Texas Department Of Aging and Disability Services Form TBD Community Living Assistance Support Services (CLASS) Case Management Agency (CMA) Page 1 MONITORING WORKBOOK Name of Legal Entity Completed By Review Level: Full Targeted Review Type: Formal Follow Up Date of Entrance (First day on-site) Contract No. Administrative Complaint Date of Exit (Last day on-site) Begin Date: Revised Exit Date End Date: Dates of Monitoring Period A response of “Yes” means the contractor has met the requirement. “No” means the contractor has not met the requirement. “N/A” means the requirement is not applicable. For any item marked as “No” attach copies of supporting documents. All attachments should be numbered and indicate the applicable Standard and item. STANDARD I. POLICIES AND PROCEDURES 1. Are complaints documented and investigated? N/A Y N N/A Y N N/A Y N Review the contractor’s CLASS complaint log or record of complaints reported during the 24-month monitoring period to verify each of the following: the date the CMA received the complaint; the name of the person who filed the complaint; a description of the nature of the complaint; the name of the staff person who conducted the investigation of the complaint; the names of persons contacted during the investigation of the complaint; the outcome of the complaint; and the date final action was taken by the CMA in response to the complaint Reference: 40 TAC §45.707 CMA: Quality Management and Complaint Process (effective 3/21/2011) 2. Does the CMA have written policies and procedures that safeguard individuals against each of the following: Infectious and communicable diseases Conflicts of interest with CMA staff persons Acts of financial impropriety Abuse, neglect and exploitation; and Deliberate damage of personal possessions Reference: 40 TAC §45.702 Protection of Individual, Initial and Annual Explanations, and Offering Access to Other Services if Termination Presents a Threat to Health and Safety (effective 3/21/2011) 3. Does the CMA have a quality assurance process to evaluate and improve the quality of case management provided based in part on the survey results? Request the contractor’s most recently completed annual satisfaction survey sent to all individuals, LARs and persons actively involved with the individual; and Ask the contractor for examples of how the survey results were used and what actions, if any, were taken to make improvements. Note: Select “N/A” if the contract was effective within the previous 12 months. Reference: CLASS Provider Manual Appendix I, Section 1300, Administrative Requirements (prior to 3/21/2011); 40 TAC §45.707 CMA: Quality Management and Complaint Process 3 7 2012 A copy of the Workbook is given to the contractor’s representative at the exit conference Texas Department Of Aging and Disability Services Form TBD Community Living Assistance Support Services (CLASS) Case Management Agency (CMA) Page 2 MONITORING WORKBOOK Name of Legal Entity Contract No. Completed By Dates of Monitoring Period A response of “Yes” means the contractor has met the requirement. “No” means the contractor has not met the requirement. “N/A” means the requirement is not applicable. For any item marked as “No” attach copies of supporting documents. All attachments should be numbered and indicate the applicable Standard and item. STANDARD I. POLICIES AND PROCEDURES (continued) 4. Does the CMA have a written process that ensures case managers are or can readily become familiar with individuals to whom they are not ordinarily assigned, but to whom they may be required to provide case management? N/A Y N N/A Y N N/A Y N Reference: 40 TAC §45.705 CMA Service Delivery; CLASS Provider Manual, Section 2310, Enrollment (effective 6/13/2011) 5. Does the contractor have a written process for screening employees and contractors for exclusion from participation in Medicare, Medicaid, the State Children’s Health Insurance Program and all Federal health care programs: prior to hiring or contracting and on a monthly basis; that includes a search of the federal HHS Office of Inspector General (HHS-OIG) List of Excluded Individuals/Entities (LEIE) website and the Texas HHSC Office of the Inspector General List of Excluded Individuals/Entities (LEIE) website; prohibits payment for any items or services furnished, ordered, or prescribed by an excluded individual or entity; and requires the contractor to immediately self-report to HHSC-OIG any exclusion information discovered? Reference: State Medicaid Director Letter, 09-001; Information Letter 09-33; Information Letter 10-20; Information Letter 11-07;Information Letter 11-102 (CMS) 6. Does the contractor conduct pre-employment/pre-contracting and monthly screening of employees and subcontractors against the federal and state LEIE? Documentation must include all elements below: Review the documentation of the checks conducted for the last month of 24-month monitoring period. date of the federal and state database searches; first and last names and date of birth of all employees and sub-contractors subject to LEIE search requirements; whether or not the employee/sub-contractor appeared in the federal/state LEIE databases; date any excluded employee/sub-contractor was self-reported to HHSC-OIG; copy of the self-report; and name(s) and signatures of staff responsible for completing the pre-employment and pre-contracting monthly searches. Reference: State Medicaid Director Letter, 09-001; Information Letter 09-33; Information Letter 10-20; Information Letter 11-07; Information Letter 11-102 (CMS) Comments: Total Yes STANDARD I. POLICIES AND PROCEDURES 3 7 2012 A copy of the Workbook is given to the contractor’s representative at the exit conference Total No Texas Department Of Aging and Disability Services Form TBD Community Living Assistance Support Services (CLASS) Case Management Agency (CMA) Page 3 MONITORING WORKBOOK Name of Legal Entity Contract No. Completed By Dates of Monitoring Period A response of “Y” means the contractor has met the requirement. “N” means the contractor has not met the requirement. “N/A” means the requirement is not applicable. For any item marked as “N” attach copies of supporting documents. All attachments should be numbered and indicate the applicable Standard and item. STANDARD II. STAFF QUALIFICATIONS/TRAINING (Complete the Staff Qualifications/Training Table to answers items II. 1-3) 1. Did staff hired during the monitoring period meet the A B required qualifications? C D E F G H I J K L M N O R S T U V W X Y Z AA BB CC DD See STAFF QUALIFICATIONS/TRAINING TABLE P Q Reference: CLASS Provider Manual, Appendix 1, Section 1403, Staff Requirements (prior to 3/21/2011); 40 TAC §45.703 CMA,Qualifications of CMA Staff Persons (effective 3/21/2011) Comments: Number Yes 2. For each staff hired during the monitoring period was a background check, resulting in no bars to employment, conducted within the required timeframe? A B C D E F G P Q R S T U V H Number No I J K L M N O X Y Z AA BB CC DD See the STAFF QUALIFICATIONS/TRAINING TABLE W Reference: CLASS Provider Manual, Section 3700, Criminal History Checks (prior to 3/21/2011); CLASS Provider Manual, Appendix VIII Criminal History Check of Employees in Certain Agencies/Facilities Serving the Elderly or Persons with Disabilities (prior to 3/21/2011); 40 TAC §45.703 Qualifications of CMA Staff Persons; 40 TAC §93 Employee Misconduct Registry; Chapter 250 Health and Safety Code §250.003 Nurse Aide Registry and Criminal History Checks of Employees and Applicants for Employment in Certain Facilities Serving the Elderly or Persons with Disabilities Comments: 3 7 2012 A copy of the Workbook is given to the contractor’s representative at the exit conference Number Yes Number No Texas Department Of Aging and Disability Services Form TBD Community Living Assistance Support Services (CLASS) Case Management Agency (CMA) Page 4 MONITORING WORKBOOK Name of Legal Entity Contract No. Completed By Dates of Monitoring Period A response of “Y” means the contractor has met the requirement. “N” means the contractor has not met the requirement. “N/A” means the requirement is not applicable. For any item marked as “N” attach copies of supporting documents. All attachments should be numbered and indicate the applicable Standard and item. STANDARD II. STAFF QUALIFICATIONS/TRAINING (continued) (Complete the Staff Qualifications/Training Table to answers items II. 1-3) 3. Did staff receive training within the