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Department of Assistive and Rehabilitative Services
Division for Early Childhood Intervention Services
ECI Services Contract
THIRD PARTY BILLING ATTACHMENT – INSTRUCTIONS
Fourth quarter reports must be retrieved from the DARS ECI web site.
SECTION TITLE
INSTRUCTIONS
Contractor Name
Field will auto-fill from entry on Form 269a.
Period Covered by this Report
Field will auto-fill from entry on Form 269a.
Third Party Collections Expended Enter Third Party Collections Expended from 09/01/12 through the
quarter end for quarters one through three. For fourth quarter this
includes collections for services provided in 2013, but received through
10/31/13. The amount must be less than or equal to the total State and
Local Funds reported as expended on line k of the Form 269a. Third
party billing collections earned as a result of services provided in
the FY 2013 contract period, but received by October 31, 2013,
must be used for eligible program expenditures within the current
contract period, except for total third party billing collections that
exceed total projections after the total ECI program budget shown
in the ECI contract has been expended, which may be placed in a
reserve account designated for ECI program use.
Reserves Designated for ECI:
Enter the amount of reserves designated for carryover to FY 2014. The
ECI designated reserves cannot exceed the difference between Third
Party Collections as reported on the fourth quarter, Third Party Billing
Attachment and Third Party projections as reported on the FY 2014
Funding Application; after the total ECI program budget shown in the
ECI Contract has been expended.
THIRD PARTY BILLING CLAIMS, UNCOLLECTED and COLLECTIONS
FY 2013 Cumulative Claims
Enter third party billing claims by source as of the quarter end. The
TOTALS line will auto-fill. FY 2013 Cumulative Claims must include the
total claims submitted for direct services provided from 09/01/12
through the quarter end for quarters one through three. For fourth
quarter, all claims for services in the fiscal year submitted for payment
should be reported. Report all claims billed to Texas Medicaid and
Healthcare Partnership as one amount on the line labeled Medicaid
TMHP. Report all claims billed to Managed Care Organizations (MCOs)
for therapies and other services as one amount on the line labeled
Medicaid MCOs. The Family Cost Share (FCS) line has been changed
to Family Payments. Charges billed to families should be reported
on this line. The "Other" line has been deleted from this report.
Items that were reported in the "Other" category (i.e., medical
records, jury duty, and copying) are not reported on the Third
Party Billing Attachment report. "Other" program income will be
reported on the Expenditure Summary by Funding Source (ESFS)
report.
Revised September 2012
Page 1 of 3
Department of Assistive and Rehabilitative Services
Division for Early Childhood Intervention Services
ECI Services Contract
THIRD PARTY BILLING ATTACHMENT – INSTRUCTIONS
Fourth quarter reports must be retrieved from the DARS ECI web site.
SECTION TITLE
INSTRUCTIONS
FY 2013 Cumulative Uncollected Field will auto-fill to subtract Cumulative Collections from Cumulative
Claims. For all contractors, the uncollected amount should include,
but is not limited to: all portions of claims not paid; all appeals in
process; and all amounts written off for all claims not received as of the
quarter end for the first through third quarter or 10/31/13 for fourth
quarter reports. For public contractors, this should include the 5% of
the Medicaid Administrative Claims retained by DARS ECI for all claims
not received as of the quarter end for the first through third quarter or
10/31/13 for fourth quarter reports. The TOTALS line will auto-fill.
FY 2013 Cumulative Collections
Enter the amount collected (received) from FY 2013 Cumulative Claims
by funding source as of the quarter end for the first through third
quarters or 10/31/13 for fourth quarter reports. Enter cash collected
from families on the Family Payments line. The TOTALS line will
auto-fill.
Prior Year Cumulative Collections Enter revenue collected (received) by source from 11/01/12 through the
quarter end for the first, second and third quarters and through
10/31/13 for fourth quarter reports for services provided before
09/01/12 and used for expenditures in FY 2013. The TOTALS line will
auto-fill.
FY 2013 UNCOLLECTED CLAIMS DETAIL
Valid Accounts Receivable (A/R) Report all uncollected claims that are not received or written off by the
quarter end on the designated line, including those claims in the
appeals process. Use the columns provided to break down the Valid
A/R into receivables less than or equal to (<) 90 days from the date
claims are filed and receivables greater than (>) 90 days. The TOTALS
line will auto-fill.
