§11-179-4 - Right to appeal.

§11-179-4 Right to appeal.

(a) Every client shall be responsible for submitting a completed financial assessment form as requested by the department.

(b) At the request ofthe community mental health center, the client shall provide verification of all statements made on the financial assessment form.

(c) The client may request in writing reconsideration of his bill by the director of the community mental health center or children's team head. If not satisfied with the findings ofthe center director or children's team head, the client may submit a written appeal to the deputy director, behavioral health services administration ofthe department whose decision shall be final.

        [Eff OCT 04 1991] (Auth: HRS §334-9) (Imp: HRS §334-6)

CENTER _________

COMMUNITY MENTAL HEALTH CENTER CHARGE SLIP

Name of Provider Number Date of Service Walk

Name of Client _________CR # _________

PATIENT COMPLAINT: _________

____________________________________ W9205-52 Clinic Visit -Group

_________90620 Consultation, Initial, Compre.__________W9206 DHS Psych. Diag./Evaluation

_________90630 Consultation, Initial, Complex_________Occupational Therapy

_________90640 F/U Consultation, Brief

_________90641 F/U Consultation, Limited

PRESCRIPTION

RX NO. NATIONAL DRUGCODE QUANTITY DAYS SUPPLY REFILL CHARGES DEDUCTIBLE BALANCE

2.____________________________________

3.____________________________________

SUMMARY/SYNOPSIS OF VISIT:__________________

Provider Signature:__________________

12/1/90

CLINIC

RATE SCHEDULE

PROC. CODE DESCRIPTION RATE

90000 OFV, BRIEF, NEW 40.00

90010 OFV, LIMITED, NEW 73.75

90015 OFV, INTERMEDIATE, NEW 116.00

90020 OFV, COMPREHENSIVE, NEW 159.00

90030 OFV, MINIMAL, ESTABLISHED 32.60

90040 OFV, BRIEF, ESTABLISHED 44.00

90050 OFV, LIMITED, ESTABLISHED 58.00

90060 OFV, INTERMEDIATE, ESTABLISHED 70.00

90070 OFV, EXTENDED, ESTABLISHED 110.00

90080 OFV, COMPREHENSIVE, ESTABLISHED 127.00

90200 INITIAL HOSP. CARE - BRIEF 100.00

90215 INITIAL HOSP. CARE - INTERMEDIATE 166.00

90220 INITIAL HOSP. CARE - COMPREHENSIVE 209.00

90600 CONSULTATION, INITIAL, LIMITED 114.00

90605 CONSULTATION, INITIAL, INTERMEDIATE 131.00

90610 CONSULTATION, INITIAL, EXTENDED 151.00

90620 CONSULTATION, INITIAL, COMPREHENSIVE 169.00

90630 CONSULTATION, INITIAL, COMPLEX 190.00

90640 CONSULTATION, FOLLOW-UP, BRIEF 42.00

90641 CONSULTATION, FOLLOW-UP, LIMITED 59.00

90642 CONSULTATION, FOLLOW-UP, INTERMEDIATE 85.00

90643 CONSULTATION, FOLLOW-UP, COMPLEX 109.00

90801 PSYCHIATRIC DIAGNOSTIC EVALUATION 141.00

90801-22 PSYCH. EVAL DIAGNOSTIC EVALUATION 180.00

90801-52 PSYCHIATRIC DIAGNOSTIC EVALUATION 70.00

90825 PSYCHIATRIC EVAL. OF HOSP. RECORDS 142.00

90830 PSYCHOLOGICAL TESTING 141.00

90841 PSYCHO-THERAPY (UP TO 15 MINUTES) 40.00

90843 PSYCHO-THERAPY (UP TO 35 MINUTES) 73.20

90844 PSYCHO-THERAPY (UP TO 50 MINUTES) 133.40

90847 FAMILY/CONJOINT PSYCHO-THERAPY 148.00

90853 GROUP PSYCHO-THERAPY 67.00

90782 THER. INJECT. INTRAMUSCULAR 5.00

90849 MULTI-FAMILY GROUP THERAPY 48.33

W9205 CLINIC VISIT 45.00

W9205-52 CLINIC VISIT 27.00

W9206 PSYCH. EVAL/DIAGNOSIS 141.00

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