Enter the Corporate Name of your agency.
Example: Life Management Consultants
Heritage Valley Health System
Beaver County Rehabilitation Center
Mental Health Association
Enter the dates of the month in which the service was rendered.
Example: From 7/1/10 to 7/31/10
Enter the type of service being provided.
Example: Family Based
Adult Training Center
1. Cost Center
Enter the appropriate cost center that the program is classified under.
Example: Administrator’s Office (Both MH and MR)
Community Services (MH only)
Service Management (MH only)
Intensive Case Management (MH only)
Supports Coordination (ID only)
Outpatient (MH only)
Inpatient Hospitalization (MH only)
Day Treatment (Partial) (MH only)
Psychosocial Rehabilitation (MH only)
Early Intervention (ID only)
Crisis Intervention (MH only)
Community Habilitation (ID only)
Employment Services (Both MH and ID)
Pre-Vocational Services (Both MH and ID)
Social Rehabilitation (MH only)
Family Support Services (Both MH and ID)
Community Residential Services (Both MH and ID)
Specialized Supports (ID only)
Transportation Services (ID only)
Family Based (MH Only)
A. PERSONNEL SERVICES
1. Wages and Salaries: Charge to this line the cost of all wages and salaries paid to employees. The annual salary charged to MH/ID is not to exceed the current compensation scale of the Beaver County MH/ID Personnel Action Plan. Overtime, standby time, on-call time is eligible for reimbursement under formally established and consistently applied agency policies. If you are entering an amount in this line item you must also complete the MH/ID 15-A Roster of Personnel Form and attach it to this invoice.
2. Employee Benefits: Charge to this line the cost of all employee benefits that are eligible for DPW participation.
3. Miscellaneous Personnel: Charge to this line the costs of temporary consultants and personnel obtained by contracts. Examples of such costs include: attorney fees, legal costs, auditing or accounting fees, management fees and other related personnel expenses.
B. OPERATING EXPENSES
1. Occupancy: Charge to this line item rent and mortgage payments; fire, liability and other insurance, general housekeeping supplies and services, utilities and contracted maintenance service for the buildings.
2. Communications: Charge to this line item the costs of telephone service, postage, printing, audio-visual materials and advertising.
3. Administrative Supplies: Charge to this account the costs of all supplies and minor equipment, which are consumed or used in the day-to-day operations of an office and the normal maintenance of office equipment.
4. Treatment and Supportive Supplies: Charge to this line item the costs of supplies and equipment purchased for activities related to social and vocational rehabilitation or recreational purposes which do not meet fixed asset requirements. Also charge to this line item supplies used in training and education and the costs of medical supplies, drugs, food and clothing.
5. Transportation: Charge to this line item the cost of employee travel allowance, including allowances for meals, lodging and other related expenses. Mileage reimbursement for use of personal vehicles may not exceed the Department’s allowance for mileage. Also charge the costs of renting vehicles, insurance and supplies for operation and maintenance of vehicles for employee use. Costs of providing transportation to clients are also to be charged to this line item.
6. Purchased Treatment Services:
Fee-for-Service: This is the only expenditure line item that is completed if billing is done on a fee-for-service basis. Charge to this line the cost of providing services on a unit cost basis. Take the number of units of service provided during the month of the billing times the rate in the contract or most current amendment.
7. Miscellaneous Operating Expenses: Charge to this line item expenditures for maintaining a library for staff and client use, including the purchase of books and periodical subscriptions. Also, charge o this line item the costs for debt service and other operating costs which cannot properly be allocated to one of the above line items.
C. EQUIPMENT AND OTHER FIXED ASSETS
1. Purchase of Fixed Assets: Charge to this line item the purchased cost of all office equipment, such as typewriters, desks, etc.; program equipment, such as living room, kitchen and bedroom furniture; and the costs of the purchase of motor vehicles. Charge also to this line item the cost of medical, equipment or instruments for use by professionals in the care and treatment of patients. If you are entering an amount in this line item you must also complete the MH/ID 19 Schedule of Equipment Purchases and attach it to this invoice.
2. Repairs and Improvements: Charge to this line item the cost of all repairs to motor vehicles. Also charge to this line item the cost of residential adaptation. Also charge to this line item the costs of repairs to buildings, property investments, equipment and furnishings.
D. TOTAL EXPENDITURES
Add the amounts entered in lines A.1. through C.2. for all of the columns and enter here.
E. FUNDING OF INELIGIBLE COSTS
1. Not Eligible for Reimbursement: Enter in this line the expenditures that were charged in the above line items that are not eligible for reimbursement, according to the County Mental Health/Intellectual Disability Fiscal Manual, Chapter 4300. This also includes that portion of salaries paid in excess of the current compensation schedule in the Beaver County Personnel Action Plan and mileage reimbursement in excess of that allowed by DPW.
2. Over Allocation: Enter in this line the amount that exceeds the contracted allocation for the program.
1. Program Service Fees (Family Liability): Enter in this line item all funds received from clients or their legally responsible relatives as payment for all or part of the costs of services rendered.
2. Private Insurance: Enter in this line item all funds to be received from private insurance plans in payment for services rendered to clients.
3. Medical Assistance: Enter in this line as funds to be received from Medical Assistance, including both Federal and State share.
4. Room and Board: Enter in this line item the room and board charges based on an amount not to exceed 72% of the client’s SSI/Social Security income.
5. Interest Income: Charge to this line item the interest earned on funds received from the MH/ID Office and all other sources.
6. Other Income: Charge to this line any other income that cannot be allocated to any of the above accounts. Specify the source(s) of that income in the line provided on the form.
G. TOTAL REVENUE
Add the amounts entered in lines F1 through F6 for all columns and enter here.
H. ADVANCE DEDUCTION
Enter in this line, in the current column, the amount of the advance or prepaid monthly estimate that is to be deducted form the monthly billing. All advances must be deducted in-full as of the June billing. If there is still a balance due from the advance, a check for the remainder of the advance should accompany the final invoice.
I. TOTAL REIMBURSEMENT
Subtract the amounts entered in lines E, G and H from the amounts entered in line D and enter here.
Enter in this column the ineligible costs included in the current month’s billing. The sum of the ineligible costs is entered in line E1.
Enter the costs and revenue for the current billing period.
Enter any corrections from previous billings in this column.
Add or subtract the adjustments and enter in this column. Carry over any line items from the current column that are not adjusted. If there are no adjustments, do not complete this column.
Accumulate all costs and revenue reported in each line item beginning July 1 and ending June 30.
Enter the contracted or established rate(s) for the program. If a rate changes during the fiscal year enter the new rate in the next column.
NUMBER OF UNITS
Enter the number of units served for the current period. The number of units served times the rate should equal the amount billed in line B.6. of the current column. Each time the rate changes, list this separately in a separate column.
UNITS TO DATE
Accumulate the units reported each month beginning July 1 and ending June 30 for each different rate.<
DEFINITION OF UNITS
Enter the definition of the units of service that are invoiced. Example of the definition of the units of service is: session, quarter-hour, hour, day, round trip, etc.