required time A B frames? C D E F G R S T U V H I J K L M N O X Y Z AA BB CC DD See the STAFF QUALIFICATIONS/TRAINING TABLE Reference: CLASS Provider Manual, Section 3400 Provider Training Requirements (prior to 6/13/2011); CLASS Provider Manual, Section 3410 Case Management and Direct Services Agencies (prior to 6/13/2011); CLASS Provider Manual, Section 2121 Initial Training (effective 1/13/2012); CLASS Provider Manual, Section 2122 Annual Training (effective 5/1/2012); 40 TAC §45.704 Training of CMA Staff Persons; Information Letter 09-110 Comments: P Q W Number Yes Number No Total Yes Total No STANDARD II. STAFF QUALIFICATIONS/TRAINING STANDARD III. CASE MANAGEMENT (See Individual Work Papers for items III. 1-16) 1. Did the CMA conduct the initial face-to-face as required? Reference: IL 09-110 (prior to 3/21/2011); CLASS Provider Manual Section 4300 (prior to 3/21/2011); 40 TAC §45.212 Process for Enrollment of an Individual; CLASS Provider Manual Section 2310, Enrollment; 40 TAC §45.217 CDS Option; 40 TAC §49.18 Client Rights and Responsibilities 1 2 3 4 5 6 16 17 18 19 20 21 7 22 8 9 10 11 12 13 14 15 23 24 25 26 27 28 29 30 Comments: 3 7 2012 Number Yes A copy of the Workbook is given to the contractor’s representative at the exit conference Number No Texas Department Of Aging and Disability Services Form TBD Community Living Assistance Support Services (CLASS) Case Management Agency (CMA) Page 5 MONITORING WORKBOOK Name of Legal Entity Contract No. Completed By Dates of Monitoring Period A response of “Y” means the contractor has met the requirement. “N” means the contractor has not met the requirement. “N/A” means the requirement is not applicable. For any item marked as “N” attach copies of supporting documents. All attachments should be numbered and indicate the applicable Standard and item. STANDARD III. CASE MANAGEMENT (See Individual Work Papers for items III. 1-16) 2. Did the CMA complete the Pre-Enrollment activities as required? 1 2 3 4 5 6 7 16 17 18 19 20 21 22 8 9 10 11 12 13 14 15 23 24 25 26 27 28 29 30 Reference: CLASS Provider Manual Section 4200, Appendix 1-1502 (prior to 3/21/2011); 40 TAC §45.212 Process for Enrollment of an Individual; CLASS Provider Manual Section 2310, Enrollment; 40 TAC §45.217 CDS Option Comments: Did the CMA conduct the initial SPT as required? 3. Number Yes 1 2 3 4 5 6 16 17 18 19 20 21 7 22 8 9 10 11 12 13 14 15 23 24 25 26 27 28 29 30 Reference: IL 2008-11 (prior to 3/21/2011); 40 TAC §45.214 Development of Enrollment IPC; 40 TAC §45.103 Definitions; CLASS Provider Manual Section 2300, Service Planning Comments: 3 7 2012 Number No A copy of the Workbook is given to the contractor’s representative at the exit conference Number Yes Number No Texas Department Of Aging and Disability Services Form TBD Community Living Assistance Support Services (CLASS) Case Management Agency (CMA) Page 6 MONITORING WORKBOOK Name of Legal Entity Contract No. Completed By Dates of Monitoring Period A response of “Y” means the contractor has met the requirement. “N” means the contractor has not met the requirement. “N/A” means the requirement is not applicable. For any item marked as “N” attach copies of supporting documents. All attachments should be numbered and indicate the applicable Standard and item. STANDARD III. CASE MANAGEMENT (continued) (See Individual Work Papers for Items III. 1-16) 4. Did the CMA complete the SPT enrollment activities as required? 1 2 3 4 5 6 16 17 18 19 20 21 7 22 8 9 10 11 12 13 14 15 23 24 25 26 27 28 29 30 Reference: CLASS Provider Manual Section 4400, Corrective Action Plans (prior to 3/21/2011); 40 TAC §45.214 Development of Enrollment IPC; 40 TAC §45.103 Definitions; CLASS Provider Manual Section 2300, Service Planning Comments: 5. Did the CMA conduct the renewal SPT as required? Number Yes 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Reference: CLASS Provider Manual Section 4400, Individual Service Plan; CLASS Provider Manual Section 4600, Individual Program Plan; CLASS Provider Manual Section 4340, Interdisciplinary Team (prior to 3/21/2011); CLASS Provider Manual, Form 3621, CLASS - Individual Plan of Care, Instructions; CLASS Provider Manual, Non-Waiver Services, Instructions; CLASS Provider