How to Fill Out a Nursing Assistant Certification Reimbursement Request Form
Nursing Assistant Certification (NAC)
Reimbursement Requests
How To Fill Out a Reimbursement
Request
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•
Use
Form 06-123
for all reimbursement requests.
•
We will review Sections A-E on the form.
A. Provider Information
B. Direct Care Costs
C. Operating Costs
D. Total Costs and Reimbursement Request
E. Provider Authorization
NOTE:
Some totals on the form are automatically calculated, but some
totals need to be entered manually. See instructions for details.
Additional information can be found at:
https://www.dshs.wa.gov/altsa/management-services-
division/nursing-assistant-certified-reimbursement-forms
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The summary page contains the
“
Requested Current Costs
” which
automatically transfer from
each
respective page containing the
total amounts calculated per
item/service listed.
A
utomatically calculates
Direct Care
and
Operating Costs
above.
A
utomatically calculates
Facility
Reimbursement
amount
based
on Direct Care plus Operating
costs multiplied by the Medicaid
Reimbursement %.
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A
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1.
Enter the
Provider name
. If a name change occurred within the last (2) years, enter that name, too.
2.
Enter the
Medicaid Reimbursement Percent
.
NOTE: The reimbursement percentage is calculated by taking the number of
Medicaid patients days reported on your cost report Schedule N divided by the total patient days on the same schedule. The
reimbursement percentage is updated July each year and posted on our
website
.
3.
Enter your
Provider One number
.
4.
Enter your seven-digit Medicaid
Vendor Number
.
5.
Enter the name of the
Contact Person
for questions concerning this form.
6.
Enter the
Contact Person’s e-mail address
.
7.
Enter the
C
ontact Person’s Telephone Number
.
8.
Enter the
Administrator Name
.
9.
Enter the
Administrator’s Email Address
.
10.
Check the appropriate box for the
Reimbursement Period (three-month period ending)
and enter the
Year
.
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n
B
.
D
i
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e
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t
C
a
r
e
C
o
s
t
s
(
1
.
a
,
b
,
c
)
1. Follow instructions on the
Instructor Information
page
(page 2)
and
the amount
automatically transfers
to
the
Summary Page
.
NOTE:
A facility can claim up to
150 hours
TOTAL
for all teachers and helpers
per class
.
NOTE:
Instructor payroll taxes are limited
to 7.85% of total hourly pay for training,
regardless of the amount actually paid.
NOTE:
This section applies only if
you have
instructor-led
training
provided by the facility
.
S
e
c
t
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n
B
.
D
i
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t
C
a
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o
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t
s
(
2
.
O
n
l
i
n
e
T
r
a
i
n
i
n
g
)
2
. If a facility paid for a subscription
for
an online hybrid-training program,
fill out the bottom of the
Student
Information
page
(page 3)
and the
amount
automatically transfers
to the
Summary Page
.
S
e
c
t
i
o
n
C
.
O
p
e
r
a
t
i
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n
s
C
o
s
t
s
(
1
.
S
u
p
p
l
i
e
s
)
1.
Fill out the
Supplies
Information
page
(page 4)
and the amount
automatically transfers
to the
Summary Page
.
NOTE:
Supplies are limited to the number
of students taught for the quarter.
S
e
c
t
i
o
n
C
.
O
p
e
r
a
t
i
o
n
s
C
o
s
t
s
(
2
.
C
P
R
&
F
i
r
s
t
A
i
d
)
2
. If an outside entity conducted CRP
and/or First Aid
training,
fill out the bottom of the
Instructor Information
page
(page 2)
and
the amount automatically
transfers
to the
Summary Page
.
S
e
c
t
i
o
n
C
.
O
p
e
r
a
t
i
o
n
s
C
o
s
t
s
(
3
.
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e
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b
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s
e
d
t
o
S
t
u
d
e
n
t
s
)
3. If a student was
reimbursed for prior testing
and training
, fill out the
Student
Information
page
(page 3)
and
the amount automatically
transfers
to the
Summary Page
.
NOTE
: All facilities with a Medicaid contract must offer
reimbursement to NAC students, provided that the nursing
facility is the first one the student works at within a year of
completing their training and their training wasn’t paid for with
a scholarship or some other form of public funding
NOTE:
This section must be filled out for each
student that participated in a training program
regardless if the training was or was not completed
by the student.
S
e
c
t
i
o
n
C
.
