Payment Schedule

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AUTHORIZATION TO PURCHASE OF SERVICE AND PROVIDER OF CARE CLAIM FORMS

Please process the Authorization to Purchase of Service and Provider of Care Claim forms within the appropriate time frame. The properly completed and signed claim should reach us by the 3rd working day of the month for our first payment on the 11th and by the 15th working day of the month for our second payment on the 21st day of the month. Although we make every attempt to meet these dates, there may be a delay of up to 3 working days.

PAYMENTS FOR RESPITE SERVICE FAMILY MEMBER

Please complete the DS1811 form (English DS1811, Spanish DS1811) along with our Provider of Care Claim form.

PAYMENTS FOR BEHAVIORAL SERVICES

Please complete the DS5862 form (English DS5862, Spanish DS5862, Chinese DS5862, Vietnamese DS5862) and submit by email attachment or fax to the respective Fiscal Service Representative.

PAYMENTS FOR BEHAVIORAL SERVICES CO-PAY

Please submit the Explanation Of Benefit (EOB) form by email attachment or fax to the respective Fiscal Service Representative.