DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 1 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL ---------------------------------------------------------- CONTRACT NUM=0100018 NAME=ADAMS CO BD OF DD ---------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 08/04/2009 617086 262.00 0.00 0.00 0.00 0.00 0.00 0.00 2,862.70 08/04/2009 618978 0.00 0.00 0.00 0.00 1,832.65 632.95 2,465.60 26,952.82 08/04/2009 619015 0.00 0.00 0.00 620.27 0.00 0.00 620.27 6,779.88 09/08/2009 627221 369.60 0.00 0.00 0.00 0.00 0.00 0.00 3,623.84 09/08/2009 629110 0.00 0.00 0.00 0.00 2,781.36 1,130.20 3,911.56 38,340.31 09/08/2009 629140 0.00 0.00 0.00 935.80 0.00 0.00 935.80 9,172.18 10/13/2009 637366 341.77 0.00 0.00 0.00 0.00 0.00 0.00 3,402.47 10/13/2009 639374 0.00 0.00 0.00 0.00 3,188.63 1,225.13 4,413.76 43,944.75 10/13/2009 639411 0.00 0.00 0.00 698.85 0.00 0.00 698.85 6,952.94 11/09/2009 645722 341.98 0.00 0.00 0.00 0.00 0.00 0.00 3,404.72 11/09/2009 647629 0.00 0.00 0.00 0.00 3,627.51 1,241.03 4,868.54 48,472.87 11/09/2009 647654 0.00 0.00 0.00 996.55 0.00 0.00 996.55 9,935.68 12/07/2009 654190 349.03 0.00 0.00 0.00 0.00 0.00 0.00 3,474.82 12/07/2009 656134 0.00 0.00 0.00 0.00 3,558.01 1,277.56 4,835.57 48,144.17 12/07/2009 656176 0.00 0.00 0.00 819.45 0.00 0.00 819.45 8,154.18 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 1,664.38 0.00 0.00 4,070.92 14,988.16 5,506.87 24,565.95 263,618.33 CNTRNUM 1,664.38 0.00 0.00 4,070.92 14,988.16 5,506.87 24,565.95 263,618.33 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 2 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL ---------------------------------------------------------- CONTRACT NUM=0200017 NAME=ALLEN CO BD OF DD ---------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/20/2009 613164 1,632.99 0.00 0.00 0.00 0.00 0.00 0.00 17,997.41 07/20/2009 615113 0.00 0.00 0.00 0.00 3,167.77 8,304.98 11,472.75 125,451.52 07/20/2009 615145 0.00 0.00 0.00 5,271.98 0.00 0.00 5,271.98 59,379.94 08/24/2009 623162 1,942.48 0.00 0.00 0.00 0.00 0.00 0.00 19,581.58 08/24/2009 625087 0.00 0.00 0.00 0.00 3,728.82 8,919.84 12,648.66 123,910.35 08/24/2009 625132 0.00 0.00 0.00 5,409.95 0.00 0.00 5,409.95 53,394.10 08/31/2009 627136 0.00 0.00 0.00 0.00 0.00 125.93 125.93 1,233.26 09/08/2009 629141 0.00 0.00 0.00 5,509.79 0.00 0.00 5,509.79 54,697.14 09/28/2009 633384 2,240.84 0.00 0.00 0.00 0.00 0.00 0.00 22,702.47 09/28/2009 635354 0.00 0.00 0.00 0.00 4,619.00 10,497.89 15,116.89 148,091.41 10/13/2009 637367 6,295.23 0.00 0.00 0.00 0.00 0.00 0.00 64,550.14 10/13/2009 639375 0.00 0.00 0.00 0.00 17,299.44 24,032.41 41,331.85 411,354.06 10/13/2009 639412 0.00 0.00 0.00 5,692.44 0.00 0.00 5,692.44 56,784.04 10/19/2009 641656 0.00 0.00 0.00 0.99 0.00 0.00 0.99 10.18 10/26/2009 643671 0.00 0.00 0.00 5,267.74 0.00 0.00 5,267.74 53,353.38 11/16/2009 647715 2,032.22 0.00 0.00 0.00 0.00 0.00 0.00 20,631.13 11/16/2009 650007 0.00 0.00 0.00 0.00 4,775.41 9,820.87 14,596.28 145,122.77 11/30/2009 652102 1,606.07 0.00 0.00 0.00 0.00 0.00 0.00 16,623.49 11/30/2009 654105 0.00 0.00 0.00 0.00 4,284.33 8,651.21 12,935.54 128,612.39 11/30/2009 654149 0.00 0.00 0.00 5,640.59 0.00 0.00 5,640.59 57,567.90 12/07/2009 654191 672.32 0.00 0.00 0.00 0.00 0.00 0.00 7,268.24 12/07/2009 656135 0.00 0.00 0.00 0.00 2,621.28 2,382.39 5,003.67 49,827.57 12/14/2009 658400 0.00 0.00 0.00 0.00 0.00 64.04 64.04 636.59 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 16,422.15 0.00 0.00 32,793.48 40,496.05 72,799.56 146,089.09 1,638,781.06 CNTRNUM 16,422.15 0.00 0.00 32,793.48 40,496.05 72,799.56 146,089.09 1,638,781.06 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 3 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL --------------------------------------------------------- CONTRACT NUM=0300016 NAME=ASHLAND CO BD OF DD --------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/27/2009 617026 0.00 0.00 0.00 0.00 205.93 503.10 709.03 7,747.45 07/27/2009 617063 0.00 0.00 0.00 385.48 0.00 0.00 385.48 4,214.52 08/04/2009 618979 0.00 0.00 0.00 0.00 1,801.69 5,429.40 7,231.09 79,034.83 08/17/2009 623118 0.00 0.00 0.00 0.00 949.83 3,392.15 4,341.98 42,562.66 08/17/2009 623147 0.00 0.00 0.00 1,068.82 0.00 0.00 1,068.82 10,475.22 08/31/2009 627137 0.00 0.00 0.00 0.00 138.82 19.18 158.00 1,548.43 08/31/2009 627178 0.00 0.00 0.00 129.83 0.00 0.00 129.83 1,272.50 09/14/2009 631363 0.00 0.00 0.00 0.00 738.57 2,549.75 3,288.32 32,234.28 09/14/2009 631402 0.00 0.00 0.00 288.84 0.00 0.00 288.84 2,830.04 09/21/2009 633313 0.00 0.00 0.00 0.00 947.57 3,090.93 4,038.50 39,585.50 09/28/2009 635389 0.00 0.00 0.00 87.26 0.00 0.00 87.26 855.12 10/06/2009 637294 0.00 0.00 0.00 0.00 191.83 54.10 245.93 2,448.47 10/06/2009 637335 0.00 0.00 0.00 8.18 0.00 0.00 8.18 81.44 10/26/2009 643637 0.00 0.00 0.00 0.00 881.94 2,932.56 3,814.50 37,968.78 10/26/2009 643672 0.00 0.00 0.00 297.71 0.00 0.00 297.71 2,962.38 11/09/2009 647630 0.00 0.00 0.00 0.00 1,067.75 3,422.16 4,489.91 44,644.72 12/07/2009 656136 0.00 0.00 0.00 0.00 2,733.88 12,701.54 15,435.42 153,642.37 12/14/2009 658401 0.00 0.00 0.00 0.00 562.60 1,705.26 2,267.86 22,573.39 12/14/2009 658424 0.00 0.00 0.00 576.98 0.00 0.00 576.98 5,741.52 12/21/2009 660582 0.00 0.00 0.00 0.00 0.00 598.75 598.75 5,960.93 12/21/2009 660630 0.00 0.00 0.00 8.18 0.00 0.00 8.18 81.44 12/28/2009 662642 0.00 0.00 0.00 0.00 0.00 81.48 81.48 811.02 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 0.00 0.00 0.00 2,851.28 10,220.41 36,480.36 49,552.05 499,277.01 CNTRNUM 0.00 0.00 0.00 2,851.28 10,220.41 36,480.36 49,552.05 499,277.01 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 4 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL -------------------------------------------------------- CONTRACT NUM=0400015 NAME=ASHTABULA CO BD OF DD -------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 609481 0.00 0.00 0.00 0.00 0.00 0.00 0.00 123.25 07/06/2009 611218 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,356.09 07/06/2009 611256 0.00 0.00 0.00 0.00 0.00 0.00 0.00 11,106.38 07/20/2009 613165 71.41 0.00 0.00 0.00 0.00 0.00 0.00 780.40 07/20/2009 615114 0.00 0.00 0.00 0.00 474.88 1,358.59 1,833.47 20,036.77 07/20/2009 615146 0.00 0.00 0.00 5.58 0.00 0.00 5.58 61.08 08/04/2009 618980 0.00 0.00 0.00 0.00 137.22 73.19 210.41 2,299.36 08/04/2009 619016 0.00 0.00 0.00 13.96 0.00 0.00 13.96 152.70 08/10/2009 620916 0.00 0.00 0.00 0.00 224.96 810.60 1,035.56 11,315.80 08/24/2009 623163 306.81 0.00 0.00 0.00 0.00 0.00 0.00 3,008.14 08/24/2009 625088 0.00 0.00 0.00 0.00 820.46 2,450.60 3,271.06 32,080.78 08/24/2009 625133 0.00 0.00 0.00 1,310.86 0.00 0.00 1,310.86 12,979.50 09/08/2009 629111 0.00 0.00 0.00 0.00 163.51 271.84 435.35 4,268.65 09/08/2009 629142 0.00 0.00 0.00 68.56 0.00 0.00 68.56 671.88 09/21/2009 631434 687.58 0.00 0.00 0.00 0.00 0.00 0.00 6,741.31 09/21/2009 633314 0.00 0.00 0.00 0.00 1,164.11 6,469.68 7,633.79 74,859.27 10/06/2009 637295 0.00 0.00 0.00 0.00 83.51 555.40 638.91 6,359.34 10/06/2009 637336 0.00 0.00 0.00 16.37 0.00 0.00 16.37 162.88 10/13/2009 637368 121.52 0.00 0.00 0.00 0.00 0.00 0.00 1,209.62 10/13/2009 639376 0.00 0.00 0.00 0.00 311.64 1,807.12 2,118.76 21,090.31 10/13/2009 639413 0.00 0.00 0.00 2,991.67 0.00 0.00 2,991.67 30,407.66 10/19/2009 639442 54.70 0.00 0.00 0.00 0.00 0.00 0.00 544.28 10/19/2009 641615 0.00 0.00 0.00 0.00 238.69 1,302.38 1,541.07 15,339.28 10/19/2009 641657 0.00 0.00 0.00 182.12 0.00 0.00 182.12 488.64 11/02/2009 643698 284.97 0.00 0.00 0.00 0.00 0.00 0.00 2,834.75 11/02/2009 645651 0.00 0.00 0.00 0.00 355.96 2,420.70 2,776.66 27,629.79 11/02/2009 645687 0.00 0.00 0.00 1,140.62 0.00 0.00 1,140.62 12,246.54 11/23/2009 650055 474.75 0.00 0.00 0.00 0.00 0.00 0.00 4,722.89 11/23/2009 652042 0.00 0.00 0.00 0.00 895.43 6,625.18 7,520.61 74,847.77 11/23/2009 652073 0.00 0.00 0.00 1,089.60 0.00 0.00 1,089.60 11,859.70 11/30/2009 652103 174.83 0.00 0.00 0.00 0.00 0.00 0.00 1,740.09 11/30/2009 654106 0.00 0.00 0.00 0.00 337.12 2,597.78 2,934.90 29,213.49 11/30/2009 654150 0.00 0.00 0.00 63.43 0.00 0.00 63.43 274.86 12/14/2009 656207 443.20 0.00 0.00 0.00 0.00 0.00 0.00 4,410.08 12/14/2009 658402 0.00 0.00 0.00 0.00 439.51 3,691.54 4,131.05 41,113.65 12/14/2009 658425 0.00 0.00 0.00 987.35 0.00 0.00 987.35 12,063.30 12/21/2009 660631 0.00 0.00 0.00 1.02 0.00 0.00 1.02 10.18 12/28/2009 660662 176.40 0.00 0.00 0.00 0.00 0.00 0.00 1,755.90 12/28/2009 662643 0.00 0.00 0.00 0.00 286.16 2,054.08 2,340.24 23,294.94 12/28/2009 662678 0.00 0.00 0.00 1,014.04 0.00 0.00 1,014.04 11,147.10 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 2,796.17 0.00 0.00 8,885.18 5,933.16 32,488.68 47,307.02 516,608.40 CNTRNUM 2,796.17 0.00 0.00 8,885.18 5,933.16 32,488.68 47,307.02 516,608.40 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 5 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL --------------------------------------------------------- CONTRACT NUM=0500014 NAME=ATHENS CO BD OF DD ---------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 611219 0.00 0.00 0.00 0.00 0.00 0.00 0.00 875.52 07/20/2009 615115 0.00 0.00 0.00 0.00 983.54 2,213.82 3,197.36 34,953.36 08/10/2009 620917 0.00 0.00 0.00 0.00 784.53 1,211.02 1,995.55 21,815.73 08/10/2009 620950 0.00 0.00 0.00 11,523.02 0.00 0.00 11,523.02 129,540.50 08/31/2009 627138 0.00 0.00 0.00 0.00 590.19 1,254.87 1,845.06 18,093.18 08/31/2009 627180 0.00 0.00 0.00 1,003.13 0.00 0.00 1,003.13 1,465.92 09/08/2009 627222 91.86 0.00 0.00 0.00 0.00 0.00 0.00 900.79 09/08/2009 629112 0.00 0.00 0.00 0.00 2,397.56 3,718.98 6,116.54 59,971.23 11/02/2009 643699 11.28 0.00 0.00 0.00 0.00 0.00 0.00 112.38 11/02/2009 645652 0.00 0.00 0.00 0.00 958.86 1,471.38 2,430.24 24,192.02 11/09/2009 647655 0.00 0.00 0.00 182.24 0.00 0.00 182.24 758.48 11/23/2009 650056 33.71 0.00 0.00 0.00 0.00 0.00 0.00 335.78 11/23/2009 652043 0.00 0.00 0.00 0.00 639.90 1,115.42 1,755.32 17,475.49 12/07/2009 654192 56.40 0.00 0.00 0.00 0.00 0.00 0.00 561.90 12/07/2009 656137 0.00 0.00 0.00 0.00 1,023.69 2,053.51 3,077.20 30,634.75 12/14/2009 656208 1.74 0.00 0.00 0.00 0.00 0.00 0.00 17.37 12/14/2009 658403 0.00 0.00 0.00 0.00 1.75 24.44 26.19 260.55 12/21/2009 660583 0.00 0.00 0.00 0.00 445.32 788.25 1,233.57 12,272.95 12/28/2009 660663 57.29 0.00 0.00 0.00 0.00 0.00 0.00 570.76 12/28/2009 662644 0.00 0.00 0.00 0.00 489.68 915.42 1,405.10 13,998.50 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 252.28 0.00 0.00 12,708.39 8,315.02 14,767.11 35,790.52 368,807.16 CNTRNUM 252.28 0.00 0.00 12,708.39 8,315.02 14,767.11 35,790.52 368,807.16 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 6 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL -------------------------------------------------------- CONTRACT NUM=0600013 NAME=AUGLAZIE CO BD OF DD --------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 609482 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,494.33 07/06/2009 611220 0.00 0.00 0.00 0.00 0.00 0.00 0.00 554.48 07/06/2009 611258 0.00 0.00 0.00 0.00 0.00 0.00 0.00 6,281.06 07/27/2009 617064 0.00 0.00 0.00 201.15 0.00 0.00 201.15 2,198.88 08/04/2009 617087 98.00 0.00 0.00 0.00 0.00 0.00 0.00 1,070.72 08/04/2009 618981 0.00 0.00 0.00 0.00 210.00 1,786.75 1,996.75 21,815.92 08/04/2009 619017 0.00 0.00 0.00 125.69 0.00 0.00 125.69 1,374.30 08/10/2009 620951 0.00 0.00 0.00 71.69 0.00 0.00 71.69 234.14 08/24/2009 623164 294.44 0.00 0.00 0.00 0.00 0.00 0.00 2,884.74 08/24/2009 625089 0.00 0.00 0.00 0.00 144.38 3,985.51 4,129.89 40,477.22 08/24/2009 625134 0.00 0.00 0.00 892.45 0.00 0.00 892.45 8,744.62 08/31/2009 625164 175.37 0.00 0.00 0.00 0.00 0.00 0.00 1,718.53 08/31/2009 627139 0.00 0.00 0.00 0.00 29.25 9.75 39.00 382.40 08/31/2009 627181 0.00 0.00 0.00 478.77 0.00 0.00 478.77 834.76 09/14/2009 631403 0.00 0.00 0.00 969.17 0.00 0.00 969.17 9,548.84 09/21/2009 631435 150.15 0.00 0.00 0.00 0.00 0.00 0.00 1,472.24 09/21/2009 633315 0.00 0.00 0.00 0.00 881.40 1,842.75 2,724.15 26,710.64 09/21/2009 633351 0.00 0.00 0.00 462.52 0.00 0.00 462.52 1,730.60 10/06/2009 637296 0.00 0.00 0.00 0.00 0.00 3.84 3.84 38.24 10/06/2009 637337 0.00 0.00 0.00 394.85 0.00 0.00 394.85 3,929.48 10/13/2009 637369 404.91 0.00 0.00 0.00 0.00 0.00 0.00 4,029.11 10/13/2009 639377 0.00 0.00 0.00 0.00 1,251.15 3,276.79 4,527.94 45,066.97 10/13/2009 639414 0.00 0.00 0.00 1,165.41 0.00 0.00 1,165.41 11,595.02 10/19/2009 639443 780.03 0.00 0.00 0.00 0.00 0.00 0.00 7,761.22 10/19/2009 641616 0.00 0.00 0.00 0.00 1,431.30 3,278.49 4,709.79 46,875.57 10/19/2009 641658 0.00 0.00 0.00 585.47 0.00 0.00 585.47 3,349.22 10/26/2009 641707 148.99 0.00 0.00 0.00 0.00 0.00 0.00 1,482.53 10/26/2009 643638 0.00 0.00 0.00 0.00 0.00 142.11 142.11 1,414.16 10/26/2009 643673 0.00 0.00 0.00 1,131.68 0.00 0.00 1,131.68 11,259.08 11/02/2009 645688 0.00 0.00 0.00 12.29 0.00 0.00 12.29 122.16 11/16/2009 650033 0.00 0.00 0.00 204.55 0.00 0.00 204.55 1,985.10 11/23/2009 652074 0.00 0.00 0.00 1.02 0.00 0.00 1.02 10.18 11/30/2009 652104 384.33 0.00 0.00 0.00 0.00 0.00 0.00 3,826.31 11/30/2009 654107 0.00 0.00 0.00 0.00 1,773.13 4,086.35 5,859.48 58,336.95 11/30/2009 654151 0.00 0.00 0.00 2,655.92 0.00 0.00 2,655.92 25,867.38 12/14/2009 658426 0.00 0.00 0.00 2.05 0.00 0.00 2.05 111.98 12/21/2009 658450 1,053.35 0.00 0.00 0.00 0.00 0.00 0.00 10,478.21 12/21/2009 660584 0.00 0.00 0.00 0.00 1,071.03 3,808.39 4,879.42 48,541.91 12/21/2009 660632 0.00 0.00 0.00 2.05 0.00 0.00 2.05 20.36 12/28/2009 660664 206.31 0.00 0.00 0.00 0.00 0.00 0.00 2,052.56 12/28/2009 662645 0.00 0.00 0.00 0.00 40.53 99.50 140.03 1,392.78 12/28/2009 662679 0.00 0.00 0.00 1,223.59 0.00 0.00 1,223.59 12,012.40 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 3,695.88 0.00 0.00 10,580.32 6,832.17 22,320.23 39,732.72 431,087.30 CNTRNUM 3,695.88 0.00 0.00 10,580.32 6,832.17 22,320.23 39,732.72 431,087.30 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 7 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL --------------------------------------------------------- CONTRACT NUM=0700012 NAME=BELMONT CO BD OF DD --------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 609551 0.00 0.00 0.00 0.00 0.00 0.00 0.00 655.55 07/06/2009 611221 0.00 0.00 0.00 0.00 0.00 0.00 0.00 22,195.05 07/06/2009 611259 0.00 0.00 0.00 0.00 0.00 0.00 0.00 11,849.52 07/20/2009 615116 0.00 0.00 0.00 0.00 44.59 34.30 78.89 861.58 07/27/2009 617027 0.00 0.00 0.00 0.00 78.82 24.00 102.82 1,123.80 08/04/2009 617147 0.00 0.00 0.00 0.00 0.00 66.84 66.84 280.95 08/04/2009 618982 0.00 0.00 0.00 0.00 17.15 0.00 17.15 93.65 08/10/2009 620918 0.00 0.00 0.00 0.00 1,116.27 836.68 1,952.95 21,333.47 08/10/2009 620952 0.00 0.00 0.00 1,329.63 0.00 0.00 1,329.63 14,537.04 08/17/2009 623148 0.00 0.00 0.00 436.34 0.00 0.00 436.34 4,581.00 08/24/2009 625090 0.00 0.00 0.00 0.00 91.68 17.19 108.87 1,067.61 08/24/2009 625135 0.00 0.00 0.00 55.08 0.00 0.00 55.08 539.54 08/31/2009 625233 0.00 0.00 0.00 0.00 0.00 148.98 148.98 693.01 08/31/2009 627140 0.00 0.00 0.00 0.00 82.13 0.00 82.13 412.06 08/31/2009 627182 0.00 0.00 0.00 70.58 0.00 0.00 70.58 478.46 09/14/2009 631364 0.00 0.00 0.00 0.00 36.29 3.82 40.11 393.33 09/14/2009 631404 0.00 0.00 0.00 246.25 0.00 0.00 246.25 2,412.66 09/21/2009 631501 0.00 0.00 0.00 0.00 0.00 7.64 7.64 37.46 09/28/2009 635390 0.00 0.00 0.00 2,143.30 0.00 0.00 2,143.30 21,001.34 10/13/2009 637370 56.40 0.00 0.00 0.00 0.00 0.00 0.00 561.90 10/13/2009 639378 0.00 0.00 0.00 0.00 1,233.28 994.67 2,227.95 22,195.05 10/19/2009 639444 71.44 0.00 0.00 0.00 0.00 0.00 0.00 711.74 10/19/2009 641617 0.00 0.00 0.00 0.00 1,571.77 898.82 2,470.59 24,611.22 10/26/2009 643674 0.00 0.00 0.00 1,233.57 0.00 0.00 1,233.57 12,277.08 11/02/2009 645689 0.00 0.00 0.00 10.32 0.00 0.00 10.32 50.90 11/09/2009 647656 0.00 0.00 0.00 4,644.96 0.00 0.00 4,644.96 1,905.08 11/16/2009 647716 73.32 0.00 0.00 0.00 0.00 0.00 0.00 730.47 11/16/2009 650008 0.00 0.00 0.00 0.00 1,962.73 1,005.97 2,968.70 29,574.67 11/16/2009 650034 0.00 0.00 0.00 1,423.79 0.00 0.00 1,423.79 14,241.82 11/23/2009 652044 0.00 0.00 0.00 0.00 35.72 31.96 67.68 674.28 11/23/2009 652075 0.00 0.00 0.00 1,376.92 0.00 0.00 1,376.92 13,702.28 11/30/2009 652105 58.28 0.00 0.00 0.00 0.00 0.00 0.00 580.63 11/30/2009 654108 0.00 0.00 0.00 0.00 1,312.25 926.88 2,239.13 22,363.62 11/30/2009 654152 0.00 0.00 0.00 16.19 0.00 0.00 16.19 122.16 12/21/2009 660585 0.00 0.00 0.00 0.00 95.89 26.32 122.21 1,217.45 12/21/2009 660633 0.00 0.00 0.00 614.67 0.00 0.00 614.67 6,118.18 12/28/2009 660665 69.56 0.00 0.00 0.00 0.00 0.00 0.00 693.01 12/28/2009 662646 0.00 0.00 0.00 0.00 1,494.60 810.29 2,304.89 22,962.98 12/28/2009 662680 0.00 0.00 0.00 99.21 0.00 0.00 99.21 875.48 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 329.00 0.00 0.00 13,700.81 9,173.17 5,834.36 28,708.34 280,717.08 CNTRNUM 329.00 0.00 0.00 13,700.81 9,173.17 5,834.36 28,708.34 280,717.08 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 8 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL ---------------------------------------------------------- CONTRACT NUM=0800011 NAME=BROWN CO BD OF DD ---------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 609483 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,759.37 07/06/2009 611222 0.00 0.00 0.00 0.00 0.00 0.00 0.00 54,267.42 07/06/2009 611260 0.00 0.00 0.00 0.00 0.00 0.00 0.00 12,114.20 07/13/2009 613118 0.00 0.00 0.00 0.00 0.00 0.00 0.00 650.08 07/13/2009 613142 0.00 0.00 0.00 0.00 0.00 0.00 0.00 101.80 07/20/2009 615117 0.00 0.00 0.00 0.00 17.50 0.00 17.50 95.60 07/27/2009 615179 78.75 0.00 0.00 0.00 0.00 0.00 0.00 860.40 07/27/2009 617028 0.00 0.00 0.00 0.00 619.50 2,135.00 2,754.50 30,094.88 08/04/2009 