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["Q1",null,"FY 19/20",null,"Qtr Ending 9/30"]
["Q2",null,"FY 20/21",null,"Qtr Ending 12/31"]
["Q3",null,"FY 21/22",null,"Qtr Ending 3/31"]
["Q4",null,"FY 22/23",null,"Qtr Ending 6/30"]
["Annual",null,"FY 23/24",null,"Annual Claim"]
[null,null,"FY 24/25"]

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["Template for counties to claim reimbursement after July 1, 2021. MC 1982 B: Medi-Cal Specialty Mental Health Services Claim Administrative Costs. The tab order will take you across the table by row. The sheet is organized by Total, M C H I P, Other Medi-Cal Specialty Mental Health Program, and Non-Reimbursable Administrative Costs. The document will identify what each cell is for as you tab into it.","STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Department of Health Care Services"]
[null,"MC_1982B_6-SMHS use after 7-1-2021- COVID 69.34%, 15% OA"]
["MC 1982 B: Medi-Cal Specialty Mental Health Services Quarterly Claim for Reimbursement - Administrative Cost"]
[]
["Date:",null,null,null,null,null,"County Code:",null,null,null,null,"County:",null,null,null,null,null,null,null,null,null,null,"Quarter:",null,null,null,null,null,null,null,"Q1"]
["Fiscal Year:",null,null,null,"FY 19/20",null,null,null,"Claim for Quarter Ending: ",null,null,null,null,null,null,null,null,"Qtr Ending 9/30",null,null,null,null,null,null,null,"Mark \"X\" If Replacement Claim:"]
[]
[null,null,null,null,null,null,null,null,null,null,null,"A",null,null,null,null,null,"B",null,null,null,null,null,"C",null,null,null,null,null,"D"]
[null,null,null,null,null,null,null,null,null,null,null,"Total",null,null,null,null,null,"MCHIP",null,null,null,null,null,"Other Medi-Cal Specialty Mental Health Program",null,null,null,null,null,"Non-Reimbursable"]
[1," Direct Facility Treatment Expenditures"]
[{"$f":"A10+1","v":2},"Prop 30 State - Performance Outcome Systems IT Hardware & Software Upgrades"]
[3,"Prop 30 Federal - Federal Medicaid Managed Care Final Rule and Parity Rule Administrative Costs"]
[4,"Maximum Administrative Percentage for Direct Facility Treatment Expenditures",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0.1,null,null,null,null,null,0.15]
[5,"Maximum Administrative Claim For Direct Facility Treatment Expenditures(Line 1 x Line 4)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"R10*R13","v":0},null,null,null,null,null,{"$f":"X10*X13","v":0}]
[{"$f":"A14+1","v":6},"Prop 30 Federal - Actual Administrative Expenditures",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"L15-R15-X15","v":0}]
[7,"Lower of Line 5 or 6",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"MIN(IF(R15=\"\",\"0\",R14:W15))","v":0},null,null,null,null,null,{"$f":"MIN(IF(X15=\"\",\"0\",X14:AC15))","v":0}]
[8,"Amount Eligible for State General Fund (SGF)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"R11+R12","v":0},null,null,null,null,null,{"$f":"X11+X12","v":0}]
[{"$f":"A17+1","v":9},"Administrative Federal Medical Assistance Percentage",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0.69340000000000002,null,null,null,null,null,0.5]
[10,"SGF Eligible Amount (From Line 2 and 3)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"(R11*(1-R18))+(0.5*(R12*(1-R18)))","v":0},null,null,null,null,null,{"$f":"(0.5*X11)+(0.5*(X12*(1-X18)))","v":0}]
[11,"Administrative Federal Financial Participation ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"ROUNDDOWN(R16*R18,2)","v":0},null,null,null,null,null,{"$f":"ROUNDDOWN((X16*X18),2)","v":0}]
[]
[]
[]
[]
[]
[]
["STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Department of Health Care Services"]
[]
["MC 1982 B: Medi-Cal Specialty Mental Health Services Quarterly Claim for Reimbursement - Administrative Cost"]
[]
["Date:",null,{"$f":"C5","v":"00:00:00"},null,null,null,"County Code:",null,null,{"$f":"J5","v":0},null,"County:",null,null,null,{"$f":"P5","v":0},null,null,null,null,null,null,"Quarter:",null,null,null,null,null,null,null,{"$f":"AE5","v":"Q1"}]
["Fiscal Year:",null,null,null,{"$f":"E6","v":"FY 19/20"},null,null,null,"Claim for Quarter Ending:",null,null,null,null,null,null,null,null,{"$f":"R6","v":"Qtr Ending 9/30"}]
[]
