HAR §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 of the 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 of the center director or children's team head, the client may submit a written appeal to the deputy director, behavioral health services administration of the 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 DRUG CODE QUANTITY DAYS SUPPLY REFILL CHARGES DEDUCTIBLE BALANCE 1. ______________________________________________________________ 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 l16.00 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