617088 125.46 0.00 0.00 0.00 0.00 0.00 0.00 1,371.37 08/04/2009 618983 0.00 0.00 0.00 0.00 492.65 1,914.32 2,406.97 26,299.46 08/04/2009 619018 0.00 0.00 0.00 1,770.38 0.00 0.00 1,770.38 19,342.00 08/10/2009 620919 0.00 0.00 0.00 0.00 174.73 0.00 174.73 1,911.07 08/17/2009 620976 141.14 0.00 0.00 0.00 0.00 0.00 0.00 1,382.99 08/17/2009 623119 0.00 0.00 0.00 0.00 143.19 1,114.32 1,257.51 12,318.11 08/24/2009 625136 0.00 0.00 0.00 949.32 0.00 0.00 949.32 9,304.52 08/31/2009 625165 360.61 0.00 0.00 0.00 0.00 0.00 0.00 3,532.34 08/31/2009 627141 0.00 0.00 0.00 0.00 753.95 3,279.82 4,033.77 39,514.58 08/31/2009 627183 0.00 0.00 0.00 89.33 0.00 0.00 89.33 875.48 09/08/2009 629144 0.00 0.00 0.00 7.27 0.00 0.00 7.27 50.90 09/14/2009 629174 607.50 0.00 0.00 0.00 0.00 0.00 0.00 5,953.34 09/14/2009 631365 0.00 0.00 0.00 0.00 1,376.04 5,914.56 7,290.60 71,444.63 09/21/2009 633352 0.00 0.00 0.00 190.05 0.00 0.00 190.05 692.24 09/28/2009 635391 0.00 0.00 0.00 1,403.35 0.00 0.00 1,403.35 13,753.18 10/06/2009 637297 0.00 0.00 0.00 0.00 176.64 34.95 211.59 2,107.02 10/06/2009 637338 0.00 0.00 0.00 245.54 0.00 0.00 245.54 2,443.20 10/13/2009 637455 0.00 0.00 0.00 0.00 0.00 29.25 29.25 114.72 10/19/2009 639445 247.68 0.00 0.00 0.00 0.00 0.00 0.00 2,466.48 10/19/2009 641618 0.00 0.00 0.00 0.00 689.28 2,340.48 3,029.76 30,171.36 10/19/2009 641659 0.00 0.00 0.00 1,639.02 0.00 0.00 1,639.02 15,585.58 11/02/2009 643700 1,348.99 0.00 0.00 0.00 0.00 0.00 0.00 13,422.20 11/02/2009 645653 0.00 0.00 0.00 0.00 1,982.93 9,869.82 11,852.75 117,882.95 11/02/2009 645690 0.00 0.00 0.00 41.92 0.00 0.00 41.92 417.38 11/09/2009 647657 0.00 0.00 0.00 3,550.06 0.00 0.00 3,550.06 4,860.33 11/16/2009 650035 0.00 0.00 0.00 1,439.50 0.00 0.00 1,439.50 14,323.26 11/23/2009 652076 0.00 0.00 0.00 777.62 0.00 0.00 777.62 7,736.80 11/30/2009 654153 0.00 0.00 0.00 28.45 0.00 0.00 28.45 285.04 12/07/2009 654193 748.43 0.00 0.00 0.00 0.00 0.00 0.00 7,446.27 12/07/2009 656138 0.00 0.00 0.00 0.00 1,483.14 5,925.41 7,408.55 73,710.39 12/14/2009 658427 0.00 0.00 0.00 1,610.38 0.00 0.00 1,610.38 16,125.12 12/28/2009 660666 42.75 0.00 0.00 0.00 0.00 0.00 0.00 425.04 12/28/2009 662647 0.00 0.00 0.00 0.00 159.55 632.08 791.63 7,870.15 12/28/2009 662681 0.00 0.00 0.00 1,734.09 0.00 0.00 1,734.09 17,295.82 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 3,701.31 0.00 0.00 15,476.28 8,069.10 33,190.01 56,735.39 642,379.07 CNTRNUM 3,701.31 0.00 0.00 15,476.28 8,069.10 33,190.01 56,735.39 642,379.07 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 9 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL --------------------------------------------------------- CONTRACT NUM=0900010 NAME=BUTLER CO BD OF DD ---------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/13/2009 613143 0.00 0.00 0.00 0.00 0.00 0.00 0.00 137,877.92 07/20/2009 613166 132.12 0.00 135.98 0.00 0.00 0.00 0.00 10,636.35 07/20/2009 615118 0.00 0.00 0.00 0.00 4,402.06 10,687.36 15,089.42 164,945.54 07/20/2009 615149 0.00 0.00 0.00 399.55 0.00 0.00 399.55 2,025.82 08/10/2009 620953 0.00 0.00 0.00 13,329.51 0.00 0.00 13,329.51 149,432.22 08/17/2009 623120 0.00 0.00 0.00 0.00 405.67 292.68 698.35 6,851.10 08/24/2009 623165 121.05 0.00 415.88 0.00 0.00 0.00 0.00 17,078.84 08/24/2009 625091 0.00 0.00 0.00 0.00 4,661.32 10,783.63 15,444.95 151,464.42 08/31/2009 627184 0.00 0.00 0.00 14,986.38 0.00 0.00 14,986.38 145,767.42 09/08/2009 627223 239.54 0.00 335.22 0.00 0.00 0.00 0.00 19,325.60 09/08/2009 629114 0.00 0.00 0.00 0.00 9,834.45 13,473.75 23,308.20 228,487.90 09/08/2009 629145 0.00 0.00 0.00 287.06 0.00 0.00 287.06 926.38 09/14/2009 629175 268.58 0.00 670.72 0.00 0.00 0.00 0.00 23,545.12 09/14/2009 631366 0.00 0.00 0.00 0.00 4,762.75 11,555.47 16,318.22 160,026.16 09/28/2009 635392 0.00 0.00 0.00 12,959.30 0.00 0.00 12,959.30 128,023.68 10/13/2009 637371 547.05 0.00 526.90 0.00 0.00 0.00 0.00 28,798.10 10/13/2009 639379 0.00 0.00 0.00 0.00 5,085.75 11,512.86 16,598.61 165,020.02 10/19/2009 641660 0.00 0.00 0.00 84.78 0.00 0.00 84.78 814.40 11/02/2009 645691 0.00 0.00 0.00 15,044.57 0.00 0.00 15,044.57 157,362.44 11/09/2009 645723 500.00 0.00 292.00 0.00 0.00 0.00 0.00 21,070.00 11/09/2009 647631 0.00 0.00 0.00 0.00 6,919.81 9,098.31 16,018.12 159,377.21 11/16/2009 650036 0.00 0.00 0.00 36.82 0.00 0.00 36.82 -30.54 12/07/2009 656177 0.00 0.00 0.00 12,693.04 0.00 0.00 12,693.04 131,545.96 12/14/2009 656209 902.98 0.00 1,040.10 0.00 0.00 0.00 0.00 51,001.56 12/14/2009 658404 0.00 0.00 0.00 0.00 9,858.88 21,928.60 31,787.48 316,300.98 12/21/2009 658451 350.00 0.00 298.00 0.00 0.00 0.00 0.00 19,707.70 12/21/2009 660586 0.00 0.00 0.00 0.00 6,536.31 8,894.93 15,431.24 153,536.85 12/28/2009 660667 516.05 0.00 547.15 0.00 0.00 0.00 0.00 25,542.52 12/28/2009 662648 0.00 0.00 0.00 0.00 5,233.86 11,552.76 16,786.62 167,036.08 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 3,577.37 0.00 4,261.95 69,821.01 57,700.86 109,780.35 237,302.22 2,743,497.75 CNTRNUM 3,577.37 0.00 4,261.95 69,821.01 57,700.86 109,780.35 237,302.22 2,743,497.75 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 10 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL --------------------------------------------------------- CONTRACT NUM=1000017 NAME=CARROLL CO BD OF DD --------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/20/2009 613167 37.42 0.00 0.00 0.00 0.00 0.00 0.00 408.63 07/20/2009 615119 0.00 0.00 0.00 0.00 388.33 1,943.72 2,332.05 25,475.61 10/26/2009 641708 151.62 0.00 0.00 0.00 0.00 0.00 0.00 1,510.50 10/26/2009 643639 0.00 0.00 0.00 0.00 1,509.03 6,890.25 8,399.28 83,617.55 10/26/2009 643675 0.00 0.00 0.00 5,036.69 0.00 0.00 5,036.69 50,116.14 11/02/2009 645692 0.00 0.00 0.00 206.70 0.00 0.00 206.70 875.48 11/09/2009 647658 0.00 0.00 0.00 644.84 0.00 0.00 644.84 2,355.89 11/30/2009 652106 224.20 0.00 0.00 0.00 0.00 0.00 0.00 2,233.74 11/30/2009 654109 0.00 0.00 0.00 0.00 1,768.90 7,233.30 9,002.20 89,690.34 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 413.24 0.00 0.00 5,888.23 3,666.26 16,067.27 25,621.76 256,283.88 CNTRNUM 413.24 0.00 0.00 5,888.23 3,666.26 16,067.27 25,621.76 256,283.88 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 11 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL -------------------------------------------------------- CONTRACT NUM=1100016 NAME=CHAMPAIGN CO BD OF DD -------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 611261 0.00 0.00 0.00 0.00 0.00 0.00 0.00 12,928.60 07/20/2009 615120 0.00 0.00 0.00 0.00 199.30 0.00 199.30 1,963.81 07/20/2009 615150 0.00 0.00 0.00 5.58 0.00 0.00 5.58 61.08 07/27/2009 615286 0.00 0.00 0.00 0.00 0.00 32.13 32.13 95.41 08/04/2009 617089 305.29 0.00 0.00 0.00 0.00 3.57 3.57 3,355.72 08/04/2009 618984 0.00 0.00 0.00 0.00 3,239.96 2,488.85 5,728.81 62,501.25 08/04/2009 619019 0.00 0.00 0.00 1,008.45 0.00 0.00 1,008.45 11,330.34 08/10/2009 620920 0.00 0.00 0.00 0.00 342.80 175.00 517.80 5,657.90 08/17/2009 623121 0.00 0.00 0.00 0.00 129.35 0.00 129.35 1,268.15 08/17/2009 623149 0.00 0.00 0.00 761.46 0.00 0.00 761.46 7,553.56 08/24/2009 623294 0.00 0.00 0.00 0.00 0.00 11.94 11.94 58.53 08/31/2009 627142 0.00 0.00 0.00 0.00 11.94 0.00 11.94 58.53 09/08/2009 627224 223.37 0.00 0.00 0.00 0.00 0.00 0.00 2,190.18 09/08/2009 629115 0.00 0.00 0.00 0.00 3,754.68 3,571.26 7,325.94 71,837.48 09/08/2009 629146 0.00 0.00 0.00 3.12 0.00 0.00 3.12 30.54 09/14/2009 629176 137.81 0.00 0.00 0.00 0.00 0.00 0.00 1,351.36 09/14/2009 631367 0.00 0.00 0.00 0.00 2,365.72 2,679.86 5,045.58 49,477.50 09/14/2009 631405 0.00 0.00 0.00 577.48 0.00 0.00 577.48 5,670.26 09/21/2009 631437 89.55 0.00 0.00 0.00 0.00 0.00 0.00 877.95 09/21/2009 633317 0.00 0.00 0.00 0.00 799.98 746.25 1,546.23 15,159.27 09/28/2009 635393 0.00 0.00 0.00 1,536.21 0.00 0.00 1,536.21 15,056.22 10/06/2009 637298 0.00 0.00 0.00 0.00 342.72 0.00 342.72 3,409.82 10/06/2009 637339 0.00 0.00 0.00 16.36 0.00 0.00 16.36 162.88 10/13/2009 637372 149.64 0.00 0.00 0.00 0.00 0.00 0.00 1,489.12 10/13/2009 639380 0.00 0.00 0.00 0.00 2,636.09 3,126.86 5,762.95 57,339.40 10/13/2009 639415 0.00 0.00 0.00 1,099.84 0.00 0.00 1,099.84 10,943.50 10/19/2009 639446 6.22 0.00 0.00 0.00 0.00 0.00 0.00 61.94 10/19/2009 641619 0.00 0.00 0.00 0.00 192.50 119.73 312.23 3,106.51 10/19/2009 641661 0.00 0.00 0.00 3.07 0.00 0.00 3.07 10.18 10/26/2009 641709 2.97 0.00 0.00 0.00 0.00 0.00 0.00 29.52 10/26/2009 643640 0.00 0.00 0.00 0.00 262.59 113.11 375.70 3,738.58 10/26/2009 643676 0.00 0.00 0.00 690.60 0.00 0.00 690.60 6,871.50 11/09/2009 645724 261.14 0.00 0.00 0.00 0.00 0.00 0.00 2,598.98 11/09/2009 647632 0.00 0.00 0.00 0.00 4,021.82 3,750.65 7,772.47 75,427.44 11/09/2009 647659 0.00 0.00 0.00 3,656.54 0.00 0.00 3,656.54 1,595.73 11/23/2009 650057 553.98 0.00 0.00 0.00 0.00 0.00 0.00 5,513.63 11/23/2009 652045 0.00 0.00 0.00 0.00 8,681.87 7,803.05 16,484.92 164,041.75 11/23/2009 652077 0.00 0.00 0.00 1,831.41 0.00 0.00 1,831.41 18,680.30 11/30/2009 654110 0.00 0.00 0.00 0.00 128.77 65.91 194.68 1,930.61 11/30/2009 654154 0.00 0.00 0.00 4.08 0.00 0.00 4.08 40.72 12/07/2009 656178 0.00 0.00 0.00 506.50 0.00 0.00 506.50 5,303.78 12/14/2009 658428 0.00 0.00 0.00 7.16 0.00 0.00 7.16 81.44 12/21/2009 658452 154.84 0.00 0.00 0.00 0.00 0.00 0.00 1,541.29 12/21/2009 660587 0.00 0.00 0.00 0.00 1,401.40 962.36 2,363.76 23,470.53 12/21/2009 660634 0.00 0.00 0.00 62.40 0.00 0.00 62.40 620.98 12/28/2009 662649 0.00 0.00 0.00 0.00 14.67 0.00 14.67 145.96 12/28/2009 662682 0.00 0.00 0.00 1,337.19 0.00 0.00 1,337.19 13,529.22 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 1,884.81 0.00 0.00 13,107.45 28,526.16 25,650.53 67,284.14 670,168.95 CNTRNUM 1,884.81 0.00 0.00 13,107.45 28,526.16 25,650.53 67,284.14 670,168.95 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 12 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL ---------------------------------------------------------- CONTRACT NUM=1200015 NAME=CLARK CO BD OF DD ---------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 609484 0.00 0.00 0.00 0.00 0.00 0.00 0.00 10,365.53 07/06/2009 611223 0.00 0.00 0.00 0.00 0.00 0.00 0.00 216,048.14 07/06/2009 611262 0.00 0.00 0.00 0.00 0.00 0.00 0.00 48,914.90 07/13/2009 611296 0.00 0.00 0.00 0.00 0.00 0.00 0.00 14,465.24 07/13/2009 613119 0.00 0.00 0.00 0.00 0.00 0.00 0.00 81,141.69 07/27/2009 615302 0.00 0.00 0.00 0.00 0.00 0.00 0.00 -888.00 08/04/2009 617090 89.34 0.00 0.00 0.00 0.00 0.00 0.00 6,028.59 08/04/2009 618985 0.00 0.00 0.00 0.00 3,781.55 5,525.88 9,307.43 101,705.63 08/10/2009 619053 776.22 0.00 0.00 0.00 0.00 0.00 0.00 20,979.05 08/10/2009 620921 0.00 0.00 0.00 0.00 7,193.16 11,116.28 18,309.44 200,144.13 08/10/2009 620954 0.00 0.00 0.00 3,501.35 0.00 0.00 3,501.35 40,557.12 08/17/2009 620977 78.25 0.00 0.00 0.00 0.00 0.00 0.00 1,784.17 08/17/2009 623122 0.00 0.00 0.00 0.00 1,349.97 2,423.30 3,773.27 37,001.07 09/08/2009 629147 0.00 0.00 0.00 5,274.24 0.00 0.00 5,274.24 54,076.16 09/28/2009 633385 1,921.37 0.00 0.00 0.00 0.00 0.00 0.00 29,490.09 09/28/2009 635355 0.00 0.00 0.00 0.00 11,259.56 16,250.98 27,510.54 269,721.89 10/13/2009 639416 0.00 0.00 0.00 4,301.08 0.00 0.00 4,301.08 45,586.04 10/19/2009 639447 156.56 0.00 0.00 0.00 0.00 0.00 0.00 2,542.00 10/19/2009 641620 0.00 0.00 0.00 0.00 2,939.81 4,083.33 7,023.14 69,897.99 10/19/2009 641662 0.00 0.00 0.00 96.88 0.00 0.00 96.88 946.74 10/26/2009 641710 2,409.24 0.00 0.00 0.00 0.00 0.00 0.00 50,113.44 10/26/2009 643641 0.00 0.00 0.00 0.00 14,731.78 22,607.11 37,338.89 371,610.68 11/09/2009 647660 0.00 0.00 0.00 89.01 0.00 0.00 89.01 193.42 11/16/2009 650037 0.00 0.00 0.00 3,409.83 0.00 0.00 3,409.83 36,963.58 11/23/2009 650058 2,131.12 0.00 0.00 0.00 0.00 0.00 0.00 68,792.62 11/23/2009 652046 0.00 0.00 0.00 0.00 9,501.80 16,927.49 26,429.29 263,020.78 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 7,562.10 0.00 0.00 16,672.39 50,757.63 78,934.37 146,364.39 2,041,202.69 CNTRNUM 7,562.10 0.00 0.00 16,672.39 50,757.63 78,934.37 146,364.39 2,041,202.69 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 13 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL -------------------------------------------------------- CONTRACT NUM=1300014 NAME=CLERMONT CO BD OF DD --------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/13/2009 611297 0.00 0.00 0.00 0.00 0.00 0.00 0.00 5,861.00 07/13/2009 613120 0.00 0.00 0.00 0.00 0.00 0.00 0.00 90,452.48 07/13/2009 613144 0.00 0.00 0.00 0.00 0.00 0.00 0.00 18,863.54 08/10/2009 619054 591.37 0.00 0.00 0.00 0.00 0.00 0.00 6,461.10 08/10/2009 620922 0.00 0.00 0.00 0.00 2,615.49 5,765.49 8,380.98 91,532.89 08/24/2009 625137 0.00 0.00 0.00 1,873.04 0.00 0.00 1,873.04 18,354.54 09/14/2009 629177 643.26 0.00 0.00 0.00 0.00 0.00 0.00 6,309.65 09/14/2009 631368 0.00 0.00 0.00 0.00 2,937.73 6,359.90 9,297.63 91,171.26 09/14/2009 631406 0.00 0.00 0.00 1,806.46 0.00 0.00 1,806.46 17,835.36 09/21/2009 633353 0.00 0.00 0.00 1.04 0.00 0.00 1.04 10.18 09/28/2009 633386 8.25 0.00 0.00 0.00 0.00 0.00 0.00 80.90 09/28/2009 635356 0.00 0.00 0.00 0.00 0.00 20.52 20.52 201.20 10/13/2009 637373 571.15 0.00 0.00 0.00 0.00 0.00 0.00 5,684.40 10/13/2009 639381 0.00 0.00 0.00 0.00 2,981.27 6,556.16 9,537.43 94,909.21 10/19/2009 641663 0.00 0.00 0.00 1,765.85 0.00 0.00 1,765.85 17,570.68 11/09/2009 645725 633.96 0.00 0.00 0.00 0.00 0.00 0.00 6,309.65 11/09/2009 647633 0.00 0.00 0.00 0.00 3,465.35 5,931.43 9,396.78 93,511.57 11/09/2009 647661 0.00 0.00 0.00 394.58 0.00 0.00 394.58 1,872.58 11/16/2009 650038 0.00 0.00 0.00 2,015.33 0.00 0.00 2,015.33 20,054.60 12/07/2009 654194 678.66 0.00 0.00 0.00 0.00 0.00 0.00 6,754.56 12/07/2009 656139 0.00 0.00 0.00 0.00 3,356.44 5,776.68 9,133.12 90,887.61 12/14/2009 656210 91.53 0.00 0.00 0.00 0.00 0.00 0.00 910.90 12/14/2009 658429 0.00 0.00 0.00 1,712.70 0.00 0.00 1,712.70 17,041.32 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 3,218.18 0.00 0.00 9,569.00 15,356.28 30,410.18 55,335.46 702,641.18 CNTRNUM 3,218.18 0.00 0.00 9,569.00 15,356.28 30,410.18 55,335.46 702,641.18 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 14 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL --------------------------------------------------------- CONTRACT NUM=1400013 NAME=CLINTON CO BD OF DD --------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 611224 0.00 0.00 0.00 0.00 0.00 0.00 0.00 3,105.19 07/20/2009 613168 196.00 0.00 0.00 0.00 0.00 10.50 10.50 2,179.68 07/20/2009 615121 0.00 0.00 0.00 0.00 497.00 1,232.00 1,729.00 18,737.60 07/20/2009 615151 0.00 0.00 0.00 1,397.83 0.00 0.00 1,397.83 15,361.62 07/27/2009 615360 0.00 0.00 0.00 0.00 0.00 28.00 28.00 95.60 08/04/2009 617091 512.46 0.00 0.00 0.00 0.00 0.00 0.00 5,599.92 08/04/2009 618986 0.00 0.00 0.00 0.00 897.82 2,318.36 3,216.18 35,152.69 08/17/2009 623123 0.00 0.00 0.00 0.00 0.00 70.20 70.20 688.32 08/17/2009 623150 0.00 0.00 0.00 1,779.17 0.00 0.00 1,779.17 17,438.34 08/31/2009 625166 14.93 0.00 0.00 0.00 0.00 7.80 7.80 184.75 08/31/2009 627143 0.00 0.00 0.00 0.00 90.96 46.17 137.13 1,248.63 08/31/2009 627185 0.00 0.00 0.00 29.72 0.00 0.00 29.72 285.04 09/08/2009 627403 0.00 0.00 0.00 0.00 0.00 48.75 48.75 100.69 09/14/2009 629178 718.95 0.00 0.00 0.00 0.00 0.00 0.00 7,046.89 09/14/2009 631369 0.00 0.00 0.00 0.00 1,200.67 3,255.15 4,455.82 43,669.69 09/14/2009 631407 0.00 0.00 0.00 1,797.73 0.00 0.00 1,797.73 17,682.66 09/21/2009 631438 576.64 0.00 0.00 0.00 0.00 0.00 0.00 5,650.48 09/21/2009 633318 0.00 0.00 0.00 0.00 450.18 1,639.94 2,090.12 20,477.14 09/28/2009 633387 278.85 0.00 0.00 0.00 0.00 0.00 0.00 2,734.16 09/28/2009 635357 0.00 0.00 0.00 0.00 376.35 1,029.60 1,405.95 13,785.52 09/28/2009 635394 0.00 0.00 0.00 1,619.28 0.00 0.00 1,619.28 15,870.62 10/06/2009 637299 0.00 0.00 0.00 0.00 17.28 14.75 32.03 318.73 10/06/2009 637340 0.00 0.00 0.00 117.65 0.00 0.00 117.65 1,170.70 10/13/2009 639417 0.00 0.00 0.00 225.08 0.00 0.00 225.08 2,239.60 10/19/2009 639448 635.44 0.00 0.00 0.00 0.00 0.00 0.00 6,319.53 10/19/2009 641621 0.00 0.00 0.00 0.00 376.78 1,756.28 2,133.06 21,210.55 10/19/2009 641664 0.00 0.00 0.00 1,670.57 0.00 0.00 1,670.57 16,308.36 10/26/2009 641711 299.52 0.00 0.00 0.00 0.00 0.00 0.00 2,982.72 10/26/2009 643642 0.00 0.00 0.00 0.00 311.04 1,242.18 1,553.22 15,465.94 11/02/2009 643701 889.00 0.00 0.00 0.00 0.00 15.36 15.36 8,692.21 11/02/2009 645654 0.00 0.00 0.00 0.00 588.97 2,701.82 3,290.79 32,629.36 11/09/2009 647662 0.00 0.00 0.00 159.63 0.00 0.00 159.63 773.68 11/16/2009 650039 0.00 0.00 0.00 2,843.58 0.00 0.00 2,843.58 28,218.96 11/23/2009 652047 0.00 0.00 0.00 0.00 55.58 0.00 55.58 552.94 11/23/2009 652078 0.00 0.00 0.00 22.52 0.00 0.00 22.52 223.96 11/30/2009 652107 621.49 0.00 0.00 0.00 0.00 0.00 0.00 6,180.75 11/30/2009 654111 0.00 0.00 0.00 0.00 379.00 1,658.43 2,037.43 20,260.02 11/30/2009 654155 0.00 0.00 0.00 26.51 0.00 0.00 26.51 142.52 12/21/2009 658453 297.64 0.00 0.00 0.00 0.00 0.00 0.00 2,963.60 12/21/2009 660588 0.00 0.00 0.00 0.00 328.33 1,071.42 1,399.75 13,938.48 12/21/2009 660635 0.00 0.00 0.00 80.83 0.00 0.00 80.83 804.22 12/28/2009 662650 0.00 0.00 0.00 0.00 0.00 110.80 110.80 1,102.00 12/28/2009 662683 0.00 0.00 0.00 63.97 0.00 0.00 63.97 356.30 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 5,040.92 0.00 0.00 11,834.07 5,569.96 18,257.51 35,661.54 409,950.36 CNTRNUM 5,040.92 0.00 0.00 11,834.07 5,569.96 18,257.51 35,661.54 409,950.36 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 15 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL ------------------------------------------------------- CONTRACT NUM=1500012 NAME=COLUMBIANA CO BD OF DD -------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/20/2009 613169 