Manual, Form 8606, Individual Program Plan (IPP) - CLASS and CWP Instructions; CLASS Provider Manual, Form 3596 CLASS Habilitation Plan, Instructions; CLASS Provider Manual, Form 3597 CLASS Habilitation Training Plan, Instructions (prior to 6/13/2011); 40 TAC §45.223 Renewal and Revision of an IPC(effective 3/21/2011); CLASS Provider Manual Section 2320 Renewal (effective 6/13/2011) Comments: 3 7 2012 Number No A copy of the Workbook is given to the contractor’s representative at the exit conference Number Yes Number No Texas Department Of Aging and Disability Services Form TBD Community Living Assistance Support Services (CLASS) Case Management Agency (CMA) Page 7 MONITORING WORKBOOK Name of Legal Entity Contract No. Completed By Dates of Monitoring Period A response of “Y” means the contractor has met the requirement. “N” means the contractor has not met the requirement. “N/A” means the requirement is not applicable. For any item marked as “N” attach copies of supporting documents. All attachments should be numbered and indicate the applicable Standard and item. STANDARD III. CASE MANAGEMENT (continued) (See Individual Work Papers for Items III. 1-16) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 6. Did the CMA complete the SPT renewal activities as required? Reference: CLASS Provider Manual Section 4400, Individual Service Plan (prior to 6/13/2011); 40 TAC §45.223 Renewal and Revision of an IPC; CLASS Provider Manual Section 2320 Renewal Comments: 7. Did the CMA conduct the SPT revision(s) as required? Reference: CLASS Provider Manual, Section 4711, DHS Approval of Updated ISP; CLASS Provider Manual, Section 4400, Individual Service Plan; CLASS Provider Manual, Section 4600, Individual Program Plan; CLASS Provider Manual, Form 8606 , Individual Program Plan (IPP) Instructions (prior to 6/13/11); 40 TAC §45.223 Renewal and Revision of an IPC; CLASS Provider Manual Section 2330 Revision Comments: 3 7 2012 Number Yes Number No 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 A copy of the Workbook is given to the contractor’s representative at the exit conference Number Yes Number No Texas Department Of Aging and Disability Services Form TBD Community Living Assistance Support Services (CLASS) Case Management Agency (CMA) Page 8 MONITORING WORKBOOK Name of Legal Entity Contract No. Completed By Dates of Monitoring Period A response of “Y” means the contractor has met the requirement. “N” means the contractor has not met the requirement. “N/A” means the requirement is not applicable. For any item marked as “N” attach copies of supporting documents. All attachments should be numbered and indicate the applicable Standard and item. STANDARD III. CASE MANAGEMENT (continued) (See Individual Work Papers for Items III. 1-16) 8. Were the SPT revision activities completed as required? 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Reference: CLASS Provider Manual Section 4400, Individual Service Plan (prior to 6/13/2011); 40 TAC §45.223 Renewal and Revision of an IPC; CLASS Provider Manual Section 2330, Revision and 2331 Immediate Jeopardy Comments: 9. Were IPP quarterly reviews completed as required? Reference: CLASS Provider Manual, Section 4700, Service Delivery Verification and Evaluation; CLASS Provider Manual, Section 4710, ISP/IPP Review and Updates; CLASS Provider Manual, Appendix I Section 1503, Individual Service Plan; and CLASS Provider Manual, Form 3595, IPP Quarterly Review, Instructions (prior to 6/13/2011); 40 TAC §45.223 Renewal and Revision of an IPC; CLASS Provider Manual Section 2350 Quarterly Review Comments: 3 7 2012 Number Yes Number No 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 A copy of the Workbook is given to the contractor’s representative at the exit conference Number Yes Number No Texas Department Of Aging and Disability Services Form TBD Community Living Assistance Support Services (CLASS) Case Management Agency (CMA) Page 9 MONITORING WORKBOOK Name of Legal Entity Contract No. Completed By Dates of Monitoring Period A response of “Y” means the contractor has met the requirement. “N” means the contractor has not met the requirement. “N/A” means the requirement is not applicable. For any item marked as “N” attach copies of supporting documents. All attachments should be numbered and indicate the applicable Standard and item. STANDARD III. CASE MANAGEMENT (continued) (See Individual Work Papers for Items III. 1-16) 10. Did the CMA verify the individual’s Medicaid Eligibility as required? 