ࡱ> wyv Jbjbjzz B\PgPgL  8<24&4Z"|||W"y "4$4$4$4$4$4$4$6G9H4WWH4||]4"""^||"4""4""j13| #[|14s40429s9(33923"H4H4a 49 X p: FORM B SERVICE SUMMARY AND PUBLIC FUNDING/INSURANCE PARTICIPATION FORM Agency: Location: 1. REIMBURSEMENT RATES UNITS - For each service element you are proposing, enter the proposed unit reimbursement rate in the column labeled Fixed Unit Rate. Service ElementFixed Unit RateOutpatient Initial Clinical Assessment Outpatient Individual Therapy Session (90834)Outpatient Individual Half/Short Session (90832)Outpatient Group (90853) Select length:  FORMCHECKBOX  90-Minute  FORMCHECKBOX  60-MinuteOutpatient Didactic (H2027):Select length:  FORMCHECKBOX  90-Minute  FORMCHECKBOX  60-MinuteOutpatient/Ambulatory: Psychiatric Evaluation Outpatient Drug-Free Psychiatric/Medication Review Case Management (15 minute unit)IOP Chair DayPartial Hospitalization Chair DayOther: Specify__________________________________ Indicate the total expected number of unduplicated clients you expect to serve each month by service category, per site for MCOSA as well as the total capacity of unduplicated clients you can serve per site in the following table. Indicate the type of service. Level of Care# MCOSA Clients # Total Agency Capacity FORM B (cont.) Agency: Location: In the table below, list your customary charge for each service proposed, along with the rate by Payer type for each entity you contract with for substance abuse treatment services, public and private, and your contracted rate with that agency for each service listed that you propose to provide for MCOSA. Be sure to include Medicare, other PIHP Entities, Insurance Companies, etc. Place N/A in any cell that does not apply to your proposal with MCOSA or the other paying agency. PayerPartial HospitalizationIOPIndividual SessionGroup (___min)Didactic (____min)Pscyh EvalMed Review IntakeCustomary Charge (required) For every case where it appears the proposed MCOSAs rate is higher than that of another payer, describe below the difference in the services provided to MCOSA clients resulting in the higher rate (provide justification for the rate).     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