2,047.11 0.00 0.00 0.00 0.00 0.00 0.00 26,232.82 07/20/2009 613365 0.00 0.00 0.00 0.00 0.00 3.50 3.50 19.12 07/20/2009 615122 0.00 0.00 0.00 0.00 8,244.32 7,235.73 15,480.05 169,207.91 07/20/2009 615152 0.00 0.00 0.00 972.00 0.00 0.00 972.00 10,658.46 07/27/2009 615180 65.65 0.00 0.00 0.00 0.00 0.00 0.00 718.06 07/27/2009 617029 0.00 0.00 0.00 0.00 622.52 475.53 1,098.05 11,997.99 08/04/2009 618987 0.00 0.00 0.00 0.00 154.00 41.22 195.22 2,133.36 08/04/2009 619020 0.00 0.00 0.00 186.21 0.00 0.00 186.21 2,412.66 08/10/2009 620923 0.00 0.00 0.00 0.00 21.00 0.00 21.00 229.44 08/24/2009 623166 1,178.96 0.00 0.00 0.00 0.00 0.00 0.00 11,551.24 08/24/2009 625092 0.00 0.00 0.00 0.00 3,063.34 3,367.72 6,431.06 63,000.32 08/24/2009 625138 0.00 0.00 0.00 61.29 0.00 0.00 61.29 600.62 08/31/2009 625167 611.33 0.00 0.00 0.00 0.00 0.00 0.00 5,989.85 08/31/2009 627144 0.00 0.00 0.00 0.00 2,931.60 2,195.66 5,127.26 50,235.62 08/31/2009 627186 0.00 0.00 0.00 157.85 0.00 0.00 157.85 570.08 09/08/2009 627225 0.00 0.00 0.00 0.00 0.00 4.30 4.30 38.24 09/08/2009 627407 0.00 0.00 0.00 0.00 0.00 19.50 19.50 95.60 09/08/2009 629116 0.00 0.00 0.00 0.00 15.60 0.00 15.60 76.48 09/14/2009 631408 0.00 0.00 0.00 286.67 0.00 0.00 286.67 2,809.68 09/21/2009 631439 712.90 0.00 0.00 0.00 0.00 0.00 0.00 6,990.10 09/21/2009 633319 0.00 0.00 0.00 0.00 1,861.89 2,516.96 4,378.85 42,935.39 09/21/2009 633354 0.00 0.00 0.00 -4.87 0.00 0.00 -4.87 -50.90 09/28/2009 633388 510.90 0.00 0.00 0.00 0.00 0.00 0.00 5,009.44 09/28/2009 635358 0.00 0.00 0.00 0.00 3,480.75 2,901.60 6,382.35 62,579.76 09/28/2009 635395 0.00 0.00 0.00 220.27 0.00 0.00 220.27 2,158.16 10/06/2009 635426 147.51 0.00 0.00 0.00 0.00 0.00 0.00 1,467.26 10/06/2009 637300 0.00 0.00 0.00 0.00 4,188.21 1,557.96 5,746.17 57,147.25 10/06/2009 637341 0.00 0.00 0.00 3.06 0.00 0.00 3.06 30.54 10/19/2009 639449 67.21 0.00 0.00 0.00 0.00 0.00 0.00 668.25 10/19/2009 641622 0.00 0.00 0.00 0.00 307.73 204.51 512.24 5,092.23 10/26/2009 641712 2,919.15 0.00 0.00 0.00 0.00 0.00 0.00 29,027.42 10/26/2009 643643 0.00 0.00 0.00 0.00 12,286.51 9,643.64 21,930.15 218,058.17 10/26/2009 643677 0.00 0.00 0.00 25.57 0.00 0.00 25.57 254.50 11/02/2009 645693 0.00 0.00 0.00 5.08 0.00 0.00 5.08 20.36 11/09/2009 645726 2,654.93 0.00 0.00 0.00 0.00 0.00 0.00 26,426.67 11/09/2009 647634 0.00 0.00 0.00 0.00 14,806.11 11,917.82 26,723.93 266,022.33 11/09/2009 647663 0.00 0.00 0.00 1,640.38 0.00 0.00 1,640.38 16,328.72 11/16/2009 650040 0.00 0.00 0.00 2,711.91 0.00 0.00 2,711.91 -0.00 11/23/2009 650059 2,653.61 0.00 0.00 0.00 0.00 0.00 0.00 31,069.02 11/23/2009 652048 0.00 0.00 0.00 0.00 17,322.46 14,627.56 31,950.02 317,760.60 11/23/2009 652079 0.00 0.00 0.00 2,231.86 0.00 0.00 2,231.86 22,742.12 11/30/2009 652108 1,089.40 0.00 0.00 0.00 0.00 0.00 0.00 13,918.21 11/30/2009 654112 0.00 0.00 0.00 0.00 6,455.12 5,323.23 11,778.35 117,032.70 12/07/2009 654195 76.80 0.00 0.00 0.00 0.00 0.00 0.00 803.04 12/07/2009 656140 0.00 0.00 0.00 0.00 368.64 157.44 526.08 5,238.88 12/14/2009 658430 0.00 0.00 0.00 13.30 0.00 0.00 13.30 132.34 12/21/2009 658454 524.16 0.00 0.00 0.00 0.00 0.00 0.00 6,003.68 12/21/2009 660589 0.00 0.00 0.00 0.00 4,077.15 3,323.66 7,400.81 73,699.41 12/21/2009 660636 0.00 0.00 0.00 3,147.44 0.00 0.00 3,147.44 31,303.50 12/28/2009 662651 0.00 0.00 0.00 0.00 44.92 97.92 142.84 1,422.44 12/28/2009 662684 0.00 0.00 0.00 316.54 0.00 0.00 316.54 3,094.72 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 15,259.62 0.00 0.00 11,974.56 80,251.87 65,615.46 157,841.89 1,722,963.86 CNTRNUM 15,259.62 0.00 0.00 11,974.56 80,251.87 65,615.46 157,841.89 1,722,963.86 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 16 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL -------------------------------------------------------- CONTRACT NUM=1600011 NAME=COSHOCTON CO BD OF DD -------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 609485 0.00 0.00 0.00 0.00 0.00 0.00 0.00 956.00 07/06/2009 609678 0.00 0.00 0.00 0.00 0.00 0.00 0.00 9.26 07/06/2009 611225 0.00 0.00 0.00 0.00 0.00 0.00 0.00 9,979.05 07/06/2009 611263 0.00 0.00 0.00 0.00 0.00 0.00 0.00 10,495.58 07/20/2009 613170 0.00 0.00 0.00 0.00 0.00 0.00 0.00 650.08 07/20/2009 615123 0.00 0.00 0.00 0.00 255.71 937.48 1,193.19 13,034.26 07/20/2009 615153 0.00 0.00 0.00 101.50 0.00 0.00 101.50 1,109.62 07/27/2009 615181 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2,443.98 07/27/2009 617030 0.00 0.00 0.00 0.00 344.32 1,767.17 2,111.49 23,087.66 07/27/2009 617066 0.00 0.00 0.00 2.79 0.00 0.00 2.79 -132.34 08/04/2009 618988 0.00 0.00 0.00 0.00 0.44 122.09 122.53 1,339.07 08/04/2009 619021 0.00 0.00 0.00 793.26 0.00 0.00 793.26 9,823.70 08/10/2009 619055 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2,023.77 08/10/2009 620924 0.00 0.00 0.00 0.00 252.63 1,310.63 1,563.26 17,093.18 08/24/2009 623167 0.00 0.00 0.00 0.00 0.00 0.00 0.00 764.80 08/24/2009 625093 0.00 0.00 0.00 0.00 277.35 865.66 1,143.01 11,207.45 08/24/2009 625139 0.00 0.00 0.00 604.69 0.00 0.00 604.69 6,148.72 08/31/2009 627145 0.00 0.00 0.00 0.00 24.41 339.80 364.21 3,570.25 08/31/2009 627187 0.00 0.00 0.00 470.51 0.00 0.00 470.51 4,509.74 09/14/2009 629417 0.00 0.00 0.00 0.00 0.00 23.45 23.45 -13.08 09/21/2009 631440 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2,662.79 09/21/2009 633320 0.00 0.00 0.00 0.00 673.84 2,055.90 2,729.74 26,571.52 09/28/2009 635396 0.00 0.00 0.00 470.61 0.00 0.00 470.61 4,611.54 10/06/2009 637342 0.00 0.00 0.00 1,246.07 0.00 0.00 1,246.07 12,592.66 10/13/2009 637374 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,941.66 10/13/2009 639382 0.00 0.00 0.00 0.00 289.36 1,041.00 1,330.36 13,228.96 10/19/2009 641665 0.00 0.00 0.00 165.07 0.00 0.00 165.07 661.70 10/26/2009 641713 65.29 0.00 0.00 0.00 0.00 0.00 0.00 2,522.95 10/26/2009 643644 0.00 0.00 0.00 0.00 1,060.94 2,078.90 3,139.84 31,237.04 10/26/2009 643678 0.00 0.00 0.00 1,219.60 0.00 0.00 1,219.60 12,368.70 11/02/2009 643702 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,185.44 11/02/2009 645655 0.00 0.00 0.00 0.00 531.84 397.44 929.28 9,254.08 11/09/2009 647664 0.00 0.00 0.00 4,632.64 0.00 0.00 4,632.64 4,066.75 11/30/2009 652109 514.24 0.00 0.00 0.00 0.00 0.00 0.00 5,116.46 11/30/2009 654113 0.00 0.00 0.00 0.00 1,779.01 3,199.76 4,978.77 49,521.60 11/30/2009 654156 0.00 0.00 0.00 3,115.95 0.00 0.00 3,115.95 29,226.78 12/07/2009 654196 3.84 0.00 0.00 0.00 0.00 0.00 0.00 344.16 12/07/2009 656141 0.00 0.00 0.00 0.00 123.63 224.36 347.99 3,463.80 12/07/2009 656179 0.00 0.00 0.00 482.91 0.00 0.00 482.91 4,886.40 12/28/2009 660668 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2,302.57 12/28/2009 662652 0.00 0.00 0.00 0.00 1,271.82 2,032.83 3,304.65 32,876.18 12/28/2009 662685 0.00 0.00 0.00 239.25 0.00 0.00 239.25 1,822.22 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 583.37 0.00 0.00 13,544.85 6,885.30 16,396.47 36,826.62 370,566.71 CNTRNUM 583.37 0.00 0.00 13,544.85 6,885.30 16,396.47 36,826.62 370,566.71 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 17 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL -------------------------------------------------------- CONTRACT NUM=1700010 NAME=CRAWFORD CO BD OF DD --------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 08/04/2009 617092 101.73 0.00 0.00 0.00 0.00 0.00 0.00 1,110.00 08/04/2009 618989 0.00 0.00 0.00 0.00 253.98 4,302.84 4,556.82 49,725.00 09/14/2009 629179 64.05 0.00 0.00 0.00 0.00 0.00 0.00 627.06 09/14/2009 631370 0.00 0.00 0.00 0.00 210.75 4,517.26 4,728.01 46,341.47 10/13/2009 639383 0.00 0.00 0.00 0.00 0.00 151.00 151.00 1,500.00 10/13/2009 639418 0.00 0.00 0.00 6,594.80 0.00 0.00 6,594.80 65,620.28 10/19/2009 639450 204.00 0.00 0.00 0.00 0.00 0.00 0.00 2,030.48 10/19/2009 641623 0.00 0.00 0.00 0.00 654.52 13,735.05 14,389.57 143,223.52 11/09/2009 647665 0.00 0.00 0.00 138.14 0.00 0.00 138.14 111.98 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 369.78 0.00 0.00 6,732.94 1,119.25 22,706.15 30,558.34 310,289.79 CNTRNUM 369.78 0.00 0.00 6,732.94 1,119.25 22,706.15 30,558.34 310,289.79 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 18 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL -------------------------------------------------------- CONTRACT NUM=1800019 NAME=CUYAHOGA CO BD OF DD --------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 609486 0.00 0.00 0.00 0.00 0.00 0.00 0.00 26,832.24 07/06/2009 609688 0.00 0.00 0.00 0.00 0.00 0.00 0.00 16,218.50 07/06/2009 611226 0.00 0.00 0.00 0.00 0.00 0.00 0.00 831,909.39 07/06/2009 611264 0.00 0.00 0.00 0.00 0.00 0.00 0.00 349,815.34 07/13/2009 611298 0.00 0.00 0.00 0.00 0.00 0.00 0.00 26,209.53 07/13/2009 611510 0.00 0.00 0.00 0.00 0.00 0.00 0.00 8,931.35 07/13/2009 613121 0.00 0.00 0.00 0.00 0.00 0.00 0.00 454,940.80 07/13/2009 613145 0.00 0.00 0.00 0.00 0.00 0.00 0.00 9,691.36 07/20/2009 613171 0.00 0.00 0.00 0.00 0.00 16.03 16.03 87.58 07/20/2009 615124 0.00 0.00 0.00 0.00 3,028.43 6,540.52 9,568.95 104,764.98 07/20/2009 615154 0.00 0.00 0.00 61.45 0.00 0.00 61.45 671.88 07/27/2009 615182 3,894.83 0.00 0.00 0.00 0.00 0.00 0.00 52,349.46 07/27/2009 615376 993.63 0.00 0.00 0.00 0.00 3,177.08 3,177.08 36,075.93 07/27/2009 617031 0.00 0.00 0.00 0.00 16,370.83 30,313.53 46,684.36 502,011.56 08/04/2009 617093 1,030.51 0.00 0.00 0.00 0.00 0.00 0.00 14,535.05 08/04/2009 617299 0.00 0.00 0.00 0.00 0.00 1,102.05 1,102.05 10,151.42 08/04/2009 618990 0.00 0.00 0.00 0.00 17,740.42 37,833.17 55,573.59 584,641.10 08/04/2009 619022 0.00 0.00 0.00 29,554.53 0.00 0.00 29,554.53 331,420.08 08/10/2009 619056 2,069.79 0.00 0.00 0.00 0.00 0.00 0.00 28,962.40 08/10/2009 620925 0.00 0.00 0.00 0.00 22,779.86 49,662.88 72,442.74 792,606.03 08/10/2009 620955 0.00 0.00 0.00 11.17 0.00 0.00 11.17 122.16 08/17/2009 620978 2,233.52 0.00 0.00 0.00 0.00 0.00 0.00 25,899.44 08/17/2009 623124 0.00 0.00 0.00 0.00 13,934.80 32,805.14 46,739.94 458,558.67 08/24/2009 623168 5,758.96 0.00 0.00 0.00 0.00 0.00 0.00 78,565.81 08/24/2009 625094 0.00 0.00 0.00 0.00 20,847.53 31,151.52 51,999.05 510,231.16 08/31/2009 625168 2,561.10 0.00 0.00 0.00 0.00 6.47 6.47 31,218.87 08/31/2009 625387 0.00 0.00 0.00 0.00 4.06 5,790.16 5,794.22 44,620.46 08/31/2009 627146 0.00 0.00 0.00 0.00 22,475.35 44,253.96 66,729.31 644,170.98 08/31/2009 627188 0.00 0.00 0.00 33,890.02 0.00 0.00 33,890.02 335,033.98 09/08/2009 627226 1,474.40 0.00 0.00 0.00 0.00 0.00 0.00 18,022.70 09/08/2009 627420 0.00 0.00 0.00 0.00 0.00 1,364.47 1,364.47 13,117.20 09/08/2009 629117 0.00 0.00 0.00 0.00 18,594.93 37,291.77 55,886.70 519,232.76 09/08/2009 629150 0.00 0.00 0.00 254.38 0.00 0.00 254.38 732.96 09/14/2009 629180 1,608.05 0.00 0.00 0.00 0.00 0.00 0.00 19,508.33 09/14/2009 631371 0.00 0.00 0.00 0.00 21,837.93 39,071.11 60,909.04 597,629.56 09/14/2009 631409 0.00 0.00 0.00 28.04 0.00 0.00 28.04 274.86 09/21/2009 631441 1,122.41 0.00 0.00 0.00 0.00 0.00 0.00 17,952.56 09/21/2009 631645 0.00 0.00 0.00 0.00 4.06 241.86 245.92 1,814.89 09/21/2009 633321 0.00 0.00 0.00 0.00 8,879.03 21,827.26 30,706.29 301,256.75 09/28/2009 633389 1,127.61 0.00 0.00 0.00 0.00 0.00 0.00 12,832.13 09/28/2009 635359 0.00 0.00 0.00 0.00 19,213.94 33,493.94 52,707.88 517,038.50 09/28/2009 635397 0.00 0.00 0.00 34,189.06 0.00 0.00 34,189.06 338,658.06 10/06/2009 635427 2,067.00 0.00 0.00 0.00 0.00 0.00 0.00 27,805.76 10/06/2009 637301 0.00 0.00 0.00 0.00 31,586.94 53,877.61 85,464.55 850,583.63 10/06/2009 637343 0.00 0.00 0.00 3.07 0.00 0.00 3.07 30.54 10/13/2009 637375 5,434.99 0.00 0.00 0.00 0.00 0.00 0.00 57,733.46 10/13/2009 639384 0.00 0.00 0.00 0.00 38,663.52 61,845.44 100,508.96 1,000,206.29 10/19/2009 639451 2,605.42 0.00 0.00 0.00 0.00 13.26 13.26 33,055.73 10/19/2009 639692 0.00 0.00 0.00 0.00 0.00 6,207.72 6,207.72 51,937.44 10/19/2009 641624 0.00 0.00 0.00 0.00 27,912.45 37,845.92 65,758.37 651,467.72 10/19/2009 641666 0.00 0.00 0.00 398.98 0.00 0.00 398.98 3,970.20 10/26/2009 641714 1,915.27 0.00 0.00 0.00 0.00 0.00 0.00 32,863.53 10/26/2009 643645 0.00 0.00 0.00 0.00 25,636.31 55,510.58 81,146.89 807,715.26 10/26/2009 643679 0.00 0.00 0.00 7,436.88 0.00 0.00 7,436.88 76,472.16 11/02/2009 643703 2,332.38 0.00 0.00 0.00 0.00 0.00 0.00 32,099.07 11/02/2009 643913 0.00 0.00 0.00 0.00 0.00 1,317.44 1,317.44 12,763.00 11/02/2009 645656 0.00 0.00 0.00 0.00 28,641.64 44,779.16 73,420.80 730,177.99 11/02/2009 645694 0.00 0.00 0.00 34,871.85 0.00 0.00 34,871.85 353,032.22 11/09/2009 645727 2,111.34 0.00 0.00 0.00 0.00 0.00 0.00 22,599.34 11/09/2009 647635 0.00 0.00 0.00 0.00 18,035.17 37,505.79 55,540.96 552,845.98 11/16/2009 647717 3,577.10 0.00 0.00 0.00 0.00 238.00 238.00 48,541.18 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 19 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL -------------------------------------------------------- CONTRACT NUM=1800019 NAME=CUYAHOGA CO BD OF DD --------------------------------------------------------- (continued) POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 11/16/2009 647969 0.00 0.00 0.00 0.00 0.00 7,845.60 7,845.60 65,974.80 11/16/2009 650009 0.00 0.00 0.00 0.00 22,259.02 30,895.69 53,154.71 527,110.78 11/23/2009 650060 2,082.23 0.00 0.00 0.00 0.00 0.00 0.00 27,467.27 11/23/2009 652049 0.00 0.00 0.00 0.00 25,535.87 51,210.27 76,746.14 763,993.78 11/30/2009 652110 1,476.13 0.00 0.00 0.00 4.00 34.00 38.00 16,210.07 11/30/2009 652320 0.00 0.00 0.00 0.00 4.00 2,984.00 2,988.00 28,357.50 11/30/2009 654114 0.00 0.00 0.00 0.00 12,777.26 20,446.26 33,223.52 330,238.34 11/30/2009 654157 0.00 0.00 0.00 35,641.02 0.00 0.00 35,641.02 363,018.80 12/07/2009 654197 18,620.35 0.00 0.00 0.00 0.00 0.00 0.00 219,647.22 12/07/2009 656142 0.00 0.00 0.00 0.00 27,728.06 49,234.97 76,963.03 765,972.76 12/07/2009 656180 0.00 0.00 0.00 674.22 0.00 0.00 674.22 6,708.62 12/14/2009 656211 1,937.40 0.00 0.00 0.00 0.00 0.00 0.00 21,644.76 12/14/2009 658405 0.00 0.00 0.00 0.00 17,747.09 28,398.94 46,146.03 459,392.04 12/21/2009 658455 1,963.43 0.00 0.00 0.00 0.00 0.00 0.00 22,756.00 12/21/2009 658712 93.87 0.00 0.00 0.00 0.00 3,803.80 3,803.80 38,782.74 12/21/2009 660590 0.00 0.00 0.00 0.00 14,169.28 22,594.40 36,763.68 366,055.10 12/28/2009 660669 2,410.91 0.00 0.00 0.00 0.00 454.90 454.90 31,522.87 12/28/2009 660886 0.00 0.00 0.00 0.00 0.00 7,983.09 7,983.09 61,415.91 12/28/2009 662653 0.00 0.00 0.00 0.00 32,877.54 40,595.27 73,472.81 727,498.82 12/28/2009 662686 0.00 0.00 0.00 31,716.56 0.00 0.00 31,716.56 319,967.58 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 72,502.63 0.00 0.00 208,731.23 509,289.32 941,565.03 1,659,585.58 19,178,955.03 CNTRNUM 72,502.63 0.00 0.00 208,731.23 509,289.32 941,565.03 1,659,585.58 19,178,955.03 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 20 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL ---------------------------------------------------------- CONTRACT NUM=1900018 NAME=DARKE CO BD OF DD ---------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 609487 0.00 0.00 0.00 0.00 0.00 0.00 0.00 4,634.40 07/06/2009 611227 0.00 0.00 0.00 0.00 0.00 0.00 0.00 34,140.08 07/06/2009 611265 0.00 0.00 0.00 0.00 0.00 0.00 0.00 24,747.58 07/13/2009 611299 0.00 0.00 0.00 0.00 0.00 0.00 0.00 7,357.96 07/13/2009 613122 0.00 0.00 0.00 0.00 0.00 0.00 0.00 33,455.20 07/20/2009 615155 0.00 0.00 0.00 109.92 0.00 0.00 109.92 559.90 07/27/2009 617067 0.00 0.00 0.00 27.94 0.00 0.00 27.94 305.40 08/04/2009 618991 0.00 0.00 0.00 0.00 87.12 0.00 87.12 952.44 08/10/2009 619057 1,372.84 0.00 0.00 0.00 0.00 0.00 0.00 17,271.27 08/10/2009 620926 0.00 0.00 0.00 0.00 1,758.92 1,710.52 3,469.44 37,907.29 08/10/2009 620956 0.00 0.00 0.00 70.77 0.00 0.00 70.77 773.68 08/17/2009 620979 19.70 0.00 0.00 0.00 0.00 0.00 0.00 193.10 08/17/2009 623125 0.00 0.00 0.00 0.00 84.71 0.00 84.71 830.33 08/17/2009 623151 0.00 0.00 0.00 8.31 0.00 0.00 8.31 81.44 08/31/2009 625169 7.88 0.00 0.00 0.00 0.00 0.00 0.00 77.24 08/31/2009 627147 0.00 0.00 0.00 0.00 82.53 59.20 141.73 1,389.10 08/31/2009 627189 0.00 0.00 0.00 3,006.14 0.00 0.00 3,006.14 29,674.70 09/08/2009 629151 0.00 0.00 0.00 20.78 0.00 0.00 20.78 61.08 09/14/2009 629181 1,223.13 0.00 0.00 0.00 0.00 0.00 0.00 11,990.02 09/14/2009 631372 0.00 0.00 0.00 0.00 3,308.08 2,426.50 5,734.58 56,200.06 09/14/2009 631410 0.00 0.00 0.00 214.00 0.00 0.00 214.00 2,392.30 09/21/2009 631442 625.30 0.00 0.00 0.00 0.00 0.00 0.00 6,130.19 09/21/2009 633322 0.00 0.00 0.00 0.00 1,775.10 1,230.44 3,005.54 29,448.80 09/28/2009 633390 262.23 0.00 0.00 0.00 0.00 0.00 0.00 2,571.38 09/28/2009 635360 0.00 0.00 0.00 0.00 724.96 623.18 1,348.14 13,212.21 10/06/2009 635428 27.16 0.00 0.00 0.00 0.00 0.00 0.00 270.34 10/06/2009 637302 0.00 0.00 0.00 0.00 89.24 71.78 161.02 1,602.73 10/13/2009 639419 0.00 0.00 0.00 5,497.30 0.00 0.00 5,497.30 54,839.66 10/19/2009 639452 2,089.63 0.00 0.00 0.00 3.94 0.00 3.94 20,661.94 10/19/2009 641625 0.00 0.00 0.00 0.00 5,565.37 4,327.93 9,893.30 98,455.57 10/19/2009 641667 0.00 0.00 0.00 334.82 0.00 0.00 334.82 315.58 10/26/2009 642081 0.00 0.00 0.00 0.00 0.00 7.76 7.76 38.62 11/02/2009 643704 230.63 0.00 0.00 0.00 0.00 0.00 0.00 2,294.87 11/02/2009 645657 0.00 0.00 0.00 0.00 182.95 191.28 374.23 3,723.45 11/02/2009 645695 0.00 0.00 0.00 34.78 0.00 0.00 34.78 346.12 11/09/2009 647666 0.00 0.00 0.00 5.98 0.00 0.00 5.98 61.08 11/16/2009 647718 630.26 0.00 0.00 0.00 0.00 0.00 0.00 6,271.62 11/16/2009 650010 0.00 0.00 0.00 0.00 1,769.57 1,175.39 2,944.96 29,218.96 11/16/2009 650041 0.00 0.00 0.00 5,417.31 0.00 0.00 5,417.31 58,361.94 11/23/2009 650061 1,416.18 0.00 0.00 0.00 0.00 0.00 0.00 14,095.73 11/23/2009 652050 0.00 0.00 0.00 0.00 3,422.88 2,631.47 6,054.35 60,261.63 11/23/2009 