8000, Required Forms and Reports | Texas Health and Human Services

Revision 22-2; Effective April 1, 2022

Description: Includes Form B-13X, Form 4116, Authorization for Expenditures, and Form Data Management
Submission Date: By the last business day of the month following the month in which expenses were incurred or services provided. Final voucher due within 45 days after end of the contract term.
Accepted Method of Submission: Email
Submit Copy to: PSPS_Finance@hhs.texas.gov
Original Signature Required: No
Number of Copies: One
Instructions: Enter Cost Reimbursement monthly expenses per budget category, program income collection and data collection.
Note: The Monthly Voucher Packet templates are sent to contracted providers by their contract manager. Vouchers must be submitted each month even if there are no expenditures. Vouchers must still be submitted each month for actual expenditures of the program even if the contract limit has been reached.

Description: Quarterly report encompassing all expenditures and program income for the defining three months with amount received from HHSC.
Submission Date: Reports are due as follows: Quarter 1: September through November; Quarter 2: December through February; Quarter 3: March through May; Quarter 4: June through August. Submit 30 days after the end of each quarter. The final quarterly FSR is due 45 days after the end of the contract term. The final quarter report includes all final charges and expenses associated with the program contract. Mark it as "Final."
Accepted Method of Submission: Email
Submit Copy to: PSPS_Finance@hhs.texas.gov
Original Signature Required: Yes
Number of Copies: One
Instructions: Form 269A must have an original signature (scanned email or fax accepted).

Description: Fee-for-Service (File furnished voucher through Texas Medicaid & Healthcare Partnership (TMHP) TexMedConnect/Compass 21)
Submission Date: Claims Filing Deadline: Within 95 days from date of service or date of third-party insurance EOB form. Within 45 days after the end of the contract term.
Accepted Method of Submission: TMHP/Compass 21
Submit Copy to: Not applicable
Original Signature Required: No
Number of Copies: Not applicable
Instructions: Claims must continue to be submitted to TMHP TexMedConnect/Compass 21 even if the contract limit has been reached.
Note: Appeals must be submitted within 120 days of rejection during the contract term. All appeals must be submitted and finalized within 45 days after the end of the contract term.

Submission Date: No later than 60 days after the end of the contract term.
Accepted Method of Submission: Email, scan or fax
Submit Copy to: PSPS_Finance@hhs.texas.gov
Original Signature Required: Yes
Number of Copies: Not applicable
Instructions: The FRR form requires a signature (scan or fax accepted). The FRR is necessary only if the contractor has only a fee-for-service component without a cost reimbursement component.

Description: This plan should outline the contractor’s goals to inform the public of the purpose of the program and available services, enhance community understanding of its objectives, disseminate basic family planning and women’s health care knowledge, enlist community support and recruit potential clients for FPP.
Submission Date: The report is due within 45 days of the start of the contract period.
Accepted Method of Submission: Email
Submit Copy to: famplan@hhs.texas.gov
Original Signature Required: No
Number of copies: Not applicable
Instructions: Submit completed plan annually by due date outlined.

Description: This report should include summary of the efficacy of program promotion and client outreach activities outlined in Form 1080, Health and Developmental Services (HDS) Promotion and Outreach Annual Plan.
Submission Date: The report is due within 15 days of the close of each quarter.
Accepted Method of Submission: Email
Submit Copy to: famplan@hhs.texas.gov
Original Signature Required: No
Number of Copies: Not Applicable
Instructions: Submit completed reports quarterly by the due date outlined.