- To provide the Emergency Response Services (ERS) contractor with findings of the fiscal monitoring review.
- To serve as a data entry document for tracking ERS fiscal monitoring results.
When to Prepare
Complete Pages 1 and 2 according to the instructions on the form after completing the fiscal review of sample individuals.
Number of Copies
Complete an original and make one copy.
If requested by the ERS contractor during or after the exit conference, contract staff give a copy of the form to the contractor. HHSC staff should retain the original for agency records.
Retain the form and any supporting documentation in accordance with records retention requirements in the Health and Human Services (HHS) System Procurement and Contract Management Handbook.
Name of Legal Entity — Self-explanatory.
Contract No. — Self-explanatory.
Provider No. – Enter the contractor’s 9-digit provider number, if applicable.
Contract Begin Date — Enter the begin date of the contract.
Contract End Date — Enter the end date of the contract.
Type of Review — Select the type of review being conducted.
Review Level — Check the review level conducted: Full or Targeted.
Completed By — Enter the first and last name of the monitoring team lead.
Date of Entrance — Enter the date of the entrance conference.
Date of Exit — Enter the date of the exit conference.
Date of Revised Exit — Enter the date of the revised exit.
Dates of Monitoring Period — Enter the begin and end dates of the monitoring period.
Service Code — Enter the two-digit service code for each service reviewed.
Amount to be Recouped — By service code, enter amount to be recouped (from Page 2).
Item A. Total to be Recouped — Enter total amount to be recouped.
Item B. Total Dollar Amount Reimbursed for Sample Reviewed — Total reimbursement amounts for each sample for the sample months.
Item C. Error Rate — Enter the recoupment error percentage by dividing the total in Item A to be recouped for financial standard errors identified on Form 3061, Emergency Response Services Financial Errors Standard, by the total reimbursed amount in Item B.
Mark one of the boxes depending on findings:
- “Our review indicated no recoupment due to no documentation errors ...” box if there are no errors, or
- “Our review indicated recoupment due to documentation errors ...” box if there are errors.
Comments — Self-explanatory.
To complete the table, use Form 3061, Emergency Response Services Financial Errors Standard, and Business Objects.
Item 1. Sample No. — Enter the sample number.
Item 2. Individual ID No. — By the service code, list the identification number of each individual assigned this service code with an amount due to HHSC.
Item 3. Last Name — By the service code, list the last name of each sample assigned this service code with an amount due to HHSC.
Item 4. First Initial — By the service code, list the first initial of each sample assigned this service code with an amount due to HHSC.
Item 5. Service Code — Enter the service code for the service reviewed for the sample.
Item 6. Service Begin Date — By the service code, enter the begin date of the billing period.
Item 7. Service End Date — By the service code, enter the end date of the billing period.
Item 8. No. Units Paid — By the service code, enter the number of units paid for the billing period.
Item 9. Amount Paid — By the service code, enter the amount paid for the billing period.
Item 10. Unit Rate — By the service code, enter the unit rate.
Item 11. Units Verified — By the service code, enter the number of units documented for the billing period.
Item 12. Units Disallowed — By the service code, enter the number of units for the billing period in error.
Item 13. Amount Due to HHSC — By the service code, enter the amount reimbursed in error.