiaj sib npaug rau nws tus nqi PPS.​​ 

Raws li Txoj Cai Welfare & Institutions (W&I) ntu 14105.201, DHCS tau tsim cov nqi nce ntxiv (TRI) rau cov neeg muab kev pabcuam hauv Medi-Cal uas siv tau rau hnub ua haujlwm rau lossis tom qab Lub Ib Hlis 1, 2024. Xav paub ntxiv txog TRI tuaj yeem nrhiav tau ntawm Medi-Cal Targeted Provider Rate Increases and Investments.​​ 

W&I Code Tshooj 14087.325(d) xav kom MCPs them rov qab cov kev cog lus FQHC thiab RHC cov chaw muab kev pab raws li qhov tsis tsawg dua li qib thiab cov nyiaj them uas MCP yuav ua rau tib qhov kev pabcuam yog tias cov kev pabcuam tau muab los ntawm tus kws khomob uas tsis yog FQHC lossis RHC. Txawm hais tias tus nqi TRI tsis cuam tshuam ncaj qha rau FQHC lossis RHC cov chaw muab kev pabcuam, DHCS lees paub tias qee lub sijhawm, qhov nce ntawm MCP tus nqi them rau cov neeg tsis yog FQHC thiab RHC yuav ua rau MCPs nce cov nqi cog lus them rau FQHC thiab RHC cov chaw muab kev pabcuam. FQHC thiab RHC cov chaw muab kev pabcuam yuav tsum suav tag nrho cov nyiaj them MCP hauv kev thov kom rov sib haum, suav nrog cov nyiaj tau los ntawm TRI.​​ 

Raws li lub sijhawm siv TRI, DHCS tab tom ncua hnub kawg ntawm Daim Ntawv Thov Kev Sib Tham Txog Xyoo Nyiaj Txiag (FYE) 2024 DHCS 3097 rau cov neeg muab kev pabcuam FQHC thiab RHC uas muaj Xyoo Nyiaj Txiag (FYE) ntawm Lub Ib Hlis 31st thiab Cuaj Hlis 30th. Qhov kev ncua sij hawm no yog tsim los kom muaj sij hawm txaus rau cov neeg muab kev pab FQHC thiab RHC tau txais thiab sau tag nrho cov nyiaj them MCP, suav nrog txhua qhov uas tau los ntawm TRI. FYE 2024 DHCS 3097 Daim Ntawv Thov Kev Sib Haum Xeeb rau cov neeg muab kev pab FQHC thiab RHC uas muaj FYE ntawm Lub Ib Hlis 31st thiab Cuaj Hlis 30th yuav tsum tau ua tiav rau Lub Peb Hlis 31, 2025. ​​ 

  • Daim Ntawv Thov Kev Sib Tham DHCS 3097 tsuas yog nkag tau los ntawm lub portal web tshiab Enterprise Cost Reporting Settlement System (ECRS).​​ 
  • Txhua lub tsev kho mob yuav tsum muaj ib tus thawj coj ntxiv rau hauv lub system. Yog koj tsis tau muab ib tus thawj coj rau koj, xa email rau CRTS ntawm Reconciliation.clinics@dhcs.ca.gov thiab muab cov hauv qab no: Tus lej National Provider Identifier (NPI), Lub Npe Raug Cai (chaw kho mob), Chaw Nyob Pabcuam, Lub Npe thiab Lub Xeem ntawm Tus Thawj Coj, thiab email (thov siv email ntawm lub tuam txhab).​​ 
  • Yog koj muaj teeb meem txog kev siv tshuab, thov xa email rau ECRS@dhcs.ca.gov.​​ 

Indian Health Services Memorandum of Agreement Reconciliation​​ 

Txhua lub tsev kho mob IHS-MOA, 638 Lub Tsev Kho Mob thiab Pab Pawg Pab Pawg Saib Xyuas Kev Noj Qab Haus Huv (TRIBAL-FQHC) yuav tsum ua kom tiav thiab xa DHCS 3098 Daim Ntawv Thov Kev Sib Koom Ua Ke txhua xyoo rau DHCS los ua kev sib haum xeeb rau Managed Care Plans thiab Medicare crossover mus xyuas kom ntseeg tau tias cov chaw kho mob tau them tus nqi sib npaug.​​ 

  • DHCS 3098 IHS Reconciliation Request tsuas yog nkag tau los ntawm lub portal web tshiab ECRS xwb.​​ 
  • Txhua lub tsev kho mob yuav tsum muaj ib tus thawj coj ntxiv rau hauv lub system. Yog koj tsis tau muab ib tus thawj coj rau koj, xa email rau CRTS ntawm Reconciliation.clinics@dhcs.ca.gov thiab muab cov hauv qab no: Tus lej NPI, Lub Npe Raug Cai (chaw kho mob), Chaw Nyob Pabcuam, Lub Npe thiab Lub Xeem ntawm Tus Thawj Coj, thiab email (thov siv email ntawm lub tuam txhab).​​ 
  • Yog koj muaj teeb meem txog kev siv tshuab, thov xa email rau ECRS@dhcs.ca.gov.​​ 

Kev thov tus nqi sib txawv​​ 

FQHC thiab RHC cov kws kho mob yuav tsum ua kom tiav thiab xa DHCS 3100 Daim Ntawv Thov Kev Sib Nrauj Sib txawv los tsim lossis hloov Tus Txheej Txheem Kev Pabcuam Kev Tswjhwm Sib txawv, tus lej 521 T1015 SE (yav dhau los code 18). Daim foos no yog tsim los txiav txim siab tus nqi ib ntus rau cov neeg muab kev pab them rov qab rau qhov sib txawv ntawm lawv tus nqi PPS thiab lawv cov Medi-Cal Managed Care Plan them.​​ 

Medicare Advantage Plan Code 529​​ 

Cov kws kho mob FQHC thiab RHC yuav tsum ua kom tiav thiab xa daim ntawv thov DHCS 3104 los tsim lossis hloov tus nqi Medicare Advantage Plan, tus lej 529 G0466-G0470 (yav tas los yog tus lej 20). Daim ntawv no yog tsim los txiav txim siab tus nqi ib ntus los them rov qab rau cov kws kho mob rau qhov sib txawv ntawm lawv tus nqi PPS thiab lawv cov nyiaj them rau Capitated Medicare Advantage Plan.​​ 

Thawj Tus Nqi Them Daim Ntawv Thov Pob​​ 

FQHC/RHC Thawj Tus Nqi Them Daim Ntawv Thov pob, DHCS 3106, suav nrog:​​ 

  • Cov lus qhia rau kev thov (nplooj 1-4),​​ 
  • Daim Ntawv Pov Thawj Them Nqi Xaiv Tsa (nplooj 5-6),​​ 
  • Kev xaiv tsa (nplooj 7-8),​​ 
  • Cov ntsiab lus ntawm cov kev pabcuam tam sim no muab los ntawm Clinic (nplooj 9), thiab​​ 
  • Cov ntsiab lus ntawm Cov Kws Kho Mob (nplooj 10).​​ 

Cov ntawv no yuav raug siv los tsim tus nqi PPS thawj zaug rau FQHC thiab RHC uas tau pom zoo tshiab. Yog koj muaj lus nug txog pob khoom no, thov xa email rau clinics@dhcs.ca.gov lossis tiv tauj CRTS ntawm (916) 650-6696.​​