["I HEREBY CERTIFY under penalty of perjury that I am the official responsible for the administration of Community Mental Health Services in and for said claimant; that I am authorized to sign this certification on behalf of the County; that I have not violated any of the provisions of Section 1090 et sec. of the Government Code; that the amount for which reimbursement is claimed herein is in accordance with Chapter 3, Part 2, Division 5 of the Welfare and Institutions Code; that the claim is based on actual, total-funds expenditures for services to eligible beneficiaries; and that to the best of my knowledge and belief this claim is in all respects true, correct, and in accordance with the law. The County further certifies under penalty of perjury that:  all claims for services provided to county mental health clients have been provided to the clients by the County; the services were, to the best of the County's knowledge, provided in accordance with the client's written treatment plan; and that all information submitted to the Department is accurate and complete.  The County understands that payment of these claims will be from Federal and/or State funds, and any falsification or concealment of a material fact may be prosecuted under Federal and/or State laws.  Pursuant to Section 433.32 of Title 42, Code of Federal Regulations (CFR), the County agrees to keep for a minimum of three years after final determination of costs is made through the DHCS reconciled Cost Report settlement process and retained beyond the three-year period if audit findings have not been resolved, a printed representation of all records which are necessary to disclose fully the extent of services furnished to the client.  The County agrees to furnish these records and any information regarding payments claimed for providing services, on request, within the State of California to the California Department of Health Care Services (DHCS), the Medi-Cal Fraud Unit, California Department of Justice, Office of the State Controller, U.S. Department of Health and Human Services, or their duly authorized representatives.  The County also certified under penalty of perjury that services are offered and provided without discrimination based on race, religion, color, national or ethnic origin, sex, or physical or mental disability."]
[]
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[]
["Date:",null,null,null,null,null,null,null,null,null,"Print Name & Title:"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Local Mental Health Director"]
[]
[]
["Executed at:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Signature:"]
[]
[]
[]
[]
[]
["STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Department of Health Care Services"]
[]
["MC 1982 B: Medi-Cal Specialty Mental Health Services Quarterly Claim for Reimbursement - Administrative Cost"]
[]
["Date:",null,{"$f":"C5","v":"00:00:00"},null,null,null,"County Code:",null,null,{"$f":"J5","v":0},null,"County:",null,null,null,{"$f":"P5","v":0},null,null,null,null,null,null,"Quarter:",null,null,null,null,null,null,null,{"$f":"AE5","v":"Q1"}]
["Fiscal Year:",null,null,null,{"$f":"E6","v":"FY 19/20"},null,null,null,"Claim for Quarter Ending:",null,null,null,null,null,null,null,null,{"$f":"R6","v":"Qtr Ending 9/30"}]
[]
["I HEREBY CERTIFY under penalty of perjury that I am the official responsible for the administration of Community Mental Health Services in and for said claimant; that I am authorized to sign this certification on behalf of the County; that I have not violated any of the provisions of Section 1090 et sec. of the Government Code; that the amount for which reimbursement is claimed herein is in accordance with Chapter 3, Part 2, Division 5 of the Welfare and Institutions Code; that the claim is based on actual, total-funds expenditures for services to eligible beneficiaries; and that to the best of my knowledge and belief this claim is in all respects true, correct, and in accordance with the law. The County further certifies under penalty of perjury that:  all claims for services provided to county mental health clients have been provided to the clients by the County; the services were, to the best of the County's knowledge, provided in accordance with the client's written treatment plan; and that all information submitted to the Department is accurate and complete.  The County understands that payment of these claims will be from Federal and/or State funds, and any falsification or concealment of a material fact may be prosecuted under Federal and/or State laws.  Pursuant to Section 433.32 of Title 42, Code of Federal Regulations (CFR), the County agrees to keep for a minimum of three years after final determination of costs is made through the DHCS reconciled Cost Report settlement process and retained beyond the three-year period if audit findings have not been resolved, a printed representation of all records which are necessary to disclose fully the extent of services furnished to the client.  The County agrees to furnish these records and any information regarding payments claimed for providing services, on request, within the State of California to the California Department of Health Care Services (DHCS), the Medi-Cal Fraud Unit, California Department of Justice, Office of the State Controller, U.S. Department of Health and Human Services, or their duly authorized representatives.  The County also certified under penalty of perjury that services are offered and provided without discrimination based on race, religion, color, national or ethnic origin, sex, or physical or mental disability."]