O
p
e
r
a
t
i
o
n
s
C
o
s
t
s
(
4
.
T
e
s
t
i
n
g
F
e
e
s
)
4. If testing fees for nursing assistants were
incurred,
f
ill out the
Student
Information
page
(page 3)
and
the amount autom
atically
transfers
to the
Summary Page
.
NOTE:
Department of Health expenses
(including nursing license application
fees) are
non-allowable expenses.
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1.
T
otal
Direct Care Costs
(Section B, items 1. a-c & 2.) is
automatically calculated
.
2.
Total
Operating Costs
(Section C, items 1. through 4.) is
automatically calculated
.
3.
Total D.1. and D.2 is
automatically calculated
.
4.
Your Medicaid percentage entered in
Section A, item 2
is automatically entered
(
Section D, item 4) to calculate the amount of reimbursement for the quarter.
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The Nursing Home Administrator must sign and date this form. Submit originals signed in
ink
.
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Send the completed and signed reimbursement form, along with all support documentation, by the quarterly
due date in .pdf format to the email address below. The submission email address is a secure email address
*NOTICE FOR SUBMISSION OF CONFIDENTIAL INFORMATION*
Beginning January 31, 2022, All CONFIDENTIAL information contained in a NAC reimbursement request
MUST BE SENT VIA SECURED EMAIL
OR
IN AN EMAIL REPLY
to a secured email originated by
DSHSALTSANACReimbursement@dshs.wa.gov
.
If you do not have the ability to secure an email and did NOT
receive a secure email to reply to, contact the email address above with the
Subject
: Secure Email Needed.
All NAC reimbursement packet submissions to be
sent via secured email OR in a secured reply
to the
email above.
In your secured email or secured reply, change the
Subject
:
xx Quarter 202x NAC Submission.
If you did not receive a secured email, please send an email to
DSHSALTSANACReimbursement@dshs.wa.gov
with the
Subject
: Secure Email Needed.
You have up to thirty (30) days from the end of the quarter to submit a reimbursement request.
It must be
emailed by the last day of the month following the reimbursement quarter. No late reimbursement packets
will be accepted unless there are extenuating circumstances and approval from the NAC Lead is obtained
prior to submission.
Due dates are as follows:
1
st
Quarter: July 31
st
(processed with 2
nd
quarter to accommodate the cost report review)
2
nd
Quarter: July 31
st
3
rd
Quarter: October 31
st
4
th
Quarter: January 31
st
the following year
(example - the quarter ending December 31, 2020, would be
due by January 31, 2021)
Use the forms found on our website
https://www.dshs.wa.gov/altsa/management-services-division/nursing-
assistant-certified-reimbursement-forms
to request reimbursement for nursing assistant training and testing
costs. Submit forms and supporting documents at the end of the quarter in which training and/or testing
was completed.
NAC FAQs
Please submit one request packet per quarter with all costs pertaining to that quarter.
If a class went over into the next quarter by a week or two, you must include it in the quarter in
which it ended.
Listing the facility’s full-time instructors as Outside CPR & First Aid expenses is incorrect; this
should be listed under Direct Care Costs in the instructor section.
If listing “Other” as a reason for not completing the class, you must explain the reason.
Supplies and moveable asset expenses over $750 per item will be paid through the NAC
training program. This is for classroom specific items only and should correspond to average
class sizes. For instance, if a facility generally only teaches 10 students, we will not allow 20
computers/tablets/etc. to be reimbursed. We would not allow items such as a bed hoist, since
that is equipment that is normally used in the nursing home and could be borrowed the class.
Use the DSHS NAC Supplies Form. Please itemize all expenses and fill out the invoice section of
the form for each invoice.
If the forms are incomplete, an email will be sent to the facility requesting documents etc. If no
response is received from the facility within a week, the request will not be processed for
reimbursement. Please make sure your contact information is updated and correct; especially
your email address, as this is our main form of contact for questions.
You must write the name of the student(s) on the copy of the check submitted for proof of
payment.
When a student is trained at an outside facility, proof of payment for student testing and a
detailed invoice, including cost breakdown, is required.
Proof of payment and proof of purchase is required for reimbursement.
Proof of employment, which must contain the hourly wage, is required for facility employed
training instructors.
Questions?
