Get Instructions For Completing The Map-100501 Form - Chfs Ky

The MAP-100501 form is essential for providers seeking a change in scope of services, which may involve requests for rate adjustments. Completing this form accurately is crucial to ensure the Department can assess the change effectively and fairly.

Follow the steps to complete the MAP-100501 form online.

1. Click ‘Get Form’ button to access the MAP-100501 form and open it in the editor.
2. Fill in the general information at the top of the form, including the name of the provider, Medicaid provider number, reason for the change in scope, and the effective date of change.
3. Indicate whether you are requesting an interim CIS rate or a final CIS rate by completing the rate notice box.
4. Complete the 'For Provider Use' section by providing details on direct and indirect costs. For line 1, input the actual direct cost associated with the CIS. For line 2, input the indirect costs, ensuring administrative costs do not exceed allowable limits.
5. For line 3, enter the number of Medicaid visits related to the CIS, as defined by applicable regulations. For line 4, input the total visits associated with the change.
6. Gather and prepare additional documentation that supports your request, including a narrative of the change, supporting documents for costs, and necessary Universal Cost Reports.
7. Once all sections are filled out, review the completed MAP-100501 form for accuracy before submitting.
8. You can then save your changes, download the form, print it, or share it according to your needs.

Complete your MAP-100501 form online today to ensure your request is processed efficiently.