Form 6002, Autism Program Invoice

Instructions

Updated: 4/2017

Purpose

Form 6002 is used by the Children’s Autism Program contractors to submit monthly invoices to the Texas Health and Human Services Commission (HHSC).

When and Where to Send the Completed Form

Contractors must submit the completed and signed Form 6002 by the end of the tenth business day of the following month:

Bill To: Invoice-HHSC Accounting
Texas Health and Human Services Commission
4900 N. Lamar Blvd.
Austin, TX 78751
Phone: 512-424-6518
Fax: 512-424-6901
Email: HHSC_AP@hhsc.state.tx.us

Send a copy to the HHSC Children's Autism Program contract manager.

Invoices may be sent by mail or electronic mail (attach a completed and signed copy).

Detailed Instructions

Contractor Information

Contractor Name—name of contractor.

Contact Name—name of contractor contact person.

Phone Number—phone number of contractor contact person.

Contractor Remittance Address, City, State, ZIP Code—where payment is to be sent.

Texas Identification Number (TIN)—contractor Texas Identification Number.

HHSC Contract Number—ten-digit grant award number.

HHSC P.O. Number—HHSC purchase order number.

Autism Services

Dates of Service—the date range for services being billed.

Treatment Hours/Current Month/No Third-Party Payer

Aggregate number of direct service hours provided in the month for which there is no third-payer coverage.

Treatment Hours/Current Month/Third-Party Payment Received or Denied

Aggregate number of direct service hours for the current month for which third-party payment was received or denied.

Treatment Hours/Previous Month(s)/Third-Party Payment Received or Denied

Aggregate number of direct service hours for previous months for which third-party payment was received or denied.

Third-Party Payer Reimbursement—sum of all third-party payer reimbursements received during the month.

Cost Share/Current Month—amount of cost share collected or owed for the month.

Deduction for Repayment of Previous Advance Payment—amount of repayment for previously approved advances.

Third-Party Payer Reimbursements

List months for which third-party payer reimbursements were received and the amount received for each listed month.

Certification

Authorized Contractor Signature—signature of authorized contractor staff member.

Date—date of request.

Note about Retention

Internal HHSC users: In most cases, the original version of completed forms must be maintained in accordance with federal and state laws and HHSC policy. If you are unsure how long to maintain a given form, consult the HHSC Records Retention Schedule or HHSC Records Management Office.

Providers and contractors: The original version of completed forms must be maintained in accordance with federal and state laws, HHSC policy, and your contract with HHSC. If you have any questions, contact your contract manager.

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