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Reference: 40 TAC §45.302 Mandatory Participation; CLASS Provider Manual Section 2200, Eligibility Comments: Number Yes 11. Were transfer activities completed as required? Number No 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Reference: CLASS Provider Manual, Transfer Procedures, Section 4930 (prior to 6/13/2011); 40 TAC §45.401 Coordination of Transfers (effective 3/21/2011); CLASS Provider Manual 2340 Transfer (effective 6/13/2011) Comments: 3 7 2012 Number Yes A copy of the Workbook is given to the contractor’s representative at the exit conference Number No Texas Department Of Aging and Disability Services Form TBD Community Living Assistance Support Services (CLASS) Case Management Agency (CMA) Page 10 MONITORING WORKBOOK Name of Legal Entity Contract No. Completed By Dates of Monitoring Period A response of “Y” means the contractor has met the requirement. “N” means the contractor has not met the requirement. “N/A” means the requirement is not applicable. For any item marked as “N” attach copies of supporting documents. All attachments should be numbered and indicate the applicable Standard and item. STANDARD III. CASE MANAGEMENT (continued) (See Individual Work Papers for Items III. 1-16) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Reference: CLASS Provider Manual, Section 4940, Denials, Reductions, Suspensions, and Terminations (prior to 3/21/2011); 40 TAC §45.403 Denial of a CLASS Program Service; 40 TAC §45.410 Requirement to Submit Fair Hearing Request Summary to DADS; CLASS Provider Manual Section 2410 Denial (effective 6/13/2011) Comments: 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 13. Did the CMA suspend services to the individual as required? 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Reference: CLASS Provider Manual, Section 4940, Denials, Reductions, Suspensions, and Terminations (prior to 3/21/2011); 40 TAC §45.404 Suspension of CLASS Program Services; 40 TAC §45.410 Requirement to Submit Fair Hearing Request Summary to DADS; CLASS Provider Manual Section 2430 Suspension Comments: 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 12. Did the CMA send notice of denial of program service to the individual as required? 14. Did the CMA send notification of reduction as required? Reference: CLASS Provider Manual, Section 4940, Denials, Reductions, Suspensions, and Terminations (prior to 3/21/2011); 40 TAC §45.405 Reduction of a CLASS Program Service; 40 TAC §45.410 Requirement to Submit Fair Hearing Request Summary to DADS; CLASS Provider Manual 2420 Reduction Comments: 3 7 2012 Number Yes Number No Number Yes Number No 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 A copy of the Workbook is given to the contractor’s representative at the exit conference Number Yes Number No Texas Department Of Aging and Disability Services Form TBD Community Living Assistance Support Services (CLASS) Case Management Agency (CMA) Page 11 MONITORING WORKBOOK Name of Legal Entity Contract No. Completed By Dates of Monitoring Period A response of “Y” means the contractor has met the requirement. “N” means the contractor has not met the requirement. “N/A” means the requirement is not applicable. For any item marked as “N” attach copies of supporting documents. All attachments should be numbered and indicate the applicable Standard and item. STANDARD III. CASE MANAGEMENT (continued) (See Individual Work Papers for Items III. 1-16) 15. Did the CMA send notification of termination as required? 