652080 0.00 0.00 0.00 4.09 0.00 0.00 4.09 40.72 11/30/2009 652111 481.89 0.00 0.00 0.00 0.00 0.00 0.00 4,795.38 11/30/2009 654115 0.00 0.00 0.00 0.00 1,690.37 1,034.93 2,725.30 27,112.27 11/30/2009 654158 0.00 0.00 0.00 138.12 0.00 0.00 138.12 702.42 12/07/2009 656181 0.00 0.00 0.00 2,729.81 0.00 0.00 2,729.81 28,860.30 12/21/2009 658456 19.40 0.00 0.00 0.00 0.00 0.00 0.00 193.10 12/21/2009 660591 0.00 0.00 0.00 0.00 37.09 0.00 37.09 369.45 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 8,406.23 0.00 0.00 17,620.07 20,582.83 15,490.38 53,693.28 729,250.63 CNTRNUM 8,406.23 0.00 0.00 17,620.07 20,582.83 15,490.38 53,693.28 729,250.63 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 21 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL -------------------------------------------------------- CONTRACT NUM=2000015 NAME=DEFIANCE CO BD OF DD --------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 609488 0.00 0.00 0.00 0.00 0.00 0.00 0.00 700.41 07/06/2009 611228 0.00 0.00 0.00 0.00 0.00 0.00 0.00 4,475.04 07/06/2009 611266 0.00 0.00 0.00 0.00 0.00 0.00 0.00 50.90 08/04/2009 617094 1,023.49 0.00 0.00 0.00 0.00 0.00 0.00 11,185.57 08/04/2009 618992 0.00 0.00 0.00 0.00 9,415.11 9,962.69 19,377.80 211,818.69 08/04/2009 619024 0.00 0.00 0.00 895.56 0.00 0.00 895.56 9,793.16 08/10/2009 619058 348.67 0.00 0.00 0.00 0.00 0.00 0.00 3,810.83 08/10/2009 620927 0.00 0.00 0.00 0.00 3,040.74 3,160.41 6,201.15 67,787.30 08/24/2009 625095 0.00 0.00 0.00 0.00 54.01 43.45 97.46 955.79 08/31/2009 625170 394.08 0.00 0.00 0.00 0.00 0.00 0.00 3,862.92 08/31/2009 627148 0.00 0.00 0.00 0.00 3,471.13 3,473.13 6,944.26 68,037.42 09/08/2009 629118 0.00 0.00 0.00 0.00 20.13 0.00 20.13 197.23 10/06/2009 635429 380.02 0.00 0.00 0.00 0.00 0.00 0.00 3,782.09 10/06/2009 637303 0.00 0.00 0.00 0.00 3,314.15 3,132.83 6,446.98 64,165.99 11/02/2009 643705 329.23 0.00 0.00 0.00 0.00 0.00 0.00 3,276.43 11/02/2009 645658 0.00 0.00 0.00 0.00 3,626.51 3,113.95 6,740.46 67,087.57 11/09/2009 647636 0.00 0.00 0.00 0.00 0.00 1.90 1.90 18.93 11/23/2009 652081 0.00 0.00 0.00 2,190.52 0.00 0.00 2,190.52 21,795.38 11/30/2009 654159 0.00 0.00 0.00 1,241.00 0.00 0.00 1,241.00 12,348.34 12/07/2009 656143 0.00 0.00 0.00 0.00 801.70 1,025.58 1,827.28 18,202.17 12/21/2009 658457 354.74 0.00 0.00 0.00 0.00 0.00 0.00 3,530.40 12/21/2009 660592 0.00 0.00 0.00 0.00 4,297.78 2,963.60 7,261.38 72,274.17 12/28/2009 662687 0.00 0.00 0.00 1,262.51 0.00 0.00 1,262.51 12,562.12 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 2,830.23 0.00 0.00 5,589.59 28,041.26 26,877.54 60,508.39 661,718.85 CNTRNUM 2,830.23 0.00 0.00 5,589.59 28,041.26 26,877.54 60,508.39 661,718.85 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 22 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL -------------------------------------------------------- CONTRACT NUM=2100014 NAME=DELAWARE CO BD OF DD --------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/13/2009 613146 0.00 0.00 0.00 0.00 0.00 0.00 0.00 33,746.70 08/24/2009 625140 0.00 0.00 0.00 4,597.76 0.00 0.00 4,597.76 45,056.68 08/31/2009 625552 5.20 0.00 0.00 0.00 852.19 979.20 1,831.39 18,005.51 09/08/2009 627565 0.00 0.00 0.00 0.00 13.87 74.64 88.51 867.80 09/21/2009 631800 0.00 0.00 0.00 0.00 37.08 0.00 37.08 363.63 09/28/2009 635398 0.00 0.00 0.00 4,279.24 0.00 0.00 4,279.24 41,931.42 10/19/2009 641668 0.00 0.00 0.00 3,512.67 0.00 0.00 3,512.67 34,958.12 11/09/2009 647667 0.00 0.00 0.00 3,750.00 0.00 0.00 3,750.00 37,879.78 11/23/2009 650450 0.00 0.00 0.00 0.00 1,008.58 0.00 1,008.58 10,035.95 11/30/2009 652474 0.00 0.00 0.00 0.00 142.51 18.69 161.20 1,603.98 12/07/2009 654575 0.00 0.00 0.00 0.00 840.52 158.63 999.15 9,941.85 12/14/2009 658431 0.00 0.00 0.00 3,616.09 0.00 0.00 3,616.09 36,210.26 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 5.20 0.00 0.00 19,755.76 2,894.75 1,231.16 23,881.67 270,601.68 CNTRNUM 5.20 0.00 0.00 19,755.76 2,894.75 1,231.16 23,881.67 270,601.68 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 23 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL ---------------------------------------------------------- CONTRACT NUM=2200013 NAME=ERIE CO BD OF DD ----------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/13/2009 613123 0.00 0.00 0.00 0.00 0.00 0.00 0.00 22,126.12 07/20/2009 615125 0.00 0.00 0.00 0.00 57.90 0.00 57.90 632.15 07/27/2009 617068 0.00 0.00 0.00 2,055.13 0.00 0.00 2,055.13 22,467.26 09/08/2009 629119 0.00 0.00 0.00 0.00 547.72 3,541.63 4,089.35 40,106.13 09/28/2009 635399 0.00 0.00 0.00 4,432.25 0.00 0.00 4,432.25 43,438.06 10/19/2009 641669 0.00 0.00 0.00 9.21 0.00 0.00 9.21 30.54 11/02/2009 645696 0.00 0.00 0.00 2,532.15 0.00 0.00 2,532.15 25,531.44 11/23/2009 652051 0.00 0.00 0.00 0.00 670.75 4,297.37 4,968.12 49,417.43 11/30/2009 652514 0.00 0.00 0.00 0.00 0.00 144.93 144.93 1,362.58 11/30/2009 654160 0.00 0.00 0.00 2,253.91 0.00 0.00 2,253.91 23,108.60 12/21/2009 660593 0.00 0.00 0.00 0.00 482.92 1,933.90 2,416.82 24,040.62 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 0.00 0.00 0.00 11,282.65 1,759.29 9,917.83 22,959.77 252,260.93 CNTRNUM 0.00 0.00 0.00 11,282.65 1,759.29 9,917.83 22,959.77 252,260.93 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 24 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL -------------------------------------------------------- CONTRACT NUM=2300012 NAME=FAIRFIELD CO BD OF DD -------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 609489 0.00 0.00 0.00 0.00 0.00 0.00 0.00 193.10 07/06/2009 611229 0.00 0.00 0.00 0.00 0.00 0.00 0.00 135.17 07/20/2009 613172 1,554.36 0.00 0.00 0.00 0.00 0.00 0.00 16,991.61 07/20/2009 615126 0.00 0.00 0.00 0.00 10,267.29 12,047.20 22,314.49 244,041.52 08/10/2009 619059 296.67 0.00 0.00 0.00 0.00 0.00 0.00 3,244.08 08/10/2009 620928 0.00 0.00 0.00 0.00 2,219.97 2,370.87 4,590.84 50,216.50 08/10/2009 620957 0.00 0.00 0.00 4,462.38 0.00 0.00 4,462.38 49,199.94 08/17/2009 620980 468.71 0.00 0.00 0.00 0.00 0.00 0.00 4,594.27 08/17/2009 623126 0.00 0.00 0.00 0.00 1,921.78 2,814.75 4,736.53 46,425.18 08/24/2009 623169 843.67 0.00 0.00 0.00 0.00 0.00 0.00 8,269.85 08/24/2009 625096 0.00 0.00 0.00 0.00 3,901.55 5,918.57 9,820.12 96,252.23 08/31/2009 625171 295.50 0.00 0.00 0.00 0.00 0.00 0.00 2,896.50 08/31/2009 627149 0.00 0.00 0.00 0.00 2,864.12 3,185.00 6,049.12 59,292.70 09/08/2009 627615 0.00 0.00 0.00 0.00 0.00 23.91 23.91 212.41 09/21/2009 631443 48.82 0.00 0.00 0.00 0.00 0.00 0.00 478.59 09/21/2009 633323 0.00 0.00 0.00 0.00 538.79 693.71 1,232.50 12,082.29 09/21/2009 633355 0.00 0.00 0.00 4,789.50 0.00 0.00 4,789.50 46,939.98 09/28/2009 633391 43.80 0.00 0.00 0.00 0.00 0.00 0.00 429.44 09/28/2009 635361 0.00 0.00 0.00 0.00 659.64 105.22 764.86 7,497.52 09/28/2009 635400 0.00 0.00 0.00 4,082.27 0.00 0.00 4,082.27 40,007.40 10/13/2009 637376 3,458.43 0.00 0.00 0.00 0.00 -1.56 -1.56 34,349.49 10/13/2009 639385 0.00 0.00 0.00 0.00 14,915.33 19,809.49 34,724.82 345,421.48 10/19/2009 639453 24.16 0.00 0.00 0.00 0.00 4.22 4.22 278.86 10/19/2009 641626 0.00 0.00 0.00 0.00 1,021.20 603.78 1,624.98 16,149.14 10/26/2009 641715 708.63 0.00 0.00 0.00 0.00 0.00 0.00 7,051.14 10/26/2009 643646 0.00 0.00 0.00 0.00 1,559.05 3,581.02 5,140.07 51,141.40 11/02/2009 643706 129.49 0.00 0.00 0.00 0.00 0.00 0.00 1,288.59 11/02/2009 645659 0.00 0.00 0.00 0.00 1,072.59 971.51 2,044.10 20,282.65 11/09/2009 646140 0.00 0.00 0.00 0.00 0.00 0.28 0.28 0.00 11/16/2009 650011 0.00 0.00 0.00 0.00 6.60 0.00 6.60 65.67 11/23/2009 652052 0.00 0.00 0.00 0.00 143.25 73.20 216.45 2,153.47 11/23/2009 652082 0.00 0.00 0.00 3,742.50 0.00 0.00 3,742.50 37,564.20 11/30/2009 652112 22.00 0.00 0.00 0.00 0.00 0.00 0.00 218.94 11/30/2009 654116 0.00 0.00 0.00 0.00 482.11 492.36 974.47 9,698.11 12/07/2009 656144 0.00 0.00 0.00 0.00 2.11 0.00 2.11 19.31 12/14/2009 656212 0.16 0.00 0.00 0.00 0.00 0.00 0.00 1.63 12/14/2009 658406 0.00 0.00 0.00 0.00 1.72 8.52 10.24 101.97 12/14/2009 658432 0.00 0.00 0.00 3,661.71 0.00 0.00 3,661.71 36,973.76 12/21/2009 660594 0.00 0.00 0.00 0.00 105.01 132.00 237.01 2,357.99 12/28/2009 662654 0.00 0.00 0.00 0.00 1.94 0.00 1.94 19.31 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 7,894.40 0.00 0.00 20,738.36 41,684.05 52,834.05 115,256.46 1,254,537.39 CNTRNUM 7,894.40 0.00 0.00 20,738.36 41,684.05 52,834.05 115,256.46 1,254,537.39 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 25 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL --------------------------------------------------------- CONTRACT NUM=2400011 NAME=FAYETTE CO BD OF DD --------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/13/2009 613147 0.00 0.00 0.00 0.00 0.00 0.00 0.00 5,721.16 07/20/2009 613173 167.23 0.00 0.00 0.00 0.00 0.00 0.00 1,827.82 07/20/2009 615127 0.00 0.00 0.00 0.00 83.27 3,163.85 3,247.12 35,505.21 07/27/2009 617069 0.00 0.00 0.00 10.25 0.00 0.00 10.25 20.36 08/24/2009 623170 208.38 0.00 0.00 0.00 0.00 0.00 0.00 2,042.12 08/24/2009 625097 0.00 0.00 0.00 0.00 58.71 2,388.67 2,447.38 23,979.49 08/24/2009 625141 0.00 0.00 0.00 1,853.06 0.00 0.00 1,853.06 18,161.12 08/31/2009 627190 0.00 0.00 0.00 61.28 0.00 0.00 61.28 -40.72 09/14/2009 629182 128.89 0.00 0.00 0.00 0.00 0.00 0.00 1,262.63 09/14/2009 631373 0.00 0.00 0.00 0.00 82.76 1,736.99 1,819.75 17,827.28 09/14/2009 631411 0.00 0.00 0.00 166.19 0.00 0.00 166.19 1,628.80 09/21/2009 633356 0.00 0.00 0.00 28.04 0.00 0.00 28.04 193.42 10/06/2009 637344 0.00 0.00 0.00 883.98 0.00 0.00 883.98 8,795.52 10/13/2009 639420 0.00 0.00 0.00 367.32 0.00 0.00 367.32 3,654.62 10/19/2009 641670 0.00 0.00 0.00 101.42 0.00 0.00 101.42 101.80 11/02/2009 645697 0.00 0.00 0.00 763.85 0.00 0.00 763.85 7,390.68 11/09/2009 647668 0.00 0.00 0.00 3,681.71 0.00 0.00 3,681.71 2,653.60 11/16/2009 647719 883.77 0.00 0.00 0.00 0.00 0.00 0.00 8,800.32 11/16/2009 648245 0.00 0.00 0.00 0.00 0.00 28.01 28.01 267.68 11/16/2009 650012 0.00 0.00 0.00 0.00 274.91 8,879.59 9,154.50 91,094.25 11/16/2009 650042 0.00 0.00 0.00 757.10 0.00 0.00 757.10 7,563.74 12/21/2009 658458 141.03 0.00 0.00 0.00 0.00 0.00 0.00 1,404.35 12/21/2009 660595 0.00 0.00 0.00 0.00 24.28 695.58 719.86 7,161.34 12/21/2009 660637 0.00 0.00 0.00 306.97 0.00 0.00 306.97 3,054.00 12/28/2009 662688 0.00 0.00 0.00 129.52 0.00 0.00 129.52 1,058.72 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 1,529.30 0.00 0.00 9,110.69 523.93 16,892.69 26,527.31 251,129.31 CNTRNUM 1,529.30 0.00 0.00 9,110.69 523.93 16,892.69 26,527.31 251,129.31 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 26 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL -------------------------------------------------------- CONTRACT NUM=2500010 NAME=FRANKLIN CO BD OF DD --------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/27/2009 615183 342.76 0.00 0.00 0.00 0.00 0.00 0.00 3,742.22 07/27/2009 617032 0.00 0.00 0.00 0.00 8,134.44 21,312.19 29,446.63 321,706.72 09/14/2009 629183 31,940.16 0.00 0.00 0.00 0.00 0.00 0.00 329,933.28 09/14/2009 631374 0.00 0.00 0.00 0.00 113,403.36 652,834.83 766,238.19 7,513,494.89 09/14/2009 631412 0.00 0.00 0.00 85,684.70 0.00 0.00 85,684.70 866,104.22 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 32,282.92 0.00 0.00 85,684.70 121,537.80 674,147.02 881,369.52 9,034,981.33 CNTRNUM 32,282.92 0.00 0.00 85,684.70 121,537.80 674,147.02 881,369.52 9,034,981.33 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 27 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL --------------------------------------------------------- CONTRACT NUM=2600019 NAME=FULTON CO BD OF DD ---------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 609490 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,371.01 07/06/2009 611230 0.00 0.00 0.00 0.00 0.00 0.00 0.00 28,443.63 07/06/2009 611267 0.00 0.00 0.00 0.00 0.00 0.00 0.00 12,551.94 07/27/2009 615184 133.80 0.00 0.00 0.00 0.00 0.00 0.00 1,462.51 07/27/2009 617033 0.00 0.00 0.00 0.00 533.52 706.15 1,239.67 13,551.57 08/10/2009 619060 239.54 0.00 0.00 0.00 0.00 0.00 0.00 2,619.49 08/10/2009 620929 0.00 0.00 0.00 0.00 2,233.58 5,577.96 7,811.54 85,414.70 08/10/2009 620958 0.00 0.00 0.00 2,196.32 0.00 0.00 2,196.32 25,124.24 08/24/2009 623171 162.44 0.00 0.00 0.00 0.00 0.00 0.00 1,591.66 08/24/2009 625098 0.00 0.00 0.00 0.00 586.14 1,092.62 1,678.76 16,450.91 09/08/2009 629152 0.00 0.00 0.00 341.79 0.00 0.00 341.79 3,216.88 09/14/2009 629184 192.52 0.00 0.00 0.00 0.00 0.00 0.00 1,885.91 09/14/2009 631375 0.00 0.00 0.00 0.00 1,721.62 5,122.80 6,844.42 67,079.83 09/28/2009 633392 162.00 0.00 0.00 0.00 0.00 0.00 0.00 1,587.40 09/28/2009 635362 0.00 0.00 0.00 0.00 651.11 776.12 1,427.23 13,984.89 09/28/2009 635401 0.00 0.00 0.00 834.30 0.00 0.00 834.30 8,174.54 10/13/2009 637377 234.49 0.00 0.00 0.00 0.00 0.00 0.00 2,333.21 10/13/2009 639386 0.00 0.00 0.00 0.00 1,855.73 4,101.25 5,956.98 59,269.28 10/19/2009 641627 0.00 0.00 0.00 0.00 31.59 242.43 274.02 2,727.14 10/19/2009 641671 0.00 0.00 0.00 1,383.08 0.00 0.00 1,383.08 13,763.36 11/02/2009 643707 261.25 0.00 0.00 0.00 0.00 0.00 0.00 2,598.12 11/02/2009 645660 0.00 0.00 0.00 0.00 1,782.24 3,568.77 5,351.01 53,220.73 11/02/2009 645698 0.00 0.00 0.00 611.70 0.00 0.00 611.70 6,158.90 11/09/2009 647669 0.00 0.00 0.00 2,424.93 0.00 0.00 2,424.93 1,099.38 11/16/2009 647720 258.52 0.00 0.00 0.00 0.00 0.00 0.00 2,572.20 11/16/2009 650013 0.00 0.00 0.00 0.00 1,979.94 5,134.36 7,114.30 70,785.34 11/23/2009 652053 0.00 0.00 0.00 0.00 3.88 135.44 139.32 1,386.65 11/23/2009 652083 0.00 0.00 0.00 939.18 0.00 0.00 939.18 9,375.78 11/30/2009 652113 246.80 0.00 0.00 0.00 0.00 1.94 1.94 2,473.74 11/30/2009 654117 0.00 0.00 0.00 0.00 1,921.20 4,746.67 6,667.87 66,322.11 11/30/2009 654161 0.00 0.00 0.00 1,345.80 0.00 0.00 1,345.80 13,508.86 12/14/2009 656213 131.92 0.00 0.00 0.00 0.00 0.00 0.00 1,313.08 12/14/2009 658407 0.00 0.00 0.00 0.00 1,008.80 1,806.14 2,814.94 28,018.81 12/21/2009 658459 88.88 0.00 0.00 0.00 0.00 0.00 0.00 883.46 12/21/2009 660596 0.00 0.00 0.00 0.00 1,135.27 2,849.46 3,984.73 39,634.72 12/28/2009 660670 189.76 0.00 0.00 0.00 0.00 2.11 2.11 1,907.66 12/28/2009 662655 0.00 0.00 0.00 0.00 1,614.23 3,512.62 5,126.85 51,018.23 12/28/2009 662689 0.00 0.00 0.00 1,348.22 0.00 0.00 1,348.22 13,508.86 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 2,301.92 0.00 0.00 11,425.32 17,058.85 39,376.84 67,861.01 728,390.73 CNTRNUM 2,301.92 0.00 0.00 11,425.32 17,058.85 39,376.84 67,861.01 728,390.73 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 28 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL --------------------------------------------------------- CONTRACT NUM=2700018 NAME=GALLIA CO BD OF DD ---------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 611268 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2,565.36 08/04/2009 617095 58.56 0.00 0.00 0.00 0.00 0.00 0.00 639.75 08/04/2009 618993 0.00 0.00 0.00 0.00 261.16 894.06 1,155.22 12,627.36 08/10/2009 620959 0.00 0.00 0.00 254.20 0.00 0.00 254.20 2,789.32 08/31/2009 627191 0.00 0.00 0.00 4.15 0.00 0.00 4.15 10.18 09/08/2009 627227 126.15 0.00 0.00 0.00 0.00 0.00 0.00 1,236.18 09/08/2009 629120 0.00 0.00 0.00 0.00 421.37 1,459.83 1,881.20 18,438.27 09/08/2009 629153 0.00 0.00 0.00 170.43 0.00 0.00 170.43 1,669.52 10/13/2009 637378 81.85 0.00 0.00 0.00 0.00 0.00 0.00 815.07 10/13/2009 639387 0.00 0.00 0.00 0.00 549.38 1,308.16 1,857.54 18,493.90 10/13/2009 639421 0.00 0.00 0.00 497.13 0.00 0.00 497.13 4,947.48 10/19/2009 641672 0.00 0.00 0.00 198.42 0.00 0.00 198.42 1,974.92 10/26/2009 641716 95.22 0.00 0.00 0.00 0.00 0.00 0.00 947.87 10/26/2009 643647 0.00 0.00 0.00 0.00 145.04 198.15 343.19 3,415.18 11/02/2009 643708 128.02 0.00 0.00 0.00 0.00 0.00 0.00 1,274.88 11/02/2009 645661 0.00 0.00 0.00 0.00 1,062.91 1,412.58 2,475.49 24,647.09 11/02/2009 645699 0.00 0.00 0.00 178.97 0.00 0.00 178.97 1,781.50 12/07/2009 654198 103.89 0.00 0.00 0.00 0.00 0.00 0.00 1,034.62 12/07/2009 656145 0.00 0.00 0.00 0.00 849.09 1,262.67 2,111.76 21,024.54 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 593.69 0.00 0.00 1,303.30 3,288.95 6,535.45 11,127.70 120,332.99 CNTRNUM 593.69 0.00 0.00 1,303.30 3,288.95 6,535.45 11,127.70 120,332.99 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 29 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL --------------------------------------------------------- CONTRACT NUM=2800017 NAME=GEAUGA CO BD OF DD ---------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/20/2009 615156 0.00 0.00 0.00 15.82 0.00 0.00 15.82 173.06 08/10/2009 620960 0.00 0.00 0.00 1,574.63 0.00 0.00 1,574.63 17,631.76 09/14/2009 629185 514.56 0.00 0.00 0.00 0.00 0.00 0.00 5,043.20 09/14/2009 631376 0.00 0.00 0.00 0.00 2,848.17 2,982.84 5,831.01 57,149.70 09/14/2009 631413 0.00 0.00 0.00 2,787.67 0.00 0.00 2,787.67 27,506.36 10/06/2009 635430 605.88 0.00 0.00 0.00 0.00 0.00 0.00 6,028.20 10/06/2009 637304 0.00 0.00 0.00 0.00 4,106.52 3,779.82 7,886.34 78,465.10 10/06/2009 637345 0.00 0.00 0.00 2,310.99 0.00 0.00 2,310.99 22,996.62 11/09/2009 645728 255.42 0.00 0.00 0.00 0.00 0.00 0.00 2,541.30 11/09/2009 647637 0.00 0.00 0.00 0.00 1,092.96 1,215.72 2,308.68 22,970.20 11/09/2009 647670 0.00 0.00 0.00 3,463.46 0.00 0.00 3,463.46 23,494.28 11/16/2009 647721 543.76 0.00 0.00 0.00 0.00 0.00 0.00 5,411.60 11/16/2009 650014 0.00 0.00 0.00 0.00 789.06 1,690.99 2,480.05 24,681.62 11/30/2009 652114 730.60 0.00 0.00 0.00 0.00 0.00 0.00 7,270.80 11/30/2009 654118 0.00 0.00 0.00 0.00 1,460.91 2,309.91 3,770.82 37,527.49 12/07/2009 656182 0.00 0.00 0.00 1,112.02 0.00 0.00 1,112.02 11,595.02 12/14/2009 656214 182.16 0.00 0.00 0.00 0.00 0.00 0.00 1,812.40 12/14/2009 658408 0.00 0.00 0.00 0.00 1,199.88 