Rate Certification Form Outpatient - Delaware Department Of Services For Children, Youth And Their Families
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4State of Delaware
Division of Management Support Services
The Department of Services
Cost Recovery Unit
For Children, Youth and
Their Families
Dear Service Provider:
Under an agreement between DSCYF and Delaware Medicaid, DSCYF is the exclusive provider of Medicaid
behavioral health and substance abuse services to children in Delaware.
In order for DSCYF’s Cost Recovery Unit to pursue reimbursement from Medicaid for services provided to Delaware
children through a third party such as your organization, we must annually obtain documentation from you. In your
Contract or Statement of Agreement (Article I, Section B.5) with DSCYF you agreed to provide this information.
Completing these forms and supplying the below requested information will not enroll you in Medicaid. It will simply
enable the State of Delaware to lower its cost by requesting partial compensation from Medicaid. We are requesting
the following:
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1. Rate Certification Form (enclosed)
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2. Usual and Customary Rate Schedule showing your rates for services like the services in this contract
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3. CMS Sanctions Certification Form (enclosed)
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4. Accreditation Status Form (enclosed)
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5. Letters of Accreditation, such as JCAHO (copy)
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6. State issued licenses (copy)
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7. National Provider ID (NPI) Number (copy of NPI letter or printout from NPI Registry)
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8. State issued Medicaid Letter, showing your Medicaid enrollment and rates (copy)
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9. Provider Disclosure Statement (attached as separate document)
Please return the completed forms and other documents via email, fax, or mail:
You can scan and email to:
brian.calio@state.de.us
This is the preferred method
302.661.7224 (This is a shared fax number, so include a
You can fax to:
cover page to Brian Calio’s attention)
(Must use all 10 digits)
STATE OF DELAWARE
DSCYF-DMSS-N301
You can mail to
COST RECOVERY UNIT (ATTN: BRIAN CALIO)
1825 FAULKLAND ROAD, WILMINGTON, DE 19805
If you expect a delay of more than two weeks in your response or if you have any questions, please contact me. The
funds we recover from Medicaid allow us to provide more services, through service providers like you, to the children
of Delaware. Once you send these documents, you may call the number below to confirm receipt.
Brian Calio
Fiscal Management Analyst
DSCYF Cost Recovery Unit
Phone: 302.892.4570
Outpatient
Revised 12/2013
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