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Reference: CLASS Provider Manual, Section 4940, Denials, Reductions, Suspensions, and Terminations(prior to 3/21/2011); 40 TAC §45.406 Termination of CLASS Program Services With Advance Notice Because of Ineligibility or Leave from the State or Because DSAs Cannot Ensure Health and Safety;40 TAC §45.407 Termination of CLASS Program Services With Advance Notice Because of Non-compliance With Mandatory Participation Requirements; 40 TAC §45.408 Termination of CLASS Program Services Without Advance Notice; 40 TAC §45.409 Termination of CLASS Program Services Without Advance Notice Because of Behavior Causing Immediate Jeopardy Termination of a CLASS Program Service; 40 TAC §45.410 Requirement to Submit Fair Hearing Request Summary to DADS; CLASS Provider Manual 2440, Termination; CLASS Provider Manual 2441, Termination with Advance Notice; CLASS Provider Manual 2442, Termination without Advance Notice Comments: Number Yes 16. Did the Case Manager manage the crisis as required? 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Reference: CLASS Provider Manual, Section 4720, Crisis Intervention (prior to 3/21/2011) Comments: STANDARD III. CASE MANAGEMENT 3 7 2012 Number No A copy of the Workbook is given to the contractor’s representative at the exit conference Number Yes Number No Total Yes Total No Texas Department Of Aging and Disability Services Form TBD Community Living Assistance Support Services (CLASS) Case Management Agency (CMA) Page 12 MONITORING WORKBOOK Name of Legal Entity Contract No. Completed By Dates of Monitoring Period A response of “Y” means the contractor has met the requirement. “N” means the contractor has not met the requirement. “N/A” means the requirement is not applicable. For any item marked as “N” attach copies of supporting documents. All attachments should be numbered and indicate the applicable Standard and item. STANDARD IV. BILLING (See Monitoring Workbook-Demand for Payment Notice for item IV.1) 1. DADS did not identify a financial, or if applicable, administrative error? 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Reference: 40 TAC §45.401 Administrative Errors (prior to 3/21/2011); 40 TAC §45.403 Financial Errors (prior to 3/21/2011); 40 TAC §45.901 Administrative Errors (effective 3/21/2011); 40 TAC §45.902 Financial Errors(effective 3/21/2011); 40 TAC §45.706 CMA Recordkeeping (effective 3/21/2011) Comments: Total Yes STANDARD IV. BILLING 3 7 2012 A copy of the Workbook is given to the contractor’s representative at the exit conference Total No Texas Department Of Aging and Disability Services Form TBD Community Living Assistance Support Services (CLASS) Case Management Agency (CMA) Page 13 MONITORING WORKBOOK Name of Legal Entity Completed By Review Level: Full Targeted Dates of Review Period Review Type: Contract No. Formal Administrative Begin Date: End Date: Follow Up Complaint Date of Entrance (First day on-site) Date of Exit (Last day on-site) A. Total Yes COMPLIANCE SCORE Standard I POLICIES AND PROCEDURES Standard II STAFF QUALIFICATIONS/TRAINING Standard III CASE MANAGEMENT Standard IV BILLING Overall Total Financial Errors AMOUNT DUE TO DADS Amount $ (Demand for Payment Notice-Sum Columns L and N) Administrative Errors Amount $ TOTAL $ 3 7 2012 A copy of the Workbook is given to the contractor’s representative at the exit conference B. Total No C. Total (A + B) D. Score (A/C x 100) Texas Department Of Aging and Disability Services Form TBD Community Living Assistance Support Services (CLASS) Case Management Agency (CMA) Page 14 MONITORING WORKBOOK DEMAND FOR PAYMENT NOTICE Name of Legal Entity Contract No. Completed By Dates of Monitoring Period Complete the Demand for Payment Notice for all disallowed Units of Service. Complete columns A-H by entering the original payment information from the Contract Monitoring Claims Report (for each individual listed below, enter “N” for IV. 1) Complete columns I - N to determine the amount due to DADS Date of Exit (Last day on-site) H/G Units of Service Tables (G-J) (IxK) H x .12 (if M is “Y”) A B C D E F G H I J K L M N Client ID Number Last Initial First Initial Svc Code Svc Begin Date Svc End Date No. of Units Amount Paid Unit Rate Units Verified Units Pd in Error Amt. Due to DADS (Admin) Y/N Amt. Due to DADS (Financial) To offset the amount(s) due to DADS the contractor must submit negative bills (by individual) as indicated above within 60 calendar days from the date of exit conference or if applicable, the date the contractor receives Form 5997. 3 7 2012 A copy of the Workbook is given to the contractor’s representative at the exit conference