Visit the ALTSA Website:
https://www.dshs.wa.gov/altsa/management-
services-division/nursing-assistant-certified-reimbursement-forms
Or contact the NAC Reimbursement Lead, Melissa Ayala, at:
E-mail:
Melissa.Ayala@dshs.wa.gov
Telephone:
360-725-2416
Detailed instructions on filling out Form 06-123 for Nursing Assistant Certification (NAC) reimbursement requests. Sections covered include Provider Information, Direct Care Costs, Operating Costs, Total Costs, and Provider Authorization. The form requires manual entry of some totals and provides automatic calculations for others. Additional information and the form itself can be accessed online. The summary page facilitates automatic transfers of requested costs and calculates Facility Reimbursement based on Direct Care and Operating costs multiplied by the Medicaid Reimbursement percentage.
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Presentation Transcript
Nursing Assistant Certification (NAC) Reimbursement Requests How To Fill Out a Reimbursement Request
How to Fill out a Reimbursement Request How to Fill out a Reimbursement Request Use Form 06-123 for all reimbursement requests. We will review Sections A-E on the form. A. Provider Information B. Direct Care Costs C. Operating Costs D. Total Costs and Reimbursement Request E. Provider Authorization NOTE: Some totals on the form are automatically calculated, but some totals need to be entered manually. See instructions for details. Additional information can be found at: https://www.dshs.wa.gov/altsa/management-services- division/nursing-assistant-certified-reimbursement-forms
Use Form 06 Form 06- -123 123 for NAC reimbursement requests. Found at: : https://www.dshs.wa.gov/altsa/management-services- division/nursing-assistant-certified-reimbursement-forms
Summary Page Automatic Amount Transfers Summary Page Automatic Amount Transfers The summary page contains the Requested Current Costs which automatically transfer from each respective page containing the total amounts calculated per item/service listed. Automatically calculates Direct Care and Operating Costs above. Automatically calculates Facility Reimbursement amountbased on Direct Care plus Operating costs multiplied by the Medicaid Reimbursement %.
Section A. Provider Information Section A. Provider Information 1. 2. Enter the Provider name. If a name change occurred within the last (2) years, enter that name, too. Enter the Medicaid Reimbursement Percent. NOTE: The reimbursement percentage is calculated by taking the number of Medicaid patients days reported on your cost report Schedule N divided by the total patient days on the same schedule. The reimbursement percentage is updated July each year and posted on our website. Enter your Provider One number. Enter your seven-digit Medicaid Vendor Number. Enter the name of the Contact Person for questions concerning this form. Enter the Contact Person s e-mail address. Enter the Contact Person s Telephone Number. Enter the Administrator Name. Enter the Administrator s Email Address. 10. Check the appropriate box for the Reimbursement Period (three-month period ending) and enter the Year. 3. 4. 5. 6. 7. 8. 9.
Section B. Section B. Direct Care Costs (1. a, Direct Care Costs (1. a, b, c) b, c) 1. Follow instructions on the Instructor Information page (page 2) and the amount automatically transfers to the Summary Page. NOTE:This section applies only if you have instructor-led training provided by the facility. NOTE: A facility can claim up to 150 hours TOTAL for all teachers and helpers per class. NOTE: Instructor payroll taxes are limited to 7.85% of total hourly pay for training, regardless of the amount actually paid.
Section B. Section B. Direct Care Costs (2. Online Training) Direct Care Costs (2. Online Training) 2. If a facility paid for a subscription for an online hybrid-training program, fill out the bottom of the Student Information page (page 3) and the amount automatically transfers to the Summary Page.
Section C. Operations Section C. Operations Costs (1. Supplies) Costs (1. Supplies) 1. Fill out the Supplies Information page (page 4) and the amount automatically transfers to the Summary Page. NOTE: Supplies are limited to the number of students taught for the quarter.
Section C. Operations Section C. Operations Costs (2. CPR & First Aid) Costs (2. CPR & First Aid) 2. If an outside entity conducted CRP and/or First Aid training, fill out the bottom of the Instructor Information page (page 2) and the amount automatically transfers to the Summary Page.
Section C. Operations Section C. Operations Costs (3. Fees Reimbursed to Students) Costs (3. Fees Reimbursed to Students) 3. If a student was reimbursed for prior testing and training, fill out the Student Information page (page 3) and the amount automatically transfers to the Summary Page. NOTE: This section must be filled out for each student that participated in a training program regardless if the training was or was not completed by the student. NOTE: All facilities with a Medicaid contract must offer reimbursement to NAC students, provided that the nursing facility is the first one the student works at within a year of completing their training and their training wasn t paid for with a scholarship or some other form of public funding
Section C. Operations Section C. Operations Costs (4. Testing Fees) Costs (4. Testing Fees) 4. If testing fees for nursing assistants were incurred, fill out the Student Information page (page 3) and the amount automatically transfers to the Summary Page. NOTE: Department of Health expenses (including nursing license application fees) are non-allowable expenses.