1,023.66 2,223.54 22,123.10 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 2,832.38 0.00 0.00 11,264.59 11,497.50 13,002.94 35,765.03 374,421.81 CNTRNUM 2,832.38 0.00 0.00 11,264.59 11,497.50 13,002.94 35,765.03 374,421.81 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 30 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL --------------------------------------------------------- CONTRACT NUM=2900016 NAME=GREENE CO BD OF DD ---------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 611269 0.00 0.00 0.00 0.00 0.00 0.00 0.00 10,037.48 07/13/2009 611300 0.00 0.00 0.00 0.00 0.00 0.00 0.00 8,748.66 07/13/2009 613124 0.00 0.00 0.00 0.00 0.00 0.00 0.00 111,894.54 08/24/2009 623172 896.90 0.00 0.00 0.00 0.00 0.00 0.00 8,791.48 08/24/2009 625099 0.00 0.00 0.00 0.00 1,878.52 3,744.45 5,622.97 55,138.91 09/08/2009 627228 2,585.38 0.00 0.00 0.00 0.00 0.00 0.00 25,346.80 09/08/2009 629121 0.00 0.00 0.00 0.00 6,539.14 11,322.21 17,861.35 175,113.61 10/06/2009 635431 863.79 0.00 0.00 0.00 0.00 0.00 0.00 8,594.52 10/06/2009 637305 0.00 0.00 0.00 0.00 2,751.97 3,039.87 5,791.84 57,628.57 10/26/2009 643680 0.00 0.00 0.00 5,232.18 0.00 0.00 5,232.18 52,864.74 11/02/2009 643709 369.59 0.00 0.00 0.00 0.00 0.00 0.00 3,677.40 11/02/2009 645662 0.00 0.00 0.00 0.00 183.98 1,009.58 1,193.56 11,881.02 12/14/2009 656215 2,468.70 0.00 0.00 0.00 0.00 0.00 0.00 24,568.77 12/14/2009 658409 0.00 0.00 0.00 0.00 6,697.54 11,312.93 18,010.47 179,251.45 12/14/2009 658433 0.00 0.00 0.00 859.39 0.00 0.00 859.39 8,551.20 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 7,184.36 0.00 0.00 6,091.57 18,051.15 30,429.04 54,571.76 742,089.15 CNTRNUM 7,184.36 0.00 0.00 6,091.57 18,051.15 30,429.04 54,571.76 742,089.15 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 31 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL -------------------------------------------------------- CONTRACT NUM=3000013 NAME=GUERNSEY CO BD OF DD --------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 611231 0.00 0.00 0.00 0.00 0.00 0.00 0.00 74.92 07/06/2009 611270 0.00 0.00 0.00 0.00 0.00 0.00 0.00 81.44 07/13/2009 611301 0.00 0.00 0.00 0.00 0.00 0.00 0.00 194.34 07/13/2009 613125 0.00 0.00 0.00 0.00 0.00 0.00 0.00 17,234.54 07/20/2009 613174 41.87 0.00 0.00 0.00 0.00 0.00 0.00 458.20 07/20/2009 615128 0.00 0.00 0.00 0.00 582.22 2,406.56 2,988.78 32,684.14 07/27/2009 615185 29.14 0.00 0.00 0.00 0.00 0.00 0.00 318.41 07/27/2009 617034 0.00 0.00 0.00 0.00 673.81 2,785.97 3,459.78 37,797.14 07/27/2009 617070 0.00 0.00 0.00 687.95 0.00 0.00 687.95 7,472.12 08/04/2009 619025 0.00 0.00 0.00 2.79 0.00 0.00 2.79 30.54 08/24/2009 623173 47.94 0.00 0.00 0.00 0.00 0.00 0.00 469.92 08/24/2009 625100 0.00 0.00 0.00 0.00 2,214.97 7,344.88 9,559.85 93,729.25 08/31/2009 627150 0.00 0.00 0.00 0.00 0.00 9.55 9.55 93.65 08/31/2009 627192 0.00 0.00 0.00 1,543.84 0.00 0.00 1,543.84 15,127.48 09/21/2009 631444 62.80 0.00 0.00 0.00 0.00 0.00 0.00 615.68 09/21/2009 633324 0.00 0.00 0.00 0.00 4,403.19 11,214.73 15,617.92 153,118.48 09/21/2009 633358 0.00 0.00 0.00 807.36 0.00 0.00 807.36 7,909.86 09/28/2009 633393 15.65 0.00 0.00 0.00 0.00 0.00 0.00 153.26 09/28/2009 635363 0.00 0.00 0.00 0.00 134.94 1,249.23 1,384.17 13,567.99 09/28/2009 635402 0.00 0.00 0.00 1,725.74 0.00 0.00 1,725.74 16,908.98 10/06/2009 637346 0.00 0.00 0.00 11.15 0.00 0.00 11.15 101.80 10/19/2009 641673 0.00 0.00 0.00 24.83 0.00 0.00 24.83 132.34 10/26/2009 643648 0.00 0.00 0.00 0.00 3,458.37 8,803.57 12,261.94 122,060.65 10/26/2009 643681 0.00 0.00 0.00 1,508.87 0.00 0.00 1,508.87 15,310.72 11/02/2009 645700 0.00 0.00 0.00 371.52 0.00 0.00 371.52 3,074.36 11/09/2009 647672 0.00 0.00 0.00 2,576.09 0.00 0.00 2,576.09 815.33 12/14/2009 658410 0.00 0.00 0.00 0.00 1,202.78 3,105.76 4,308.54 42,924.68 12/14/2009 658434 0.00 0.00 0.00 3,145.91 0.00 0.00 3,145.91 31,405.30 12/28/2009 660671 22.07 0.00 0.00 0.00 0.00 0.00 0.00 219.62 12/28/2009 662656 0.00 0.00 0.00 0.00 312.64 1,246.10 1,558.74 15,508.26 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 219.47 0.00 0.00 12,406.05 12,982.92 38,166.35 63,555.32 629,593.40 CNTRNUM 219.47 0.00 0.00 12,406.05 12,982.92 38,166.35 63,555.32 629,593.40 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 32 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL -------------------------------------------------------- CONTRACT NUM=3100012 NAME=HAMILTON CO BD OF DD --------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 611271 0.00 0.00 0.00 0.00 0.00 0.00 0.00 31,517.28 07/20/2009 613175 3,476.23 0.00 0.00 0.00 0.00 0.00 0.00 39,252.35 07/20/2009 615129 0.00 0.00 0.00 0.00 15,698.88 57,613.86 73,312.74 800,874.65 07/20/2009 615157 0.00 0.00 0.00 246.79 0.00 0.00 246.79 3,339.04 07/27/2009 615186 329.17 0.00 0.00 0.00 0.00 0.00 0.00 3,596.25 07/27/2009 617035 0.00 0.00 0.00 0.00 1,826.74 2,884.91 4,711.65 51,469.64 08/24/2009 623174 7,500.64 0.00 0.00 0.00 0.00 0.00 0.00 73,526.20 08/24/2009 625101 0.00 0.00 0.00 0.00 29,864.49 104,440.60 134,305.09 1,316,616.26 08/24/2009 625142 0.00 0.00 0.00 51,424.40 0.00 0.00 51,424.40 504,225.58 08/31/2009 625172 5,521.94 0.00 0.00 0.00 0.00 0.00 0.00 54,129.44 08/31/2009 627151 0.00 0.00 0.00 0.00 19,909.70 67,115.37 87,025.07 853,092.67 08/31/2009 627193 0.00 0.00 0.00 24,431.40 0.00 0.00 24,431.40 239,433.60 09/08/2009 627229 4,919.75 0.00 0.00 0.00 0.00 0.00 0.00 48,224.97 09/08/2009 629122 0.00 0.00 0.00 0.00 19,503.68 64,395.55 83,899.23 822,431.78 09/08/2009 629154 0.00 0.00 0.00 1,173.87 0.00 0.00 1,173.87 11,503.40 09/14/2009 631377 0.00 0.00 0.00 0.00 179.07 416.97 596.04 5,849.82 09/21/2009 632240 0.00 0.00 0.00 0.00 0.00 0.00 0.00 -26,680.62 10/06/2009 635432 5,583.83 0.00 0.00 0.00 0.00 0.00 0.00 55,542.12 10/06/2009 637306 0.00 0.00 0.00 0.00 18,697.80 63,827.30 82,525.10 820,747.51 10/06/2009 637347 0.00 0.00 0.00 26,881.34 0.00 0.00 26,881.34 267,510.04 11/02/2009 643710 3,075.15 0.00 0.00 0.00 0.00 0.00 0.00 30,587.59 11/02/2009 645663 0.00 0.00 0.00 0.00 14,188.11 46,024.76 60,212.87 598,848.82 11/09/2009 645729 152.88 0.00 0.00 0.00 0.00 0.00 0.00 1,521.00 11/09/2009 647638 0.00 0.00 0.00 0.00 746.29 944.86 1,691.15 16,505.16 11/09/2009 647673 0.00 0.00 0.00 42.97 0.00 0.00 42.97 366.48 11/16/2009 650015 0.00 0.00 0.00 0.00 29.12 0.00 29.12 0.00 12/28/2009 660672 1,972.97 0.00 0.00 0.00 0.00 -2.65 -2.65 19,590.17 12/28/2009 662657 0.00 0.00 0.00 0.00 7,091.29 21,517.50 28,608.79 284,311.16 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 32,532.56 0.00 0.00 104,200.77 127,735.17 429,179.03 661,114.97 6,927,932.36 CNTRNUM 32,532.56 0.00 0.00 104,200.77 127,735.17 429,179.03 661,114.97 6,927,932.36 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 33 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL --------------------------------------------------------- CONTRACT NUM=3200011 NAME=HANCOCK CO BD OF DD --------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 11/09/2009 647639 0.00 0.00 0.00 0.00 424.75 837.27 1,262.02 12,555.10 11/09/2009 647674 0.00 0.00 0.00 1,316.77 0.00 0.00 1,316.77 10,315.24 11/16/2009 650016 0.00 0.00 0.00 0.00 609.30 1,551.12 2,160.42 21,491.01 11/16/2009 650043 0.00 0.00 0.00 1,318.79 0.00 0.00 1,318.79 13,244.18 11/23/2009 652054 0.00 0.00 0.00 0.00 722.24 1,695.01 2,417.25 24,045.64 11/23/2009 652084 0.00 0.00 0.00 1,225.72 0.00 0.00 1,225.72 12,439.96 12/07/2009 656146 0.00 0.00 0.00 0.00 721.17 1,851.68 2,572.85 25,594.47 12/07/2009 656183 0.00 0.00 0.00 2,179.20 0.00 0.00 2,179.20 21,724.12 12/21/2009 660597 0.00 0.00 0.00 0.00 311.11 451.29 762.40 7,590.64 12/21/2009 660638 0.00 0.00 0.00 673.28 0.00 0.00 673.28 6,698.44 12/28/2009 662690 0.00 0.00 0.00 33.71 0.00 0.00 33.71 335.94 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 0.00 0.00 0.00 6,747.47 2,788.57 6,386.37 15,922.41 156,034.74 CNTRNUM 0.00 0.00 0.00 6,747.47 2,788.57 6,386.37 15,922.41 156,034.74 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 34 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL --------------------------------------------------------- CONTRACT NUM=3300010 NAME=HARDIN CO BD OF DD ---------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 08/24/2009 623175 1,367.91 0.00 0.00 0.00 0.00 0.00 0.00 13,415.12 08/24/2009 625102 0.00 0.00 0.00 0.00 766.58 4,362.03 5,128.61 50,253.79 08/31/2009 627152 0.00 0.00 0.00 0.00 49.92 0.00 49.92 489.00 09/14/2009 629186 653.85 0.00 0.00 0.00 0.00 0.00 0.00 6,412.32 09/14/2009 631378 0.00 0.00 0.00 0.00 124.22 1,674.58 1,798.80 17,628.65 09/14/2009 631414 0.00 0.00 0.00 647.18 0.00 0.00 647.18 6,342.14 09/21/2009 633359 0.00 0.00 0.00 32.20 0.00 0.00 32.20 193.42 09/28/2009 633394 258.87 0.00 0.00 0.00 0.00 0.00 0.00 2,538.33 09/28/2009 635364 0.00 0.00 0.00 0.00 157.40 890.61 1,048.01 10,271.68 10/06/2009 635433 519.82 0.00 0.00 0.00 0.00 0.00 0.00 5,172.80 10/06/2009 637307 0.00 0.00 0.00 0.00 142.05 1,386.22 1,528.27 15,198.26 10/06/2009 637348 0.00 0.00 0.00 318.17 0.00 0.00 318.17 3,165.98 10/19/2009 641629 0.00 0.00 0.00 0.00 0.00 25.25 25.25 251.17 10/26/2009 641717 524.24 0.00 0.00 0.00 0.00 -1.00 -1.00 5,206.96 10/26/2009 643649 0.00 0.00 0.00 0.00 0.00 1,456.43 1,456.43 14,485.02 11/02/2009 643711 250.30 0.00 0.00 0.00 0.00 0.00 0.00 2,491.41 11/02/2009 645664 0.00 0.00 0.00 0.00 393.82 1,673.00 2,066.82 20,572.32 11/09/2009 647640 0.00 0.00 0.00 0.00 168.49 0.00 168.49 1,027.56 11/09/2009 647675 0.00 0.00 0.00 974.71 0.00 0.00 974.71 1,921.68 11/16/2009 648871 0.00 0.00 0.00 0.00 0.00 36.27 36.27 4.56 11/23/2009 650063 175.57 0.00 0.00 0.00 0.00 0.00 0.00 1,747.04 11/23/2009 652055 0.00 0.00 0.00 0.00 0.00 594.29 594.29 5,910.94 11/23/2009 652085 0.00 0.00 0.00 276.25 0.00 0.00 276.25 2,748.60 11/30/2009 654119 0.00 0.00 0.00 0.00 72.69 0.00 72.69 723.32 11/30/2009 654162 0.00 0.00 0.00 1.85 0.00 0.00 1.85 20.36 12/14/2009 656216 143.56 0.00 0.00 0.00 0.00 0.00 0.00 1,428.94 12/14/2009 658411 0.00 0.00 0.00 0.00 248.32 919.56 1,167.88 11,624.62 12/21/2009 658460 162.96 0.00 0.00 0.00 0.00 0.00 0.00 1,622.04 12/21/2009 660598 0.00 0.00 0.00 0.00 0.00 1,034.02 1,034.02 10,292.23 12/28/2009 660673 283.24 0.00 0.00 0.00 0.00 0.00 0.00 2,819.26 12/28/2009 662658 0.00 0.00 0.00 0.00 368.60 1,811.96 2,180.56 21,704.44 12/28/2009 662691 0.00 0.00 0.00 306.91 0.00 0.00 306.91 2,483.92 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 4,340.32 0.00 0.00 2,557.27 2,492.09 15,863.22 20,912.58 240,167.88 CNTRNUM 4,340.32 0.00 0.00 2,557.27 2,492.09 15,863.22 20,912.58 240,167.88 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 35 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL -------------------------------------------------------- CONTRACT NUM=3400019 NAME=HARRISON CO BD OF DD --------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 08/17/2009 620981 180.04 0.00 0.00 0.00 0.00 0.00 0.00 1,765.40 08/17/2009 623127 0.00 0.00 0.00 0.00 402.55 709.14 1,111.69 10,895.44 08/24/2009 623176 470.02 0.00 0.00 0.00 0.00 0.00 0.00 4,608.94 08/24/2009 625103 0.00 0.00 0.00 0.00 823.12 2,064.24 2,887.36 28,310.61 08/24/2009 625143 0.00 0.00 0.00 479.13 0.00 0.00 479.13 4,692.98 10/19/2009 639456 1,139.59 0.00 0.00 0.00 0.00 0.00 0.00 11,336.25 10/19/2009 641630 0.00 0.00 0.00 0.00 1,721.92 3,652.58 5,374.50 53,501.59 10/19/2009 641675 0.00 0.00 0.00 540.94 0.00 0.00 540.94 5,385.22 10/26/2009 642713 0.00 0.00 0.00 0.00 0.00 0.53 0.53 5.68 11/09/2009 647676 0.00 0.00 0.00 1,250.63 0.00 0.00 1,250.63 1,296.65 11/16/2009 650044 0.00 0.00 0.00 106.21 0.00 0.00 106.21 1,058.72 11/30/2009 652115 67.78 0.00 0.00 0.00 0.00 1.88 1.88 692.89 11/30/2009 654120 0.00 0.00 0.00 0.00 37.33 101.52 138.85 1,383.98 11/30/2009 654163 0.00 0.00 0.00 15.28 0.00 0.00 15.28 162.88 12/07/2009 654199 75.52 0.00 0.00 0.00 0.00 0.00 0.00 750.96 12/07/2009 656147 0.00 0.00 0.00 0.00 55.53 189.04 244.57 2,432.02 12/07/2009 656184 0.00 0.00 0.00 35.76 0.00 0.00 35.76 356.30 12/14/2009 657323 0.00 0.00 0.00 0.00 0.00 20.68 20.68 127.03 12/21/2009 658461 77.68 0.00 0.00 0.00 0.00 0.00 0.00 772.48 12/21/2009 660639 0.00 0.00 0.00 25.56 0.00 0.00 25.56 254.50 12/28/2009 662692 0.00 0.00 0.00 7.13 0.00 0.00 7.13 71.26 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 2,010.63 0.00 0.00 2,460.64 3,040.45 6,739.61 12,240.70 129,861.78 CNTRNUM 2,010.63 0.00 0.00 2,460.64 3,040.45 6,739.61 12,240.70 129,861.78 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 36 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL ---------------------------------------------------------- CONTRACT NUM=3500018 NAME=HENRY CO BD OF DD ---------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/13/2009 611302 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,390.32 07/13/2009 613126 0.00 0.00 0.00 0.00 0.00 0.00 0.00 32,279.58 08/04/2009 619026 0.00 0.00 0.00 1,502.72 0.00 0.00 1,502.72 16,613.76 08/10/2009 619061 434.72 0.00 0.00 0.00 0.00 0.00 0.00 4,755.11 08/10/2009 620930 0.00 0.00 0.00 0.00 1,130.19 4,114.04 5,244.23 57,339.64 08/10/2009 620961 0.00 0.00 0.00 1,314.53 0.00 0.00 1,314.53 14,547.22 08/24/2009 625104 0.00 0.00 0.00 0.00 110.32 827.40 937.72 9,191.56 09/14/2009 629187 149.72 0.00 0.00 0.00 0.00 0.00 0.00 1,467.56 09/14/2009 631379 0.00 0.00 0.00 0.00 758.03 2,771.59 3,529.62 32,814.96 09/14/2009 631415 0.00 0.00 0.00 603.63 0.00 0.00 603.63 5,914.58 09/28/2009 633395 152.07 0.00 0.00 0.00 0.00 0.00 0.00 1,489.25 09/28/2009 635365 0.00 0.00 0.00 0.00 276.26 980.70 1,256.96 12,312.06 09/28/2009 635403 0.00 0.00 0.00 656.50 0.00 0.00 656.50 6,433.76 10/13/2009 637379 309.27 0.00 0.00 0.00 0.00 0.00 0.00 3,075.93 10/13/2009 639388 0.00 0.00 0.00 0.00 890.74 3,524.00 4,414.74 43,920.55 10/13/2009 639422 0.00 0.00 0.00 1,210.36 0.00 0.00 1,210.36 12,042.94 10/26/2009 643650 0.00 0.00 0.00 0.00 3.08 109.98 113.06 1,125.01 11/09/2009 645730 143.56 0.00 0.00 0.00 0.00 0.00 0.00 1,428.94 11/09/2009 647641 0.00 0.00 0.00 0.00 689.30 2,554.27 3,243.57 32,276.19 11/09/2009 647677 0.00 0.00 0.00 1,817.55 0.00 0.00 1,817.55 18,262.92 12/07/2009 654200 149.71 0.00 0.00 0.00 0.00 0.00 0.00 1,488.19 12/07/2009 656148 0.00 0.00 0.00 0.00 214.29 2,915.29 3,129.58 31,127.99 12/14/2009 656217 315.32 0.00 0.00 0.00 0.00 0.00 0.00 3,136.18 12/14/2009 658412 0.00 0.00 0.00 0.00 1,300.81 3,717.50 5,018.31 49,929.56 12/14/2009 658435 0.00 0.00 0.00 1,828.12 0.00 0.00 1,828.12 18,435.98 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 1,654.37 0.00 0.00 8,933.41 5,373.02 21,514.77 35,821.20 412,799.74 CNTRNUM 1,654.37 0.00 0.00 8,933.41 5,373.02 21,514.77 35,821.20 412,799.74 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 37 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL -------------------------------------------------------- CONTRACT NUM=3600017 NAME=HIGHLAND CO BD OF DD --------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 611273 0.00 0.00 0.00 0.00 0.00 0.00 0.00 3,929.48 07/20/2009 613176 128.02 0.00 0.00 0.00 0.00 0.00 0.00 1,400.82 07/20/2009 615130 0.00 0.00 0.00 0.00 204.14 1,719.78 1,923.92 21,051.74 07/27/2009 615187 89.96 0.00 0.00 0.00 0.00 0.00 0.00 984.36 07/27/2009 617036 0.00 0.00 0.00 0.00 162.62 1,769.79 1,932.41 21,144.81 07/27/2009 617071 0.00 0.00 0.00 260.74 0.00 0.00 260.74 2,850.40 08/04/2009 618995 0.00 0.00 0.00 0.00 0.00 23.82 23.82 260.48 08/04/2009 619027 0.00 0.00 0.00 81.00 0.00 0.00 81.00 885.66 08/17/2009 620982 87.84 0.00 0.00 0.00 0.00 0.00 0.00 860.57 08/17/2009 623128 0.00 0.00 0.00 0.00 107.97 1,096.91 1,204.88 11,805.73 08/17/2009 623152 0.00 0.00 0.00 118.39 0.00 0.00 118.39 1,160.52 08/24/2009 623177 34.74 0.00 0.00 0.00 0.00 0.00 0.00 340.74 08/24/2009 625105 0.00 0.00 0.00 0.00 42.46 23.16 65.62 643.62 08/24/2009 625144 0.00 0.00 0.00 60.24 0.00 0.00 60.24 590.44 08/31/2009 627195 0.00 0.00 0.00 5.20 0.00 0.00 5.20 50.90 09/14/2009 629188 337.75 0.00 0.00 0.00 0.00 0.00 0.00 3,312.75 09/14/2009 631380 0.00 0.00 0.00 0.00 393.72 3,352.41 3,746.13 36,743.13 09/14/2009 631416 0.00 0.00 0.00 326.13 0.00 0.00 326.13 3,196.52 09/28/2009 633396 20.74 0.00 0.00 0.00 0.00 0.00 0.00 203.22 09/28/2009 635366 0.00 0.00 0.00 0.00 29.89 301.70 331.59 3,249.70 09/28/2009 635404 0.00 0.00 0.00 691.76 0.00 0.00 691.76 6,779.88 10/06/2009 635434 89.30 0.00 0.00 0.00 0.00 0.00 0.00 889.71 10/06/2009 637308 0.00 0.00 0.00 0.00 172.90 1,366.10 1,539.00 15,333.30 10/13/2009 639423 0.00 0.00 0.00 903.76 0.00 0.00 903.76 8,703.90 10/19/2009 639457 7.21 0.00 0.00 0.00 0.00 0.00 0.00 71.75 10/19/2009 641631 0.00 0.00 0.00 0.00 41.84 135.09 176.93 1,760.97 10/19/2009 641676 0.00 0.00 0.00 307.67 0.00 0.00 307.67 3,003.10 10/26/2009 641718 279.25 0.00 0.00 0.00 0.00 0.00 0.00 2,779.13 10/26/2009 643651 0.00 0.00 0.00 0.00 332.68 2,445.38 2,778.06 27,650.16 10/26/2009 643682 0.00 0.00 0.00 141.17 0.00 0.00 141.17 1,404.84 11/23/2009 650064 512.59 0.00 0.00 0.00 0.00 0.00 0.00 5,103.36 11/23/2009 652056 0.00 0.00 0.00 0.00 498.91 5,687.60 6,186.51 61,596.81 11/23/2009 652086 0.00 0.00 0.00 117.53 0.00 0.00 117.53 332.70 11/30/2009 652116 81.70 0.00 0.00 0.00 0.00 0.00 0.00 813.99 11/30/2009 654121 0.00 0.00 0.00 0.00 1.87 35.56 37.43 373.08 11/30/2009 654164 0.00 0.00 0.00 783.78 0.00 0.00 783.78 7,797.88 12/07/2009 654201 7.21 0.00 0.00 0.00 0.00 0.00 0.00 71.75 12/07/2009 656149 0.00 0.00 0.00 0.00 0.00 78.93 78.93 785.64 12/14/2009 658413 0.00 0.00 0.00 0.00 0.00 1,918.05 1,918.05 19,094.35 12/21/2009 659583 0.00 0.00 0.00 0.00 0.00 13.09 13.09 -4.47 12/21/2009 660640 0.00 0.00 0.00 10.24 0.00 0.00 10.24 101.80 12/28/2009 662659 0.00 0.00 0.00 0.00 0.00 64.67 64.67 643.66 12/28/2009 662693 0.00 0.00 0.00 38.87 0.00 0.00 38.87 193.42 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 