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[]
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[]
[]
[]
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[]
[]
[]
[]
["Date:",null,null,null,null,null,null,null,null,null,"Print Name & Title:"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"County Auditor Controller or City Financial Officer"]
[]
[]
["Executed at:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Signature:"]

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["Instructions for the template for counties to claim reimbursement  after July 1, 2021. MC 1982 B: Medi-Cal Specialty Mental Health Services Claim Administrative Costs. ","STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Department of Health Care Services"]
[]
["MC 1982 B: Medi-Cal Specialty Mental Health Services Quarterly Claim for Reimbursement - Administrative Cost"]
[]
["Instructions"]
[]
["Heading Instructions:"]
["Enter the date the claim form is submitted, the County Code, the name of the County, the County Legal Entity number.  Complete one claim for each quarter.  "]
[]
[]
[]
["Line Item Instructions:"]
["Round all figures to the nearest cents.  "]
[]
["1.","The specialty mental health direct facility expenditures incurred during the quarter by the county for each program (MCHIP and other Medi-Cal Specialty Mental Health Program) based on the treatment claim costs for each program typically reported on claim form MC 1982 A.  Refer to the Mental Health Aid Code Master Chart on DHCS' website for a definition of the Medi-Cal aid codes included in each program.  MCHIP aid codes include 8N, 8R, 8P, and 8T.  Direct facility expenditures include claims for county providers and contract providers reimbursed through the Medi-Cal Specialty Mental Health system and hospital inpatient providers reimbursed through the DHCS' Medi-Cal Fiscal Intermediary."]
[]
[]
[]
[]
[]
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["2.","Enter Prop 30 State, the total Performance Outcome Systems (POS) hardware and software upgrade expenditures incurred for each program (MCHIP and other Medi-Cal Specialty Mental Health Program). The non-federal share is reimbursed with 100% State General Fund (SGF)."]
[]
[]
[]
["3.","Enter Prop 30 Federal, the total Federal Medicaid Managed Care Final Rule and Parity Rule administrative costs incurred for each program (MCHIP and other Medi-Cal Specialty Mental Health Program). The non-federal share is shared between the County and DHCS. "]
[]
[]
[]
["4.","The maximum allowed administrative percentage is shown for each program. No entry required."]
[]
["5.","The maximum allowed administrative amount is shown for each program (Line 1 x Line 4). No entry required."]
[]
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["6.","Enter Prop 30 Federal, the total administrative expenditures incurred for the program during the quarter in Line 6, Column A. Enter the actual allocated administrative expenditures incurred for the program in Line 6, Columns B and C, including costs for Performance Outcome Systems (line 2) and Final Rule/Parity (line 3). The total non-reimbursable administrative expenditures are populated in Line 6, Column D. No entry is required. Counties should allocate total administrative expenditures between the programs consistent with the allocation approaches allowed for in the cost report, which include (1) the relative percentage of program recipients in the population served by the county or (2) the gross costs of each program.  Counties should apply the same approach consistently from quarter to quarter and on the year end cost report."]
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["7.","Lower of line 5 or line 6. No entry required."]
[]
["8.","The amount eligible for SGF for each program is computed. No entry required."]
[]
["9.","The relevant Federal Medical Assistance Percentage (FMAP) is shown for each program. No entry required."]
[]
["10.","The State General Fund for POS and Managed Care Final Rule is computed. No entry required."]
[]
["11.","The Federal Financial Participation for each program is computed. No entry required."]
[]
["Certifications:"]
["Each claim form must include the signed certification of the Local Mental Health Director and either the County Auditor-Controller, City Finance Officer, or the Local Mental Health Accounting Officer."]
[]
[]
[]
["Send all claims to: 1982BClaim@dhcs.ca.gov"]