Section D. Costs and Reimbursement Request Section D. Costs and Reimbursement Request 1. Total Direct Care Costs (Section B, items 1. a-c & 2.) is automatically calculated. 2. Total Operating Costs (Section C, items 1. through 4.) is automatically calculated. 3. Total D.1. and D.2 is automatically calculated. 4. Your Medicaid percentage entered in Section A, item 2 is automatically entered (Section D, item 4) to calculate the amount of reimbursement for the quarter.
Section E. Provider Authorization Section E. Provider Authorization The Nursing Home Administrator must sign and date this form. Submit originals signed in ink.
Submitting the Packet Submitting the Packet Send the completed and signed reimbursement form, along with all support documentation, by the quarterly due date in .pdf format to the email address below. The submission email address is a secure email address *NOTICE FOR SUBMISSION OF CONFIDENTIAL INFORMATION* Beginning January 31, 2022, All CONFIDENTIAL information contained in a NAC reimbursement request MUST BE SENT VIA SECURED EMAIL OR IN AN EMAIL REPLY to a secured email originated by DSHSALTSANACReimbursement@dshs.wa.gov. If you do not have the ability to secure an email and did NOT receive a secure email to reply to, contact the email address above with the Subject: Secure Email Needed. All NAC reimbursement packet submissions to be sent via secured email OR in a secured reply to the email above. In your secured email or secured reply, change the Subject: xx Quarter 202x NAC Submission. If you did not receive a secured email, please send an email to DSHSALTSANACReimbursement@dshs.wa.gov with the Subject: Secure Email Needed. You have up to thirty (30) days from the end of the quarter to submit a reimbursement request. It must be emailed by the last day of the month following the reimbursement quarter. No late reimbursement packets will be accepted unless there are extenuating circumstances and approval from the NAC Lead is obtained prior to submission. Due dates are as follows: 1st Quarter: July 31st(processed with 2nd quarter to accommodate the cost report review) 2nd Quarter: July 31st 3rd Quarter: October 31st 4th Quarter: January 31st the following year (example - the quarter ending December 31, 2020, would be due by January 31, 2021) Use the forms found on our website https://www.dshs.wa.gov/altsa/management-services-division/nursing- assistant-certified-reimbursement-forms to request reimbursement for nursing assistant training and testing costs. Submit forms and supporting documents at the end of the quarter in which training and/or testing was completed.
NAC FAQs Please submit one request packet per quarter with all costs pertaining to that quarter. If a class went over into the next quarter by a week or two, you must include it in the quarter in which it ended. Listing the facility s full-time instructors as Outside CPR & First Aid expenses is incorrect; this should be listed under Direct Care Costs in the instructor section. If listing Other as a reason for not completing the class, you must explain the reason. Supplies and moveable asset expenses over $750 per item will be paid through the NAC training program. This is for classroom specific items only and should correspond to average class sizes. For instance, if a facility generally only teaches 10 students, we will not allow 20 computers/tablets/etc. to be reimbursed. We would not allow items such as a bed hoist, since that is equipment that is normally used in the nursing home and could be borrowed the class. Use the DSHS NAC Supplies Form. Please itemize all expenses and fill out the invoice section of the form for each invoice. If the forms are incomplete, an email will be sent to the facility requesting documents etc. If no response is received from the facility within a week, the request will not be processed for reimbursement. Please make sure your contact information is updated and correct; especially your email address, as this is our main form of contact for questions. You must write the name of the student(s) on the copy of the check submitted for proof of payment. When a student is trained at an outside facility, proof of payment for student testing and a detailed invoice, including cost breakdown, is required. Proof of payment and proof of purchase is required for reimbursement. Proof of employment, which must contain the hourly wage, is required for facility employed training instructors.
Questions? Visit the ALTSA Website: https://www.dshs.wa.gov/altsa/management- services-division/nursing-assistant-certified-reimbursement-forms Or contact the NAC Reimbursement Lead, Melissa Ayala, at: E-mail: Melissa.Ayala@dshs.wa.gov Telephone: 360-725-2416