1,676.31 0.00 0.00 3,846.48 1,989.00 20,032.04 25,867.52 279,946.30 CNTRNUM 1,676.31 0.00 0.00 3,846.48 1,989.00 20,032.04 25,867.52 279,946.30 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 38 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL --------------------------------------------------------- CONTRACT NUM=3700016 NAME=HOCKING CO BD OF DD --------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 609491 0.00 0.00 0.00 0.00 0.00 0.00 0.00 972.51 07/06/2009 611232 0.00 0.00 0.00 0.00 0.00 0.00 0.00 38,679.40 07/13/2009 613148 0.00 0.00 0.00 0.00 0.00 0.00 0.00 7,614.64 08/17/2009 620983 140.17 0.00 0.00 0.00 0.00 0.00 0.00 1,375.32 08/17/2009 623129 0.00 0.00 0.00 0.00 3,706.29 1,425.09 5,131.38 50,329.31 09/08/2009 627230 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,286.13 09/08/2009 629123 0.00 0.00 0.00 0.00 3,532.61 1,300.97 4,833.58 47,408.62 09/14/2009 631417 0.00 0.00 0.00 905.80 0.00 0.00 905.80 8,897.32 10/06/2009 637349 0.00 0.00 0.00 802.18 0.00 0.00 802.18 7,981.12 10/19/2009 639458 77.58 0.00 0.00 0.00 0.00 0.00 0.00 1,511.01 10/19/2009 641632 0.00 0.00 0.00 0.00 3,161.69 1,180.63 4,342.32 43,243.54 11/09/2009 647678 0.00 0.00 0.00 94.29 0.00 0.00 94.29 663.03 11/16/2009 647722 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,550.76 11/16/2009 650017 0.00 0.00 0.00 0.00 3,281.51 1,305.95 4,587.46 45,684.16 11/30/2009 653165 0.00 0.00 0.00 0.00 203.48 0.00 203.48 2,024.71 12/07/2009 656185 0.00 0.00 0.00 1,393.69 0.00 0.00 1,393.69 13,885.52 12/21/2009 658462 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,458.99 12/21/2009 660599 0.00 0.00 0.00 0.00 3,046.71 1,096.85 4,143.56 41,261.68 12/28/2009 662694 0.00 0.00 0.00 682.46 0.00 0.00 682.46 6,840.96 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 217.75 0.00 0.00 3,878.42 16,932.29 6,309.49 27,120.20 322,668.73 CNTRNUM 217.75 0.00 0.00 3,878.42 16,932.29 6,309.49 27,120.20 322,668.73 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 39 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL --------------------------------------------------------- CONTRACT NUM=3800015 NAME=HOLMES CO BD OF DD ---------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 609492 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,193.14 07/06/2009 611233 0.00 0.00 0.00 0.00 0.00 0.00 0.00 68,440.43 08/31/2009 625173 151.61 0.00 0.00 0.00 0.00 0.00 0.00 1,485.90 08/31/2009 627154 0.00 0.00 0.00 0.00 4,243.44 3,721.55 7,964.99 78,066.76 09/21/2009 631445 146.97 0.00 0.00 0.00 0.00 0.00 0.00 1,440.48 09/21/2009 633325 0.00 0.00 0.00 0.00 4,525.79 3,985.02 8,510.81 83,419.72 10/26/2009 641719 175.42 0.00 0.00 0.00 0.00 0.00 0.00 1,746.58 10/26/2009 643652 0.00 0.00 0.00 0.00 3,734.40 3,366.50 7,100.90 70,656.34 11/09/2009 647679 0.00 0.00 0.00 3,342.66 0.00 0.00 3,342.66 33,044.15 11/30/2009 652117 300.63 0.00 0.00 0.00 0.00 0.00 0.00 2,993.67 11/30/2009 654122 0.00 0.00 0.00 0.00 4,288.82 3,668.46 7,957.28 79,178.16 11/30/2009 654165 0.00 0.00 0.00 2,767.37 0.00 0.00 2,767.37 27,536.90 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 774.63 0.00 0.00 6,110.03 16,792.45 14,741.53 37,644.01 449,202.23 CNTRNUM 774.63 0.00 0.00 6,110.03 16,792.45 14,741.53 37,644.01 449,202.23 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 40 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL ---------------------------------------------------------- CONTRACT NUM=3900014 NAME=HURON CO BD OF DD ---------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 08/24/2009 623178 2,826.10 0.00 0.00 0.00 0.00 0.00 0.00 31,457.54 08/24/2009 625106 0.00 0.00 0.00 0.00 6,296.41 14,132.11 20,428.52 200,224.20 08/24/2009 625145 0.00 0.00 0.00 2,017.38 0.00 0.00 2,017.38 20,105.50 08/31/2009 627196 0.00 0.00 0.00 727.23 0.00 0.00 727.23 7,563.74 09/08/2009 629155 0.00 0.00 0.00 62.32 0.00 0.00 62.32 315.58 09/14/2009 629189 781.67 0.00 0.00 0.00 0.00 0.00 0.00 8,197.08 09/14/2009 631381 0.00 0.00 0.00 0.00 1,689.44 2,954.31 4,643.75 45,509.62 09/14/2009 631418 0.00 0.00 0.00 327.24 0.00 0.00 327.24 3,308.50 09/21/2009 631446 362.48 0.00 0.00 0.00 0.00 0.00 0.00 4,055.10 09/21/2009 633326 0.00 0.00 0.00 0.00 1,097.29 2,233.98 3,331.27 32,653.21 09/28/2009 635405 0.00 0.00 0.00 2,005.82 0.00 0.00 2,005.82 19,871.36 10/06/2009 635435 36.23 0.00 0.00 0.00 0.00 0.00 0.00 360.23 10/06/2009 637309 0.00 0.00 0.00 0.00 70.66 453.34 524.00 5,211.97 10/13/2009 637380 48.60 0.00 0.00 0.00 0.00 0.00 0.00 483.57 10/13/2009 639389 0.00 0.00 0.00 0.00 117.77 852.60 970.37 9,596.96 10/19/2009 641633 0.00 0.00 0.00 0.00 0.00 144.42 144.42 1,436.77 10/26/2009 643683 0.00 0.00 0.00 33.22 0.00 0.00 33.22 183.24 11/02/2009 643712 760.14 0.00 0.00 0.00 0.00 0.00 0.00 8,366.73 11/02/2009 645665 0.00 0.00 0.00 0.00 1,906.37 2,732.12 4,638.49 46,132.89 11/02/2009 645701 0.00 0.00 0.00 2,019.37 0.00 0.00 2,019.37 19,901.90 11/09/2009 647680 0.00 0.00 0.00 186.15 0.00 0.00 186.15 690.82 11/23/2009 650065 341.44 0.00 0.00 0.00 0.00 0.00 0.00 4,170.96 11/23/2009 652057 0.00 0.00 0.00 0.00 1,218.84 2,492.93 3,711.77 36,945.38 11/23/2009 652087 0.00 0.00 0.00 2,164.94 0.00 0.00 2,164.94 21,581.60 11/30/2009 652118 52.20 0.00 0.00 0.00 0.00 0.00 0.00 519.39 11/30/2009 654123 0.00 0.00 0.00 0.00 86.23 851.40 937.63 9,329.73 11/30/2009 654166 0.00 0.00 0.00 253.93 0.00 0.00 253.93 1,852.76 12/14/2009 656218 757.58 0.00 0.00 0.00 0.00 0.00 0.00 9,144.91 12/14/2009 658414 0.00 0.00 0.00 0.00 3,093.40 5,274.21 8,367.61 83,252.32 12/21/2009 660600 0.00 0.00 0.00 0.00 599.47 759.71 1,359.18 13,525.05 12/21/2009 660641 0.00 0.00 0.00 211.76 0.00 0.00 211.76 2,107.26 12/28/2009 660674 125.26 0.00 0.00 0.00 0.00 0.00 0.00 1,389.63 12/28/2009 662660 0.00 0.00 0.00 0.00 374.77 1,035.87 1,410.64 14,031.83 12/28/2009 662695 0.00 0.00 0.00 501.71 0.00 0.00 501.71 4,947.48 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 6,091.70 0.00 0.00 10,511.07 16,550.65 33,917.00 60,978.72 668,424.81 CNTRNUM 6,091.70 0.00 0.00 10,511.07 16,550.65 33,917.00 60,978.72 668,424.81 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 41 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL --------------------------------------------------------- CONTRACT NUM=4000011 NAME=JACKSON CO BD OF DD --------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/27/2009 615188 223.17 0.00 0.00 0.00 0.00 0.00 0.00 2,441.97 07/27/2009 617037 0.00 0.00 0.00 0.00 0.00 525.92 525.92 5,754.72 07/27/2009 617072 0.00 0.00 0.00 18.62 0.00 0.00 18.62 203.60 08/04/2009 618088 0.00 0.00 0.00 0.00 0.00 31.14 31.14 113.58 08/10/2009 619062 802.18 0.00 0.00 0.00 0.00 0.00 0.00 8,769.30 08/10/2009 620931 0.00 0.00 0.00 0.00 164.25 1,063.22 1,227.47 13,414.57 08/10/2009 620962 0.00 0.00 0.00 1.86 0.00 0.00 1.86 20.36 08/17/2009 620984 81.06 0.00 0.00 0.00 0.00 0.00 0.00 795.06 08/17/2009 623130 0.00 0.00 0.00 0.00 0.00 13.51 13.51 132.51 08/24/2009 623179 16.24 0.00 0.00 0.00 0.00 0.00 0.00 159.25 08/24/2009 625107 0.00 0.00 0.00 0.00 7.32 61.58 68.90 676.11 09/08/2009 629124 0.00 0.00 0.00 0.00 161.04 166.30 327.34 3,210.20 09/08/2009 629156 0.00 0.00 0.00 1.04 0.00 0.00 1.04 10.18 09/14/2009 629190 462.50 0.00 0.00 0.00 0.00 0.00 0.00 4,536.50 09/14/2009 631382 0.00 0.00 0.00 0.00 131.76 476.77 608.53 5,970.87 09/14/2009 631419 0.00 0.00 0.00 360.59 0.00 0.00 360.59 3,532.46 09/21/2009 631447 144.75 0.00 0.00 0.00 0.00 0.00 0.00 1,419.75 09/21/2009 633327 0.00 0.00 0.00 0.00 0.00 577.07 577.07 5,660.07 09/28/2009 635367 0.00 0.00 0.00 0.00 102.48 0.00 102.48 1,004.50 09/28/2009 635406 0.00 0.00 0.00 388.46 0.00 0.00 388.46 3,807.32 10/19/2009 639460 471.96 0.00 0.00 0.00 0.00 0.00 0.00 4,701.62 10/19/2009 640598 0.00 0.00 0.00 0.00 0.00 17.13 17.13 73.83 10/19/2009 641634 0.00 0.00 0.00 0.00 136.99 1,249.56 1,386.55 13,809.17 11/09/2009 647681 0.00 0.00 0.00 656.77 0.00 0.00 656.77 1,037.06 12/07/2009 654202 2,386.53 0.00 0.00 0.00 0.00 0.00 0.00 23,767.15 12/07/2009 656150 0.00 0.00 0.00 0.00 369.72 3,388.71 3,758.43 37,429.70 12/07/2009 656186 0.00 0.00 0.00 1,626.50 0.00 0.00 1,626.50 16,176.02 12/21/2009 658463 76.99 0.00 0.00 0.00 0.00 0.00 0.00 766.38 12/21/2009 660601 0.00 0.00 0.00 0.00 4.61 364.29 368.90 3,670.18 12/21/2009 660642 0.00 0.00 0.00 9.21 0.00 0.00 9.21 91.62 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 4,665.38 0.00 0.00 3,063.05 1,078.17 7,935.20 12,076.42 163,155.61 CNTRNUM 4,665.38 0.00 0.00 3,063.05 1,078.17 7,935.20 12,076.42 163,155.61 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 42 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL -------------------------------------------------------- CONTRACT NUM=4100010 NAME=JEFFERSON CO BD OF DD -------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 609493 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,301.92 07/06/2009 611234 0.00 0.00 0.00 0.00 0.00 0.00 0.00 51,263.12 07/13/2009 611303 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,294.02 07/13/2009 613127 0.00 0.00 0.00 0.00 0.00 0.00 0.00 4,215.38 07/20/2009 614185 0.00 0.00 0.00 0.00 0.00 5.05 5.05 -85.13 07/20/2009 615131 0.00 0.00 0.00 0.00 0.76 0.00 0.76 -114.11 07/27/2009 615189 184.26 0.00 0.00 0.00 0.00 0.00 0.00 2,016.08 07/27/2009 617038 0.00 0.00 0.00 0.00 846.21 2,905.51 3,751.72 41,021.87 08/24/2009 623180 213.26 0.00 0.00 0.00 0.00 0.00 0.00 2,090.34 08/24/2009 625108 0.00 0.00 0.00 0.00 1,909.43 4,942.85 6,852.28 67,174.26 08/24/2009 625146 0.00 0.00 0.00 1,651.68 0.00 0.00 1,651.68 16,186.20 09/28/2009 633397 3.82 0.00 0.00 0.00 0.00 0.00 0.00 37.46 09/28/2009 635368 0.00 0.00 0.00 0.00 1,730.87 2,293.91 4,024.78 39,470.03 09/28/2009 635407 0.00 0.00 0.00 1,643.53 0.00 0.00 1,643.53 16,104.76 10/06/2009 635436 211.36 0.00 0.00 0.00 0.00 0.00 0.00 2,102.98 10/06/2009 637310 0.00 0.00 0.00 0.00 1,000.33 3,471.93 4,472.26 44,496.24 10/06/2009 637350 0.00 0.00 0.00 1,516.17 0.00 0.00 1,516.17 15,086.76 10/19/2009 641635 0.00 0.00 0.00 0.00 2,836.88 3,511.32 6,348.20 63,218.23 11/02/2009 643713 235.19 0.00 0.00 0.00 0.00 0.00 0.00 2,339.98 11/02/2009 645666 0.00 0.00 0.00 0.00 5,059.78 7,888.78 12,948.56 128,906.35 11/16/2009 650045 0.00 0.00 0.00 1,245.30 0.00 0.00 1,245.30 12,399.24 11/23/2009 652058 0.00 0.00 0.00 0.00 0.00 11.88 11.88 118.25 11/30/2009 654124 0.00 0.00 0.00 0.00 4,873.71 3,392.62 8,266.33 82,307.38 12/14/2009 658436 0.00 0.00 0.00 1,648.27 0.00 0.00 1,648.27 16,399.98 12/21/2009 658464 207.55 0.00 0.00 0.00 0.00 0.00 0.00 2,065.06 12/21/2009 660602 0.00 0.00 0.00 0.00 2,874.62 4,691.86 7,566.48 75,283.34 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 1,055.44 0.00 0.00 7,704.95 21,132.59 33,115.71 61,953.25 686,699.99 CNTRNUM 1,055.44 0.00 0.00 7,704.95 21,132.59 33,115.71 61,953.25 686,699.99 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 43 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL ---------------------------------------------------------- CONTRACT NUM=4200019 NAME=KNOX CO BD OF DD ----------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/27/2009 617073 0.00 0.00 0.00 5,399.05 0.00 0.00 5,399.05 59,817.68 08/04/2009 619028 0.00 0.00 0.00 14.90 0.00 0.00 14.90 101.80 08/24/2009 625109 0.00 0.00 0.00 0.00 18.26 0.00 18.26 179.01 08/31/2009 627198 0.00 0.00 0.00 4,167.76 0.00 0.00 4,167.76 41,371.52 09/08/2009 629125 0.00 0.00 0.00 0.00 32.46 0.00 32.46 318.24 10/06/2009 637311 0.00 0.00 0.00 0.00 21.31 0.00 21.31 212.16 10/13/2009 639424 0.00 0.00 0.00 3,387.00 0.00 0.00 3,387.00 34,133.54 10/26/2009 643684 0.00 0.00 0.00 3,452.12 0.00 0.00 3,452.12 35,416.22 11/09/2009 647642 0.00 0.00 0.00 0.00 56.62 0.00 56.62 563.55 11/09/2009 647682 0.00 0.00 0.00 14.32 0.00 0.00 14.32 50.90 11/23/2009 652088 0.00 0.00 0.00 3,921.05 0.00 0.00 3,921.05 40,231.36 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 0.00 0.00 0.00 20,356.20 128.65 0.00 20,484.85 212,395.98 CNTRNUM 0.00 0.00 0.00 20,356.20 128.65 0.00 20,484.85 212,395.98 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 44 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL ---------------------------------------------------------- CONTRACT NUM=4300018 NAME=LAKE CO BD OF DD ----------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/20/2009 613177 1,608.20 0.00 0.00 0.00 0.00 0.00 0.00 17,577.85 07/20/2009 615132 0.00 0.00 0.00 0.00 1,227.95 37,814.62 39,042.57 426,690.34 07/20/2009 615160 0.00 0.00 0.00 2,111.00 0.00 0.00 2,111.00 23,312.20 08/17/2009 620985 721.93 0.00 0.00 0.00 0.00 0.00 0.00 7,076.24 08/17/2009 623131 0.00 0.00 0.00 0.00 356.49 15,281.45 15,637.94 153,287.81 08/24/2009 623181 217.97 0.00 0.00 0.00 0.00 0.00 0.00 2,137.87 08/24/2009 625110 0.00 0.00 0.00 0.00 271.30 7,500.59 7,771.89 76,238.58 08/24/2009 625147 0.00 0.00 0.00 2,820.22 0.00 0.00 2,820.22 27,638.70 09/21/2009 631448 1,209.11 0.00 0.00 0.00 0.00 0.00 0.00 11,855.35 09/21/2009 633328 0.00 0.00 0.00 0.00 653.47 22,712.59 23,366.06 229,091.82 09/21/2009 633362 0.00 0.00 0.00 2,561.64 0.00 0.00 2,561.64 25,114.06 09/28/2009 633398 715.90 0.00 0.00 0.00 0.00 0.00 0.00 7,021.84 09/28/2009 635369 0.00 0.00 0.00 0.00 466.17 17,852.11 18,318.28 179,645.17 09/28/2009 635408 0.00 0.00 0.00 2,506.83 0.00 0.00 2,506.83 24,564.34 10/26/2009 641720 2,568.44 0.00 0.00 0.00 0.00 0.00 0.00 25,565.43 10/26/2009 643653 0.00 0.00 0.00 0.00 1,112.63 39,193.86 40,306.49 401,195.52 11/02/2009 644779 0.00 0.00 0.00 0.00 0.00 25.71 25.71 256.10 12/07/2009 654203 3,039.08 0.00 0.00 0.00 0.00 0.00 0.00 30,256.93 12/07/2009 656151 0.00 0.00 0.00 0.00 977.89 34,486.34 35,464.23 353,066.70 12/07/2009 656187 0.00 0.00 0.00 2,017.53 0.00 0.00 2,017.53 20,095.32 12/21/2009 658465 560.34 0.00 0.00 0.00 0.00 0.00 0.00 5,575.10 12/21/2009 660603 0.00 0.00 0.00 0.00 207.90 7,369.56 7,577.46 75,391.90 12/28/2009 660675 2,198.94 0.00 0.00 0.00 0.00 0.00 0.00 21,891.40 12/28/2009 662661 0.00 0.00 0.00 0.00 807.83 27,872.26 28,680.09 285,523.21 12/28/2009 662696 0.00 0.00 0.00 2,395.06 0.00 0.00 2,395.06 23,831.38 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 12,839.91 0.00 0.00 14,412.28 6,081.63 210,109.09 230,603.00 2,453,901.16 CNTRNUM 12,839.91 0.00 0.00 14,412.28 6,081.63 210,109.09 230,603.00 2,453,901.16 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 45 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL -------------------------------------------------------- CONTRACT NUM=4400017 NAME=LAWRENCE CO BD OF DD --------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/13/2009 611304 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2,456.55 07/13/2009 613128 0.00 0.00 0.00 0.00 0.00 0.00 0.00 22,739.10 07/13/2009 613149 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,689.88 08/04/2009 619029 0.00 0.00 0.00 1,161.22 0.00 0.00 1,161.22 12,694.46 08/10/2009 619063 178.19 0.00 0.00 0.00 0.00 0.00 0.00 1,949.79 08/10/2009 620932 0.00 0.00 0.00 0.00 813.34 896.14 1,709.48 18,705.21 08/10/2009 620963 0.00 0.00 0.00 553.11 0.00 0.00 553.11 6,046.92 08/24/2009 623182 241.25 0.00 0.00 0.00 0.00 0.00 0.00 2,366.25 08/24/2009 625111 0.00 0.00 0.00 0.00 874.29 1,032.55 1,906.84 18,702.84 08/24/2009 625148 0.00 0.00 0.00 31.18 0.00 0.00 31.18 305.40 08/31/2009 627155 0.00 0.00 0.00 0.00 77.02 0.00 77.02 734.99 08/31/2009 627199 0.00 0.00 0.00 113.57 0.00 0.00 113.57 366.48 09/08/2009 628305 0.00 0.00 0.00 0.00 0.00 3.86 3.86 18.93 09/14/2009 629191 222.27 0.00 0.00 0.00 0.00 0.00 0.00 2,181.48 09/14/2009 631383 0.00 0.00 0.00 0.00 646.79 1,127.04 1,773.83 17,393.44 09/28/2009 633399 3.86 0.00 0.00 0.00 0.00 0.00 0.00 37.86 09/28/2009 635370 0.00 0.00 0.00 0.00 73.93 58.21 132.14 1,295.49 09/28/2009 635409 0.00 0.00 0.00 4,249.33 0.00 0.00 4,249.33 41,646.38 10/06/2009 635437 573.53 0.00 0.00 0.00 0.00 0.00 0.00 5,713.71 10/06/2009 637312 0.00 0.00 0.00 0.00 1,623.54 2,645.47 4,269.01 42,519.46 10/13/2009 639425 0.00 0.00 0.00 1.02 0.00 0.00 1.02 10.18 10/19/2009 639461 169.10 0.00 0.00 0.00 0.00 0.00 0.00 1,684.77 10/19/2009 641636 0.00 0.00 0.00 0.00 560.50 739.10 1,299.60 12,948.12 10/19/2009 641677 0.00 0.00 0.00 221.03 0.00 0.00 221.03 122.16 10/26/2009 641721 450.36 0.00 0.00 0.00 0.00 0.00 0.00 4,484.12 10/26/2009 643654 0.00 0.00 0.00 0.00 782.20 1,051.99 1,834.19 18,265.97 10/26/2009 643685 0.00 0.00 0.00 294.64 0.00 0.00 294.64 2,931.84 11/02/2009 645702 0.00 0.00 0.00 301.23 0.00 0.00 301.23 2,667.16 11/09/2009 647683 0.00 0.00 0.00 5,185.03 0.00 0.00 5,185.03 2,416.16 11/30/2009 652119 1,404.04 0.00 0.00 0.00 0.00 3.80 3.80 14,003.38 11/30/2009 654125 0.00 0.00 0.00 0.00 3,113.13 3,496.81 6,609.94 65,841.43 11/30/2009 654167 0.00 0.00 0.00 3,587.34 0.00 0.00 3,587.34 35,701.26 12/07/2009 656188 0.00 0.00 0.00 717.12 0.00 0.00 717.12 7,136.18 12/14/2009 658437 0.00 0.00 0.00 314.13 0.00 0.00 314.13 3,125.26 12/21/2009 658466 3.99 0.00 0.00 0.00 0.00 0.00 0.00 39.75 12/21/2009 660604 0.00 0.00 0.00 0.00 160.40 96.10 256.50 2,552.61 12/21/2009 660643 0.00 0.00 0.00 59.35 0.00 0.00 59.35 590.44 12/28/2009 662697 0.00 0.00 0.00 1,983.90 0.00 0.00 1,983.90 19,667.76 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 3,246.59 0.00 0.00 18,773.20 8,725.14 11,151.07 38,649.41 393,753.17 CNTRNUM 3,246.59 0.00 0.00 18,773.20 8,725.14 11,151.07 38,649.41 393,753.17 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 46 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL --------------------------------------------------------- CONTRACT NUM=4500016 NAME=LICKING CO BD OF DD --------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/27/2009 615190 10.17 0.00 0.00 0.00 0.00 0.00 0.00 110.00 07/27/2009 617039 0.00 0.00 0.00 0.00 89.33 65.93 155.26 1,692.00 08/04/2009 619030 0.00 0.00 0.00 4,465.64 0.00 