Medicaid billing self assessment: Fill out & sign online

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Click ‘Get Form’ to open the Medicaid Billing Self-Assessment Worksheet in the editor.
Begin by entering your Provider Name and OASAS Provider # at the top of the form. This information is essential for identifying your organization.
Select the Service Type by checking either 'Part 822 Chemical Dependence Outpatient Clinic' or 'Part 822.9 Chemical Dependence Outpatient Rehabilitation'.
Fill in the Total Score and Sample Size fields to calculate your Deficiency Rate. Use the formula provided: (Total Score / Sample Size).
In the Admission section, input the Medicaid Recipient ID Number and Patient ID Number, followed by details for each service date, including whether services were paid and if admission criteria were met.
Proceed to the Treatment Plan section, ensuring you answer Y/N for each criterion such as Evaluation Assessment and Individual Treatment Plan.
Finally, complete the Progress Notes section by confirming physician signatures and reviewing treatment plans as required.

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