Ineligible Write-Off
Enter any claims written off as ineligible. This includes the 5%
administrative fee deducted by DARS ECI for MAC claims; any
amounts billed in excess of payments received from Medicaid TMHP or
MCOs, private insurance, Children’s Health Insurance Program (CHIP),
and TRICARE; claims submitted for reimbursement that cannot be paid
by insurance because the child does not have private or public
insurance benefits and the family monthly maximum payment has been
met. (See the Uncollected Claims Guidance Tool included in this file for
more examples of uncollected claims). The TOTALS line will auto-fill.
Other Write-Off
Revised September 2012
Enter all claim write-offs that do not fall into the above categories,
including claims that have been determined to be uncollectible and
have been removed from the accounts receivable. The TOTALS line
will auto-fill.
Page 2 of 3
Department of Assistive and Rehabilitative Services
Division for Early Childhood Intervention Services
ECI Services Contract
THIRD PARTY BILLING ATTACHMENT – INSTRUCTIONS
Fourth quarter reports must be retrieved from the DARS ECI web site.
SECTION TITLE
INSTRUCTIONS
TOTALS
Field will auto-fill after data entry of amounts in other columns. The
TOTALS of Uncollected Claims Detail must equal the amounts in the
Cumulative Uncollected column in the section above.
First – Fourth Quarter
Comments
Revised September 2012
FAMILY PAYMENTS PAID BY SERVICE MONTH
Enter the number of families that paid a monthly fee by month of
service from 09/01/12 through the quarter end. Revisions can be made
to numbers of families reported for previous quarters as subsequent
quarterly reports are submitted. Collections received for Prior Year
services would not be reported as a family paying a cost share.
Examples of reporting:
Services were provided to a child in September and October. The
family paid the September and October monthly fee in November.
Report 1 family in September and 1 family in October paying the
monthly fee. Another family paid the monthly fee in December for
services provided in October. The number of families paying the
monthly fee would increase to 2 families for October.
Provide any additional explanatory information.
Page 3 of 3
Department of Assistive and Rehabilitative Services
Division for Early Childhood Intervention Services
THIRD PARTY BILLING ATTACHMENT
Please use the TAB key to navigate this page.
Contractor Name: Texas Rehabilitation Center
Period Covered by this Report: 09/01/13 - 08/31/13
Third Party Collections Expended:
$2,865,222.00
Reserves Designated for ECI:
$20,000.00
THIRD PARTY BILLING CLAIMS, UNCOLLECTED and COLLECTIONS
FY 2013
Cumulative
Uncollected
Cumulative
Claims
Sources
Prior Year
Cumulative
Collections
Cumulative
Collections
Medicaid TMHP
$2,938,108.00
$358,961.00
$2,579,147.00
$6,035.00
Medicaid MCOs
$80,000.00
$22,000.00
$58,000.00
$9,000.00
Medicaid Administrative Claiming
$76,717.00
$3,836.00
$72,881.00
$66,401.00
CHIP
$57,000.00
$12,000.00
$45,000.00
$689.00
Private Insurance
$64,353.00
$24,412.00
$39,941.00
$894.00
Family Payments
$7,838.00
$3,342.00
$4,496.00
$915.00
$2,500.00
$1,000.00
$1,500.00
$323.00
$3,226,516.00
$425,551.00
$2,800,965.00
$84,257.00
TRICARE
TOTALS
FY 2013 UNCOLLECTED CLAIMS DETAIL
Valid Accounts Receivable (A/R)
≤ 90 Days
> 90 Days
Sources
Ineligible
Write-Off
Other
Write-Off
TOTALS
Medicaid TMHP
$275,305.00
$15,697.00
$59,922.00
$8,037.00
$358,961.00
Medicaid MCOs
$12,937.00
$5,000.00
$1,563.00
$2,500.00
$22,000.00
$0.00
$0.00
$3,836.00
$0.00
$3,836.00
$8,375.00
$3,000.00
$519.00
$106.00
$12,000.00
Medicaid Administrative Claiming
CHIP
Private Insurance
$23,786.00
$0.00
$500.00
$126.00
$24,412.00
Family Payments
$2,000.00
$600.00
$445.00
$297.00
$3,342.00
$600.00
$118.00
$100.00
$182.00
$1,000.00
$323,003.00
$24,415.00
$66,885.00
$11,248.00
$425,551.00
TRICARE
TOTALS
FAMILY PAYMENTS BY SERVICE MONTH
First Quarter
Second Quarter
Third Quarter
Fourth Quarter
Month
September
December
March
June
# of Families
22
18
21
23
Month
October
January
April
July
# of Families
23
20
24
20
Month
November
February
May
August
# of Families
20
22
23
21
COMMENTS
Revised September 2012
Due Date: 30 days after quarter end
or November 15th for fourth quarter