0.00 4,465.64 49,199.94 09/21/2009 631449 3,535.80 0.00 0.00 0.00 0.00 0.00 0.00 37,886.18 09/21/2009 633329 0.00 0.00 0.00 0.00 8,204.38 25,181.91 33,386.29 327,411.94 09/21/2009 633364 0.00 0.00 0.00 10,426.59 0.00 0.00 10,426.59 102,614.40 10/13/2009 637381 1,280.08 0.00 0.00 0.00 0.00 0.00 0.00 15,363.50 10/13/2009 639390 0.00 0.00 0.00 0.00 3,635.24 9,070.21 12,705.45 126,351.04 10/13/2009 639426 0.00 0.00 0.00 4,284.83 0.00 0.00 4,284.83 43,885.98 11/09/2009 645731 1,171.36 0.00 0.00 0.00 0.00 0.00 0.00 14,365.60 11/09/2009 647643 0.00 0.00 0.00 0.00 3,444.65 8,678.99 12,123.64 120,546.71 11/09/2009 647684 0.00 0.00 0.00 3,682.17 0.00 0.00 3,682.17 37,767.80 11/23/2009 650066 1,066.74 0.00 0.00 0.00 0.00 0.00 0.00 12,506.06 11/23/2009 652059 0.00 0.00 0.00 0.00 3,265.65 7,672.04 10,937.69 108,761.74 11/23/2009 652089 0.00 0.00 0.00 4,047.12 0.00 0.00 4,047.12 42,124.84 12/07/2009 655294 0.00 0.00 0.00 0.00 31.11 0.00 31.11 309.55 12/21/2009 659687 0.00 0.00 0.00 0.00 147.33 0.00 147.33 1,466.00 12/28/2009 660676 888.58 0.00 0.00 0.00 0.00 0.00 0.00 9,159.91 12/28/2009 662662 0.00 0.00 0.00 0.00 2,394.09 6,272.97 8,667.06 86,208.64 12/28/2009 662698 0.00 0.00 0.00 4,044.29 0.00 0.00 4,044.29 42,633.84 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 7,952.73 0.00 0.00 30,950.64 21,211.78 56,942.05 109,104.47 1,180,365.67 CNTRNUM 7,952.73 0.00 0.00 30,950.64 21,211.78 56,942.05 109,104.47 1,180,365.67 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 47 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL ---------------------------------------------------------- CONTRACT NUM=4600015 NAME=LOGAN CO BD OF DD ---------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 609494 0.00 0.00 0.00 0.00 0.00 0.00 0.00 637.23 07/06/2009 611235 0.00 0.00 0.00 0.00 0.00 0.00 0.00 7,318.49 07/06/2009 611274 0.00 0.00 0.00 0.00 0.00 0.00 0.00 5,039.10 07/20/2009 615133 0.00 0.00 0.00 0.00 0.00 3.29 3.29 35.82 07/20/2009 615162 0.00 0.00 0.00 27.00 0.00 0.00 27.00 295.22 08/04/2009 619031 0.00 0.00 0.00 830.62 0.00 0.00 830.62 9,080.56 08/10/2009 620964 0.00 0.00 0.00 17.70 0.00 0.00 17.70 71.26 08/17/2009 620986 231.57 0.00 0.00 0.00 0.00 0.00 0.00 2,270.75 08/17/2009 623132 0.00 0.00 0.00 0.00 1,385.14 5,319.50 6,704.64 65,711.60 08/17/2009 623153 0.00 0.00 0.00 441.55 0.00 0.00 441.55 4,326.50 08/24/2009 623183 188.14 0.00 0.00 0.00 0.00 0.00 0.00 1,844.50 08/24/2009 625112 0.00 0.00 0.00 0.00 1,287.42 3,657.39 4,944.81 48,465.88 08/31/2009 627200 0.00 0.00 0.00 2.08 0.00 0.00 2.08 20.36 09/08/2009 628347 0.00 0.00 0.00 0.00 0.00 35.46 35.46 123.26 09/21/2009 633330 0.00 0.00 0.00 0.00 45.92 452.35 498.27 4,884.03 09/21/2009 633365 0.00 0.00 0.00 696.03 0.00 0.00 696.03 6,820.60 09/28/2009 635371 0.00 0.00 0.00 0.00 0.00 142.45 142.45 1,395.41 09/28/2009 635410 0.00 0.00 0.00 92.95 0.00 0.00 92.95 397.02 10/06/2009 635438 110.40 0.00 0.00 0.00 0.00 0.00 0.00 1,098.75 10/06/2009 637313 0.00 0.00 0.00 0.00 500.27 2,223.69 2,723.96 27,097.29 10/13/2009 637382 66.24 0.00 0.00 0.00 0.00 0.00 0.00 659.25 10/13/2009 639391 0.00 0.00 0.00 0.00 511.94 2,328.94 2,840.88 28,260.16 10/13/2009 639427 0.00 0.00 0.00 145.30 0.00 0.00 145.30 1,445.56 10/19/2009 641678 0.00 0.00 0.00 184.82 0.00 0.00 184.82 1,496.46 11/02/2009 643714 101.90 0.00 0.00 0.00 0.00 0.00 0.00 1,014.25 11/02/2009 645667 0.00 0.00 0.00 0.00 901.97 2,398.64 3,300.61 32,852.19 11/02/2009 645703 0.00 0.00 0.00 1,228.47 0.00 0.00 1,228.47 10,597.38 11/09/2009 647685 0.00 0.00 0.00 3,062.19 0.00 0.00 3,062.19 2,627.62 11/16/2009 649056 0.00 0.00 0.00 0.00 0.00 27.00 27.00 8.15 11/30/2009 652120 228.16 0.00 0.00 0.00 0.00 0.00 0.00 2,270.75 11/30/2009 654126 0.00 0.00 0.00 0.00 1,240.77 4,929.98 6,170.75 61,387.00 11/30/2009 654168 0.00 0.00 0.00 1,271.07 0.00 0.00 1,271.07 12,409.42 12/07/2009 656153 0.00 0.00 0.00 0.00 77.61 312.61 390.22 3,881.86 12/07/2009 656189 0.00 0.00 0.00 61.39 0.00 0.00 61.39 610.80 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 926.41 0.00 0.00 8,061.17 5,951.04 21,831.30 35,843.51 346,454.48 CNTRNUM 926.41 0.00 0.00 8,061.17 5,951.04 21,831.30 35,843.51 346,454.48 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 48 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL --------------------------------------------------------- CONTRACT NUM=4700014 NAME=LORAIN CO BD OF DD ---------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 610503 0.00 0.00 0.00 0.00 0.00 0.00 0.00 347,399.83 07/13/2009 611305 0.00 0.00 0.00 0.00 0.00 0.00 0.00 24.36 07/13/2009 613129 0.00 0.00 0.00 0.00 0.00 0.00 0.00 140.07 08/10/2009 619064 683.87 0.00 0.00 0.00 0.00 0.00 0.00 7,466.30 08/10/2009 620933 0.00 0.00 0.00 0.00 968.89 5,148.22 6,117.11 66,779.50 08/24/2009 624293 0.00 0.00 0.00 0.00 0.00 341.73 341.73 3,349.89 08/31/2009 625174 433.02 0.00 0.00 0.00 0.00 0.00 0.00 4,246.28 08/31/2009 627156 0.00 0.00 0.00 0.00 0.00 2,797.75 2,797.75 27,424.14 09/08/2009 627231 323.61 0.00 0.00 0.00 0.00 0.00 0.00 3,171.70 09/08/2009 629126 0.00 0.00 0.00 0.00 0.00 2,546.43 2,546.43 24,958.15 09/08/2009 629159 0.00 0.00 0.00 22,448.87 0.00 0.00 22,448.87 220,030.52 09/14/2009 629192 1,260.27 0.00 0.00 0.00 0.00 0.00 0.00 12,351.90 09/14/2009 630448 0.00 0.00 0.00 0.00 0.00 22,078.30 22,078.30 216,462.07 09/14/2009 631384 0.00 0.00 0.00 0.00 1,063.29 22,774.22 23,837.51 233,631.54 09/14/2009 631420 0.00 0.00 0.00 221.18 0.00 0.00 221.18 2,168.34 09/21/2009 631450 5.79 0.00 0.00 0.00 0.00 0.00 0.00 56.81 09/21/2009 632548 0.00 0.00 0.00 0.00 0.00 11,453.15 11,453.15 112,276.11 09/21/2009 633331 0.00 0.00 0.00 0.00 254.39 455.75 710.14 6,450.17 09/21/2009 633366 0.00 0.00 0.00 4.16 0.00 0.00 4.16 40.72 09/28/2009 635372 0.00 0.00 0.00 0.00 28.60 87.49 116.09 1,138.76 10/06/2009 637314 0.00 0.00 0.00 0.00 0.00 23.07 23.07 229.43 10/06/2009 637351 0.00 0.00 0.00 96.18 0.00 0.00 96.18 956.92 10/13/2009 638539 0.00 0.00 0.00 0.00 0.00 115.21 115.21 630.40 10/19/2009 639462 889.02 0.00 0.00 0.00 0.00 0.00 0.00 8,845.30 10/19/2009 640721 0.00 0.00 0.00 0.00 0.00 27,543.41 27,543.41 274,062.43 10/19/2009 641637 0.00 0.00 0.00 0.00 2,354.22 5,712.30 8,066.52 80,257.80 10/26/2009 642842 0.00 0.00 0.00 0.00 0.00 161.17 161.17 1,600.50 11/09/2009 646827 0.00 0.00 0.00 0.00 0.00 25,575.68 25,575.68 254,480.81 11/09/2009 647686 0.00 0.00 0.00 7,495.49 0.00 0.00 7,495.49 74,975.70 11/23/2009 650067 1,055.28 0.00 0.00 0.00 0.00 0.00 0.00 10,502.42 11/23/2009 652060 0.00 0.00 0.00 0.00 1,970.68 16,953.76 18,924.44 188,337.75 11/30/2009 652121 3,259.30 0.00 0.00 0.00 0.00 0.00 0.00 32,438.65 11/30/2009 653282 0.00 0.00 0.00 0.00 0.00 189.72 189.72 1,883.50 11/30/2009 654127 0.00 0.00 0.00 0.00 4,795.82 35,401.11 40,196.93 400,047.35 12/07/2009 654205 6,345.41 0.00 0.00 0.00 0.00 0.00 0.00 63,145.12 12/07/2009 655337 0.00 0.00 0.00 0.00 0.00 6,947.45 6,947.45 69,122.94 12/07/2009 656154 0.00 0.00 0.00 0.00 14,408.28 54,310.27 68,718.55 683,828.40 12/07/2009 656190 0.00 0.00 0.00 8,059.10 0.00 0.00 8,059.10 80,187.86 12/14/2009 658438 0.00 0.00 0.00 903.46 0.00 0.00 903.46 8,988.94 12/21/2009 660605 0.00 0.00 0.00 0.00 55.44 1,641.34 1,696.78 16,884.14 12/28/2009 662699 0.00 0.00 0.00 5.11 0.00 0.00 5.11 50.90 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 14,255.57 0.00 0.00 39,233.55 25,899.61 242,257.53 307,390.69 3,541,024.42 CNTRNUM 14,255.57 0.00 0.00 39,233.55 25,899.61 242,257.53 307,390.69 3,541,024.42 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 49 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL ---------------------------------------------------------- CONTRACT NUM=4800013 NAME=LUCAS CO BD OF DD ---------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 609495 0.00 0.00 0.00 0.00 0.00 0.00 0.00 12,695.83 07/06/2009 611236 0.00 0.00 0.00 0.00 0.00 0.00 0.00 199,556.08 07/06/2009 611275 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,364.12 07/13/2009 611306 0.00 0.00 0.00 0.00 0.00 0.00 0.00 12,465.68 07/13/2009 613130 0.00 0.00 0.00 0.00 0.00 0.00 0.00 192,111.42 07/20/2009 613178 1,021.63 0.00 0.00 0.00 0.00 0.00 0.00 12,800.80 07/20/2009 615134 0.00 0.00 0.00 0.00 6,956.79 10,929.11 17,885.90 192,256.03 07/27/2009 615191 1,002.10 0.00 0.00 0.00 0.00 0.00 0.00 16,656.55 07/27/2009 617040 0.00 0.00 0.00 0.00 5,923.88 10,050.85 15,974.73 174,583.48 07/27/2009 617074 0.00 0.00 0.00 2,354.89 0.00 0.00 2,354.89 25,745.22 08/04/2009 617097 951.32 0.00 0.00 0.00 0.00 0.00 0.00 11,997.75 08/04/2009 618996 0.00 0.00 0.00 0.00 7,178.33 10,616.27 17,794.60 194,104.97 08/04/2009 619032 0.00 0.00 0.00 15,327.39 0.00 0.00 15,327.39 166,493.90 08/10/2009 619065 1,079.83 0.00 0.00 0.00 0.00 0.00 0.00 12,171.10 08/10/2009 620934 0.00 0.00 0.00 0.00 6,981.82 10,723.54 17,705.36 193,498.32 08/10/2009 620965 0.00 0.00 0.00 14.89 0.00 0.00 14.89 162.88 08/17/2009 620987 1,232.88 0.00 0.00 0.00 0.00 0.00 0.00 12,456.70 08/17/2009 623133 0.00 0.00 0.00 0.00 7,365.54 11,160.60 18,526.14 181,625.02 08/24/2009 623184 1,199.33 0.00 0.00 0.00 0.00 0.00 0.00 12,053.89 08/24/2009 625113 0.00 0.00 0.00 0.00 7,715.15 11,127.16 18,842.31 184,726.26 08/24/2009 625149 0.00 0.00 0.00 49.87 0.00 0.00 49.87 488.64 08/31/2009 625175 1,184.80 0.00 0.00 0.00 0.00 0.00 0.00 11,985.42 08/31/2009 627157 0.00 0.00 0.00 0.00 5,285.18 9,764.24 15,049.42 147,540.96 08/31/2009 627201 0.00 0.00 0.00 18,379.18 0.00 0.00 18,379.18 180,175.82 09/08/2009 627232 1,612.72 0.00 0.00 0.00 0.00 0.00 0.00 16,527.24 09/08/2009 629127 0.00 0.00 0.00 0.00 10,735.38 15,816.13 26,551.51 260,185.63 09/08/2009 629160 0.00 0.00 0.00 586.25 0.00 0.00 586.25 5,487.02 09/14/2009 629193 3,053.59 0.00 0.00 0.00 0.00 0.00 0.00 30,660.94 09/14/2009 631385 0.00 0.00 0.00 0.00 8,436.92 13,247.03 21,683.95 212,587.17 09/14/2009 631421 0.00 0.00 0.00 2,197.86 0.00 0.00 2,197.86 23,617.60 09/21/2009 631451 1,319.09 0.00 0.00 0.00 0.00 0.00 0.00 13,672.03 09/21/2009 633332 0.00 0.00 0.00 0.00 8,414.09 13,024.51 21,438.60 209,628.49 09/21/2009 633367 0.00 0.00 0.00 248.23 0.00 0.00 248.23 2,433.02 09/28/2009 633400 1,236.75 0.00 0.00 0.00 0.00 0.00 0.00 12,790.72 09/28/2009 635373 0.00 0.00 0.00 0.00 8,244.70 12,579.13 20,823.83 204,153.90 09/28/2009 635411 0.00 0.00 0.00 5,084.71 0.00 0.00 5,084.71 49,831.10 10/06/2009 635439 1,090.28 0.00 0.00 0.00 0.00 0.00 0.00 11,125.90 10/06/2009 637315 0.00 0.00 0.00 0.00 6,878.52 10,682.56 17,561.08 174,750.64 10/06/2009 637352 0.00 0.00 0.00 14,535.96 0.00 0.00 14,535.96 144,881.76 10/13/2009 637383 1,235.10 0.00 0.00 0.00 0.00 0.00 0.00 13,722.07 10/13/2009 639392 0.00 0.00 0.00 0.00 8,159.54 12,558.48 20,718.02 206,163.22 10/13/2009 639428 0.00 0.00 0.00 1.02 0.00 0.00 1.02 10.18 10/19/2009 639463 1,375.20 0.00 0.00 0.00 0.00 0.00 0.00 15,186.58 10/19/2009 641638 0.00 0.00 0.00 0.00 7,992.33 12,919.40 20,911.73 208,059.38 10/19/2009 641679 0.00 0.00 0.00 154.23 0.00 0.00 154.23 1,425.20 10/26/2009 641722 1,373.78 0.00 0.00 0.00 0.00 0.00 0.00 14,775.00 10/26/2009 643655 0.00 0.00 0.00 0.00 8,028.81 12,823.54 20,852.35 207,498.17 10/26/2009 643686 0.00 0.00 0.00 4,093.12 0.00 0.00 4,093.12 41,167.92 11/02/2009 643715 1,726.46 0.00 0.00 0.00 0.00 7.27 7.27 17,880.57 11/02/2009 645668 0.00 0.00 0.00 0.00 10,409.76 13,465.94 23,875.70 233,937.93 11/02/2009 645704 0.00 0.00 0.00 15,552.84 0.00 0.00 15,552.84 157,250.46 11/09/2009 645732 1,034.06 0.00 0.00 0.00 0.00 0.00 0.00 17,125.64 11/09/2009 647644 0.00 0.00 0.00 0.00 5,864.76 10,679.23 16,543.99 164,608.05 11/09/2009 647687 0.00 0.00 0.00 11,095.60 0.00 0.00 11,095.60 3,144.59 11/16/2009 647723 1,827.96 0.00 0.00 0.00 0.00 23.18 23.18 18,272.22 11/16/2009 650018 0.00 0.00 0.00 0.00 12,454.43 17,079.18 29,533.61 285,879.45 11/16/2009 650046 0.00 0.00 0.00 193.38 0.00 0.00 193.38 2,911.48 11/23/2009 650068 1,305.01 0.00 0.00 0.00 0.00 0.00 0.00 12,982.67 11/23/2009 652061 0.00 0.00 0.00 0.00 5,430.44 9,969.51 15,399.95 153,222.56 11/30/2009 652122 1,343.28 0.00 0.00 0.00 0.00 0.00 0.00 13,363.36 11/30/2009 654128 0.00 0.00 0.00 0.00 5,429.36 10,579.33 16,008.69 158,658.31 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 50 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL ---------------------------------------------------------- CONTRACT NUM=4800013 NAME=LUCAS CO BD OF DD ---------------------------------------------------------- (continued) POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 11/30/2009 654169 0.00 0.00 0.00 22,866.85 0.00 0.00 22,866.85 229,640.44 12/07/2009 654206 1,475.78 0.00 0.00 0.00 0.00 0.00 0.00 14,681.67 12/07/2009 656155 0.00 0.00 0.00 0.00 6,389.90 11,241.93 17,631.83 175,429.55 12/14/2009 656219 2,338.36 0.00 0.00 0.00 0.00 0.00 0.00 23,268.62 12/14/2009 658415 0.00 0.00 0.00 0.00 15,720.40 21,997.72 37,718.12 375,375.35 12/21/2009 658467 1,352.34 0.00 0.00 0.00 0.00 0.00 0.00 13,455.86 12/21/2009 660606 0.00 0.00 0.00 0.00 6,342.50 9,907.45 16,249.95 161,693.42 12/28/2009 660677 1,644.20 0.00 0.00 0.00 0.00 0.00 0.00 16,636.82 12/28/2009 662663 0.00 0.00 0.00 0.00 8,897.63 14,233.83 23,131.46 230,168.88 12/28/2009 662700 0.00 0.00 0.00 674.17 0.00 0.00 674.17 6,708.62 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 34,015.85 0.00 0.00 113,410.44 191,236.16 297,207.12 601,853.72 6,716,354.24 CNTRNUM 34,015.85 0.00 0.00 113,410.44 191,236.16 297,207.12 601,853.72 6,716,354.24 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 51 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL --------------------------------------------------------- CONTRACT NUM=4900012 NAME=MADISON CO BD OF DD --------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 609496 0.00 0.00 0.00 0.00 0.00 0.00 0.00 3,317.44 07/06/2009 611237 0.00 0.00 0.00 0.00 0.00 0.00 0.00 52,073.01 07/13/2009 611307 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2,829.39 07/13/2009 613131 0.00 0.00 0.00 0.00 0.00 0.00 0.00 40,703.32 07/27/2009 615192 136.79 0.00 0.00 0.00 0.00 0.00 0.00 2,040.85 07/27/2009 617041 0.00 0.00 0.00 0.00 0.00 2,467.36 2,467.36 26,967.13 08/17/2009 623154 0.00 0.00 0.00 249.37 0.00 0.00 249.37 2,565.36 08/24/2009 623185 332.68 0.00 0.00 0.00 0.00 0.00 0.00 6,234.32 08/24/2009 625114 0.00 0.00 0.00 0.00 0.00 5,276.71 5,276.71 51,739.56 08/24/2009 625150 0.00 0.00 0.00 9.35 0.00 0.00 9.35 91.62 08/31/2009 627158 0.00 0.00 0.00 0.00 0.00 376.16 376.16 3,689.38 08/31/2009 627202 0.00 0.00 0.00 126.70 0.00 0.00 126.70 702.42 09/08/2009 627233 633.81 0.00 96.13 0.00 0.00 0.00 0.00 10,773.35 09/08/2009 629128 0.00 0.00 0.00 0.00 0.00 10,045.80 10,045.80 98,490.42 09/14/2009 631422 0.00 0.00 0.00 2,234.26 0.00 0.00 2,234.26 22,986.44 09/21/2009 633368 0.00 0.00 0.00 914.08 0.00 0.00 914.08 8,520.66 09/28/2009 635412 0.00 0.00 0.00 869.38 0.00 0.00 869.38 8,826.06 10/06/2009 635440 467.89 0.00 223.83 0.00 0.00 138.16 138.16 7,946.03 10/06/2009 637316 0.00 0.00 0.00 0.00 0.00 6,951.67 6,951.67 69,186.70 10/13/2009 637384 85.12 0.00 0.00 0.00 0.00 0.00 0.00 866.03 10/13/2009 639393 0.00 0.00 0.00 0.00 7,617.93 0.00 7,617.93 75,817.71 10/13/2009 639429 0.00 0.00 0.00 3,104.73 0.00 0.00 3,104.73 31,069.36 10/19/2009 639464 584.31 0.00 123.24 0.00 0.00 0.00 0.00 9,003.10 10/19/2009 641639 0.00 0.00 0.00 0.00 1,067.88 6,773.98 7,841.86 78,048.85 10/19/2009 641680 0.00 0.00 0.00 1,477.22 0.00 0.00 1,477.22 14,862.80 10/26/2009 641723 239.12 0.00 0.00 0.00 0.00 0.00 0.00 4,019.06 10/26/2009 643656 0.00 0.00 0.00 0.00 550.76 3,097.43 3,648.19 36,314.05 10/26/2009 643687 0.00 0.00 0.00 2,011.34 0.00 0.00 2,011.34 20,441.44 11/09/2009 647688 0.00 0.00 0.00 42.96 0.00 0.00 42.96 244.32 12/07/2009 654207 261.15 0.00 0.00 0.00 0.00 0.00 0.00 4,983.94 12/07/2009 656156 0.00 0.00 0.00 0.00 981.35 5,823.98 6,805.33 67,724.20 12/07/2009 656191 0.00 0.00 0.00 2,102.23 0.00 0.00 2,102.23 21,449.26 12/21/2009 660607 0.00 0.00 0.00 0.00 3.70 0.00 3.70 36.81 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 2,740.87 0.00 443.20 13,141.62 10,221.62 40,951.25 64,314.49 784,564.39 CNTRNUM 2,740.87 0.00 443.20 13,141.62 10,221.62 40,951.25 64,314.49 784,564.39 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 52 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL -------------------------------------------------------- CONTRACT NUM=5000019 NAME=MAHONING CO BD OF DD --------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 08/10/2009 619066 741.41 0.00 0.00 0.00 0.00 0.00 0.00 11,648.68 08/10/2009 620935 0.00 0.00 0.00 0.00 3,840.34 11,620.17 15,460.51 169,015.33 08/31/2009 625176 1,178.77 0.00 0.00 0.00 0.00 0.00 0.00 16,065.72 08/31/2009 627159 0.00 0.00 0.00 0.00 6,487.52 18,032.77 24,520.29 240,324.79 09/08/2009 629161 0.00 0.00 0.00 10,102.03 0.00 0.00 10,102.03 99,702.92 09/14/2009 629194 1,341.45 0.00 0.00 0.00 0.00 0.00 0.00 19,746.40 09/14/2009 631386 0.00 0.00 0.00 0.00 7,522.95 18,644.66 26,167.61 256,479.67 09/21/2009 631452 3,665.61 0.00 0.00 0.00 0.00 0.00 0.00 50,973.44 09/21/2009 633333 0.00 0.00 0.00 0.00 22,988.73 52,043.08 75,031.81 735,419.40 09/21/2009 633369 0.00 0.00 0.00 24,857.76 0.00 0.00 24,857.76 245,154.76 10/13/2009 637385 2,448.18 0.00 0.00 0.00 0.00 0.00 0.00 32,207.00 10/13/2009 639394 0.00 0.00 0.00 0.00 16,983.86 32,340.79 49,324.65 490,699.45 11/02/2009 643716 1,332.66 0.00 0.00 0.00 0.00 0.00 0.00 18,225.55 11/02/2009 645669 0.00 0.00 0.00 0.00 10,501.42 16,997.51 27,498.93 273,557.63 11/02/2009 645705 0.00 0.00 0.00 17,083.44 0.00 0.00 17,083.44 172,652.80 12/07/2009 656192 0.00 0.00 0.00 8,031.27 0.00 0.00 8,031.27 61,120.72 12/21/2009 660644 0.00 0.00 0.00 1,468.84 0.00 0.00 1,468.84 14,649.02 12/28/2009 662701 0.00 0.00 0.00 6,586.10 0.00 0.00 6,586.10 66,017.30 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 