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For all billing inquiries, please contact your assigned Billing Unit Representative. If you are uncertain as to whom your assigned representative is, please contact the Billing Manager.
This cover sheet MUST accompany all monthly claims for Crisis, Outpatient, Therapeutic Support for Families and all other services. The billing total on this form must equal the total on the individual Client Billing/Activity Forms.
Use this form to submit all claims for Crisis, Outpatient, Therapeutic Support for Families and all other services.
A Place of Service code must be listed on all claim forms for all services.
Must accompany any bill/invoice that was denied by DPBHS
Must be used for any information request following up on a claim in writing
This form is referenced in the DPBHS Billing Manual. It MUST be used by all unit or cost-reimbursable programs as well as providers that are not billing electronically for these levels of care
This form must accompany any identified claim errors submitted to DPBHS (i.e., incorrect units, dates, sub-service, or clients)
For contracted agencies that only provide Transportation and/or Translation services
This form must accompany any Written Appeal addressed to the Billing Manager upon receiving denial from the reconsideration from the Billing Representative
This form must accompany any appeal to the Manager of Provider Services, upon receiving denial from the Level 1 Appeal to the Billing Manager. This is the final level of appeal available for claims reimbursement.