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Location

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Number of Facilities

Name of EMR system used for clinical.

Name of EMR system used for therapy.

Average number of skilled HMO days billed per month.

Average number of custodial managed long term Medicaid days billed per month.

Average skilled HMO lengths of stay.

Average skilled HMO daily rate.

Short description of current case management system.

Short description of case management challenges.

Past 6 months HMO Census of Medicare HMO, Medicaid HMO (short term skilled), Commercial HMO, MLTC/MLTSS (managed Medicaid custodial long term care) indicating:
- Patient’s name
- HMO name
- Dates of service
- Level (rate code)
- Rate
- Gross Amount
- Group MCD/MCR (optional)
Copy of HMO contracts rate schedules – this is the page that lists the levels, rates and criteria for each contract. If you already have this compiled into a form, that’s what we need. Otherwise, attach the actual contracts with the specifics included in the rates, and we’ll analyze the content.
W9 for each facility.

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