10,708.08 0.00 0.00 68,129.44 68,324.82 149,678.98 286,133.24 2,973,660.58 CNTRNUM 10,708.08 0.00 0.00 68,129.44 68,324.82 149,678.98 286,133.24 2,973,660.58 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 53 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL --------------------------------------------------------- CONTRACT NUM=5100018 NAME=MARION CO BD OF DD ---------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 611276 0.00 0.00 0.00 0.00 0.00 0.00 0.00 37,930.68 07/27/2009 615193 896.83 0.00 0.00 0.00 0.00 0.00 0.00 11,163.74 07/27/2009 617042 0.00 0.00 0.00 0.00 643.17 15,170.18 15,813.35 172,880.51 08/04/2009 617098 163.12 0.00 0.00 0.00 0.00 0.00 0.00 2,231.25 08/04/2009 618997 0.00 0.00 0.00 0.00 178.26 2,446.42 2,624.68 28,713.00 08/04/2009 619033 0.00 0.00 0.00 1,587.78 0.00 0.00 1,587.78 17,356.90 08/10/2009 619067 743.13 0.00 0.00 0.00 0.00 0.00 0.00 9,505.44 08/10/2009 620936 0.00 0.00 0.00 0.00 592.33 13,105.27 13,697.60 149,767.24 10/13/2009 639430 0.00 0.00 0.00 5,746.71 0.00 0.00 5,746.71 57,181.06 11/09/2009 647689 0.00 0.00 0.00 7.16 0.00 0.00 7.16 20.36 12/07/2009 656157 0.00 0.00 0.00 0.00 0.00 435.20 435.20 4,327.98 12/07/2009 656193 0.00 0.00 0.00 4,677.47 0.00 0.00 4,677.47 42,379.34 12/14/2009 656220 1,137.39 0.00 0.00 0.00 0.00 0.00 0.00 12,736.14 12/14/2009 658416 0.00 0.00 0.00 0.00 878.91 19,090.72 19,969.63 198,618.08 12/28/2009 660678 1,877.60 0.00 0.00 0.00 0.00 0.00 0.00 20,679.65 12/28/2009 662664 0.00 0.00 0.00 0.00 1,548.68 29,887.49 31,436.17 312,744.28 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 4,818.07 0.00 0.00 12,019.12 3,841.35 80,135.28 95,995.75 1,078,235.65 CNTRNUM 4,818.07 0.00 0.00 12,019.12 3,841.35 80,135.28 95,995.75 1,078,235.65 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 54 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL --------------------------------------------------------- CONTRACT NUM=5200017 NAME=MEDINA CO BD OF DD ---------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/27/2009 615194 163.88 0.00 0.00 0.00 0.00 0.00 0.00 1,790.76 07/27/2009 617043 0.00 0.00 0.00 0.00 1,855.40 7,286.11 9,141.51 99,888.91 08/04/2009 617099 340.69 0.00 0.00 0.00 0.00 0.00 0.00 3,721.65 08/04/2009 618998 0.00 0.00 0.00 0.00 4,068.62 17,239.12 21,307.74 232,742.33 08/04/2009 619034 0.00 0.00 0.00 7,850.19 0.00 0.00 7,850.19 86,472.73 10/06/2009 635441 148.89 0.00 0.00 0.00 0.00 0.00 0.00 1,481.50 10/06/2009 637317 0.00 0.00 0.00 0.00 1,487.74 5,562.03 7,049.77 70,139.94 10/06/2009 637353 0.00 0.00 0.00 5,056.70 0.00 0.00 5,056.70 50,322.04 10/13/2009 637386 122.76 0.00 0.00 0.00 0.00 0.00 0.00 1,221.40 10/13/2009 639395 0.00 0.00 0.00 0.00 556.38 3,206.32 3,762.70 37,437.30 10/19/2009 641681 0.00 0.00 0.00 4.09 0.00 0.00 4.09 10.17 11/09/2009 647690 0.00 0.00 0.00 55.35 0.00 0.00 55.35 288.23 11/16/2009 647724 1,539.60 0.00 0.00 0.00 0.00 0.00 0.00 15,323.02 11/16/2009 650019 0.00 0.00 0.00 0.00 9,762.80 43,913.18 53,675.98 534,173.34 11/16/2009 650047 0.00 0.00 0.00 9,783.77 0.00 0.00 9,783.77 97,855.74 11/23/2009 651394 0.00 0.00 0.00 0.00 0.00 4.62 4.62 44.85 11/30/2009 652123 676.76 0.00 0.00 0.00 0.00 0.00 0.00 6,734.94 11/30/2009 654129 0.00 0.00 0.00 0.00 4,756.55 19,625.83 24,382.38 242,662.87 12/21/2009 660608 0.00 0.00 0.00 0.00 42.36 0.00 42.36 421.64 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 2,992.58 0.00 0.00 22,750.10 22,529.85 96,837.21 142,117.16 1,482,733.36 CNTRNUM 2,992.58 0.00 0.00 22,750.10 22,529.85 96,837.21 142,117.16 1,482,733.36 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 55 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL ---------------------------------------------------------- CONTRACT NUM=5300016 NAME=MEIGS CO BD OF DD ---------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 08/04/2009 617100 722.41 0.00 0.00 0.00 0.00 0.00 0.00 7,895.44 08/04/2009 618999 0.00 0.00 0.00 0.00 1,057.03 3,956.35 5,013.38 54,772.59 08/04/2009 619035 0.00 0.00 0.00 1,026.17 0.00 0.00 1,026.17 11,218.36 08/17/2009 620988 222.55 0.00 0.00 0.00 0.00 0.00 0.00 2,181.64 08/17/2009 623134 0.00 0.00 0.00 0.00 428.05 1,364.47 1,792.52 17,572.73 08/24/2009 625151 0.00 0.00 0.00 58.16 0.00 0.00 58.16 570.08 08/31/2009 625177 140.89 0.00 0.00 0.00 0.00 0.00 0.00 1,380.92 08/31/2009 627160 0.00 0.00 0.00 0.00 409.22 846.61 1,255.83 12,311.58 09/14/2009 629195 17.19 0.00 0.00 0.00 0.00 0.00 0.00 168.57 09/14/2009 631387 0.00 0.00 0.00 0.00 13.37 89.77 103.14 1,011.42 09/21/2009 631453 248.29 0.00 0.00 0.00 0.00 0.00 0.00 2,434.42 09/21/2009 633334 0.00 0.00 0.00 0.00 944.29 2,790.45 3,734.74 36,617.61 09/28/2009 633401 139.43 0.00 0.00 0.00 0.00 0.00 0.00 1,367.29 09/28/2009 635374 0.00 0.00 0.00 0.00 189.09 899.61 1,088.70 10,676.10 10/06/2009 637354 0.00 0.00 0.00 1,354.84 0.00 0.00 1,354.84 13,478.32 10/19/2009 641682 0.00 0.00 0.00 4.16 0.00 0.00 4.16 40.72 10/26/2009 641724 321.94 0.00 0.00 0.00 0.00 0.00 0.00 3,205.63 10/26/2009 643657 0.00 0.00 0.00 0.00 569.71 1,865.38 2,435.09 24,240.46 10/26/2009 643688 0.00 0.00 0.00 788.77 0.00 0.00 788.77 7,838.60 11/02/2009 645706 0.00 0.00 0.00 4.09 0.00 0.00 4.09 40.72 11/09/2009 645734 137.24 0.00 0.00 0.00 0.00 0.00 0.00 1,367.29 11/09/2009 647646 0.00 0.00 0.00 0.00 163.56 943.77 1,107.33 11,031.97 11/09/2009 647691 0.00 0.00 0.00 549.34 0.00 0.00 549.34 330.71 11/16/2009 647725 126.56 0.00 0.00 0.00 0.00 0.00 0.00 1,259.26 11/16/2009 650020 0.00 0.00 0.00 0.00 235.42 1,824.78 2,060.20 20,494.18 11/30/2009 652124 350.96 0.00 0.00 0.00 0.00 0.00 0.00 3,494.51 11/30/2009 654130 0.00 0.00 0.00 0.00 406.30 2,117.11 2,523.41 25,122.61 11/30/2009 654170 0.00 0.00 0.00 1,079.88 0.00 0.00 1,079.88 10,729.72 12/07/2009 654208 2.70 0.00 0.00 0.00 0.00 0.00 0.00 26.86 12/07/2009 656158 0.00 0.00 0.00 0.00 5.01 31.66 36.67 364.78 12/07/2009 656194 0.00 0.00 0.00 17.39 0.00 0.00 17.39 335.94 12/28/2009 660679 208.84 0.00 0.00 0.00 0.00 1.90 1.90 2,097.67 12/28/2009 662024 0.00 0.00 0.00 0.00 0.00 4.01 4.01 32.45 12/28/2009 662665 0.00 0.00 0.00 0.00 424.35 1,440.17 1,864.52 18,567.69 12/28/2009 662702 0.00 0.00 0.00 601.87 0.00 0.00 601.87 5,985.84 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 2,639.00 0.00 0.00 5,484.67 4,845.40 18,176.04 28,506.11 310,264.68 CNTRNUM 2,639.00 0.00 0.00 5,484.67 4,845.40 18,176.04 28,506.11 310,264.68 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 56 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL --------------------------------------------------------- CONTRACT NUM=5400015 NAME=MERCER CO BD OF DD ---------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/13/2009 613151 0.00 0.00 0.00 0.00 0.00 0.00 0.00 40.72 07/20/2009 613179 304.48 0.00 0.00 0.00 0.00 0.00 0.00 3,331.68 07/20/2009 615135 0.00 0.00 0.00 0.00 434.23 1,278.64 1,712.87 18,740.70 07/20/2009 615163 0.00 0.00 0.00 512.94 0.00 0.00 512.94 5,609.18 08/04/2009 617101 628.94 0.00 0.00 0.00 0.00 0.00 0.00 6,874.54 08/04/2009 619000 0.00 0.00 0.00 0.00 271.96 941.30 1,213.26 13,252.84 08/04/2009 619036 0.00 0.00 0.00 419.98 0.00 0.00 419.98 4,591.18 08/10/2009 620315 0.00 0.00 0.00 0.00 0.00 48.45 48.45 97.31 08/17/2009 623155 0.00 0.00 0.00 98.66 0.00 0.00 98.66 967.10 08/24/2009 623186 279.85 0.00 0.00 0.00 0.00 0.00 0.00 2,744.85 08/24/2009 625115 0.00 0.00 0.00 0.00 301.08 997.81 1,298.89 12,739.89 08/31/2009 625178 968.95 0.00 0.00 0.00 0.00 0.00 0.00 9,498.81 08/31/2009 627161 0.00 0.00 0.00 0.00 650.48 2,147.58 2,798.06 27,450.54 08/31/2009 627203 0.00 0.00 0.00 68.59 0.00 0.00 68.59 671.88 09/08/2009 628517 0.00 0.00 0.00 0.00 0.00 6.59 6.59 56.79 09/21/2009 631454 266.34 0.00 0.00 0.00 0.00 0.00 0.00 2,612.34 09/21/2009 633335 0.00 0.00 0.00 0.00 316.52 1,032.55 1,349.07 13,232.07 09/21/2009 633370 0.00 0.00 0.00 1,228.06 0.00 0.00 1,228.06 11,686.64 10/13/2009 637387 797.96 0.00 0.00 0.00 0.00 0.00 0.00 7,943.34 10/13/2009 639396 0.00 0.00 0.00 0.00 640.38 2,251.55 2,891.93 28,797.56 10/13/2009 639431 0.00 0.00 0.00 49.12 0.00 0.00 49.12 488.64 10/19/2009 640931 0.00 0.00 0.00 0.00 0.00 11.39 11.39 113.58 11/02/2009 643717 1,076.14 0.00 0.00 0.00 0.00 0.00 0.00 10,712.21 11/02/2009 645670 0.00 0.00 0.00 0.00 628.49 1,859.16 2,487.65 24,774.95 11/02/2009 645707 0.00 0.00 0.00 1,882.16 0.00 0.00 1,882.16 18,812.64 11/09/2009 647692 0.00 0.00 0.00 35.55 0.00 0.00 35.55 146.49 11/16/2009 647726 412.30 0.00 0.00 0.00 0.00 0.00 0.00 4,107.81 11/16/2009 650021 0.00 0.00 0.00 0.00 302.28 990.69 1,292.97 12,878.91 11/16/2009 650048 0.00 0.00 0.00 7.16 0.00 0.00 7.16 71.26 12/07/2009 654209 1,035.94 0.00 0.00 0.00 0.00 0.00 0.00 10,307.59 12/07/2009 656159 0.00 0.00 0.00 0.00 323.95 1,040.16 1,364.11 13,582.14 12/07/2009 656195 0.00 0.00 0.00 2,284.48 0.00 0.00 2,284.48 19,331.82 12/21/2009 658468 1,903.87 0.00 0.00 0.00 0.00 0.00 0.00 18,951.04 12/21/2009 660609 0.00 0.00 0.00 0.00 674.93 2,079.38 2,754.31 27,428.50 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 7,674.77 0.00 0.00 6,586.70 4,544.30 14,685.25 25,816.25 332,647.54 CNTRNUM 7,674.77 0.00 0.00 6,586.70 4,544.30 14,685.25 25,816.25 332,647.54 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 57 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL ---------------------------------------------------------- CONTRACT NUM=5500014 NAME=MIAMI CO BD OF DD ---------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 611277 0.00 0.00 0.00 0.00 0.00 0.00 0.00 254.50 07/13/2009 613132 0.00 0.00 0.00 0.00 0.00 0.00 0.00 66.33 07/13/2009 613152 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,191.06 07/20/2009 615164 0.00 0.00 0.00 5,512.40 0.00 0.00 5,512.40 58,687.70 08/04/2009 619001 0.00 0.00 0.00 0.00 141.48 33.59 175.07 1,913.12 08/10/2009 619068 450.87 0.00 0.00 0.00 0.00 0.00 0.00 4,927.30 08/10/2009 620937 0.00 0.00 0.00 0.00 3,061.45 6,766.68 9,828.13 107,410.91 08/10/2009 620966 0.00 0.00 0.00 47.50 0.00 0.00 47.50 519.18 08/17/2009 620989 53.73 0.00 0.00 0.00 0.00 0.00 0.00 526.77 08/17/2009 623135 0.00 0.00 0.00 0.00 505.46 616.90 1,122.36 11,003.64 08/24/2009 623187 533.86 0.00 0.00 0.00 0.00 0.00 0.00 5,235.10 08/24/2009 625116 0.00 0.00 0.00 0.00 3,906.55 8,515.15 12,421.70 121,795.10 08/24/2009 625152 0.00 0.00 0.00 3,048.90 0.00 0.00 3,048.90 29,878.30 08/31/2009 626497 0.00 0.00 0.00 0.00 137.31 50.59 187.90 775.48 08/31/2009 627204 0.00 0.00 0.00 122.56 0.00 0.00 122.56 529.36 09/08/2009 628519 0.00 0.00 0.00 0.00 0.00 27.86 27.86 115.25 09/08/2009 629129 0.00 0.00 0.00 0.00 75.11 64.67 139.78 1,328.93 09/08/2009 629162 0.00 0.00 0.00 100.72 0.00 0.00 100.72 987.46 09/21/2009 632718 0.00 0.00 0.00 0.00 0.00 3.52 3.52 34.51 09/21/2009 633336 0.00 0.00 0.00 0.00 42.08 348.97 391.05 3,834.31 09/21/2009 633371 0.00 0.00 0.00 10,482.29 0.00 0.00 10,482.29 101,973.06 09/28/2009 633402 62.70 0.00 0.00 0.00 0.00 0.00 0.00 615.00 09/28/2009 635375 0.00 0.00 0.00 0.00 130.28 4.18 134.46 1,318.27 09/28/2009 635413 0.00 0.00 0.00 530.79 0.00 0.00 530.79 5,201.98 10/13/2009 637388 499.80 0.00 0.00 0.00 0.00 0.00 0.00 4,975.05 10/13/2009 639397 0.00 0.00 0.00 0.00 3,230.08 5,964.28 9,194.36 91,521.41 10/19/2009 641683 0.00 0.00 0.00 1,218.94 0.00 0.00 1,218.94 10,933.32 10/26/2009 641725 225.40 0.00 0.00 0.00 0.00 0.00 0.00 2,243.65 10/26/2009 643658 0.00 0.00 0.00 0.00 1,076.04 1,924.72 3,000.76 29,869.81 11/02/2009 643718 1,084.15 0.00 0.00 0.00 0.00 0.00 0.00 10,785.52 11/02/2009 645671 0.00 0.00 0.00 0.00 4,273.36 10,834.07 15,107.43 150,228.74 11/09/2009 647693 0.00 0.00 0.00 1,552.13 0.00 0.00 1,552.13 16,257.46 11/16/2009 647727 235.20 0.00 0.00 0.00 0.00 0.00 0.00 2,341.20 11/16/2009 650022 0.00 0.00 0.00 0.00 1,283.80 2,551.92 3,835.72 38,181.07 11/30/2009 652125 1,802.07 0.00 0.00 0.00 0.00 5.94 5.94 17,939.91 11/30/2009 653468 0.00 0.00 0.00 0.00 0.00 3.92 3.92 19.51 11/30/2009 654131 0.00 0.00 0.00 0.00 6,668.28 16,147.53 22,815.81 227,004.44 12/07/2009 656196 0.00 0.00 0.00 688.47 0.00 0.00 688.47 7,268.52 12/21/2009 658469 50.60 0.00 0.00 0.00 0.00 0.00 0.00 503.48 12/21/2009 660610 0.00 0.00 0.00 0.00 337.09 56.43 393.52 3,917.01 12/28/2009 662036 0.00 0.00 0.00 0.00 0.00 11.76 11.76 97.55 12/28/2009 662666 0.00 0.00 0.00 0.00 5.88 0.00 5.88 58.53 12/28/2009 662703 0.00 0.00 0.00 958.68 0.00 0.00 958.68 9,538.66 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 4,998.38 0.00 0.00 24,263.38 24,874.25 53,932.68 103,070.31 1,083,807.46 CNTRNUM 4,998.38 0.00 0.00 24,263.38 24,874.25 53,932.68 103,070.31 1,083,807.46 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 58 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL --------------------------------------------------------- CONTRACT NUM=5600013 NAME=MONROE CO BD OF DD ---------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/27/2009 615195 84.03 0.00 0.00 0.00 0.00 0.00 0.00 917.77 07/27/2009 617044 0.00 0.00 0.00 0.00 625.43 325.81 951.24 10,389.87 07/27/2009 617075 0.00 0.00 0.00 45.61 0.00 0.00 45.61 498.82 08/31/2009 625179 93.50 0.00 0.00 0.00 0.00 0.00 0.00 916.40 08/31/2009 627163 0.00 0.00 0.00 0.00 667.91 740.99 1,408.90 13,808.62 09/08/2009 627235 76.57 0.00 0.00 0.00 0.00 0.00 0.00 750.50 09/08/2009 629130 0.00 0.00 0.00 0.00 616.28 588.63 1,204.91 11,810.49 09/14/2009 629196 141.05 0.00 0.00 0.00 0.00 0.00 0.00 1,382.50 09/14/2009 631388 0.00 0.00 0.00 0.00 1,212.85 1,097.13 2,309.98 22,642.65 09/14/2009 631423 0.00 0.00 0.00 258.66 0.00 0.00 258.66 2,534.82 09/21/2009 631455 152.80 0.00 0.00 0.00 0.00 0.00 0.00 1,498.40 09/21/2009 633337 0.00 0.00 0.00 0.00 1,165.10 548.17 1,713.27 16,800.81 10/06/2009 635442 153.89 0.00 0.00 0.00 0.00 0.00 0.00 1,532.19 10/06/2009 637318 0.00 0.00 0.00 0.00 1,179.42 633.16 1,812.58 18,045.47 10/26/2009 643659 0.00 0.00 0.00 0.00 412.35 0.00 412.35 4,101.92 10/26/2009 643689 0.00 0.00 0.00 117.66 0.00 0.00 117.66 1,170.70 11/02/2009 645067 0.00 0.00 0.00 0.00 0.00 0.57 0.57 5.68 11/02/2009 645672 0.00 0.00 0.00 0.00 0.89 0.00 0.89 9.66 11/09/2009 647694 0.00 0.00 0.00 3.07 0.00 0.00 3.07 20.36 11/23/2009 650069 465.85 0.00 0.00 0.00 0.00 0.00 0.00 4,639.85 11/23/2009 652062 0.00 0.00 0.00 0.00 2,567.78 1,147.73 3,715.51 36,996.27 11/23/2009 652090 0.00 0.00 0.00 109.47 0.00 0.00 109.47 1,089.26 11/30/2009 652126 128.56 0.00 0.00 0.00 0.00 0.00 0.00 1,279.16 11/30/2009 654132 0.00 0.00 0.00 0.00 667.89 447.52 1,115.41 11,098.68 12/21/2009 658470 97.98 0.00 0.00 0.00 0.00 0.00 0.00 974.86 12/21/2009 660611 0.00 0.00 0.00 0.00 529.86 416.26 946.12 9,414.56 12/21/2009 660645 0.00 0.00 0.00 24.56 0.00 0.00 24.56 244.32 12/28/2009 660680 141.00 0.00 0.00 0.00 0.00 0.00 0.00 1,404.75 12/28/2009 662667 0.00 0.00 0.00 0.00 588.44 201.16 789.60 7,866.60 12/28/2009 662704 0.00 0.00 0.00 139.51 0.00 0.00 139.51 1,384.48 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 1,535.23 0.00 0.00 698.54 10,234.20 6,147.13 17,079.87 185,230.42 CNTRNUM 1,535.23 0.00 0.00 698.54 10,234.20 6,147.13 17,079.87 185,230.42 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 59 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL ------------------------------------------------------- CONTRACT NUM=5700012 NAME=MONTGOMERY CO BD OF DD -------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 609497 0.00 0.00 0.00 0.00 0.00 0.00 0.00 18,273.25 07/06/2009 611238 0.00 0.00 0.00 0.00 0.00 0.00 0.00 753,487.51 07/06/2009 611278 0.00 0.00 0.00 0.00 0.00 0.00 0.00 117,517.92 07/13/2009 613133 0.00 0.00 0.00 0.00 0.00 0.00 0.00 4,382.79 07/13/2009 613153 0.00 0.00 0.00 0.00 0.00 0.00 0.00 88,688.16 07/20/2009 614508 0.00 0.00 0.00 0.00 0.00 3.57 3.57 97.55 07/27/2009 615196 74.47 0.00 0.00 0.00 0.00 0.00 0.00 814.00 07/27/2009 617045 0.00 0.00 0.00 0.00 183.16 468.77 651.93 7,123.34 07/27/2009 617076 0.00 0.00 0.00 9,658.53 0.00 0.00 9,658.53 105,586.96 08/04/2009 617102 3.57 0.00 0.00 0.00 0.00 0.00 0.00 39.02 08/04/2009 619002 0.00 0.00 0.00 0.00 14.64 375.07 389.71 4,259.63 08/24/2009 625117 0.00 0.00 0.00 0.00 63.92 62.02 125.94 1,234.48 08/31/2009 625180 2,131.67 0.00 0.00 0.00 0.00 0.00 0.00 22,920.52 08/31/2009 627164 0.00 0.00 0.00 0.00 17,815.88 57,083.26 74,899.14 734,330.11 08/31/2009 627205 0.00 0.00 0.00 9,618.12 0.00 0.00 9,618.12 94,460.22 09/08/2009 627236 352.01 0.00 0.00 0.00 0.00 0.00 0.00 3,451.76 09/08/2009 629131 0.00 0.00 0.00 0.00 362.26 11.94 374.20 3,668.01 09/14/2009 629197 2,175.54 0.00 0.00 0.00 0.00 0.00 0.00 22,236.48 09/14/2009 631389 0.00 0.00 0.00 0.00 16,285.98 52,626.64 68,912.62 675,638.41 09/14/2009 631424 0.00 0.00 0.00 11,188.60 0.00 0.00 11,188.60 110,727.86 09/21/2009 633338 0.00 0.00 0.00 0.00 401.98 0.00 401.98 1,951.00 09/28/2009 633403 3,074.47 0.00 0.00 0.00 0.00 0.00 0.00 30,534.17 09/28/2009 635376 0.00 0.00 0.00 0.00 18,146.97 54,338.27 72,485.24 710,664.01 09/28/2009 635414 0.00 0.00 0.00 11,830.14 0.00 0.00 11,830.14 116,326.86 10/06/2009 637355 0.00 0.00 0.00 9,779.85 0.00 0.00 9,779.85 97,310.62 10/13/2009 637389 21.96 0.00 0.00 0.00 0.00 0.00 0.00 218.48 10/13/2009 639398 0.00 0.00 0.00 0.00 401.64 68.27 469.91 4,677.47 10/19/2009 639465 0.00 0.00 0.00 0.00 0.00 187.31 187.31 2,496.13 10/19/2009 641640 0.00 0.00 0.00 0.00 4,518.01 705.62 5,223.63 28,033.60 10/19/2009 641684 0.00 0.00 0.00 10,651.54 0.00 0.00 10,651.54 105,983.98 11/02/2009 645673 0.00 0.00 0.00 0.00 868.06 209.76 1,077.82 10,673.51 11/02/2009 645708 0.00 0.00 0.00 11,598.56 0.00 0.00 11,598.56 115,614.26 11/09/2009 647647 0.00 0.00 0.00 0.00 226.36 113.05 339.41 3,377.83 11/16/2009 647728 0.00 0.00 0.00 0.00 0.00 160.08 160.08 496.64 11/16/2009 649310 0.00 0.00 0.00 0.00 0.00 9,817.01 9,817.01 -15,153.53 11/16/2009 650023 0.00 0.00 0.00 0.00 1,995.60 4,057.32 6,052.92 30,795.34 11/23/2009 652091 0.00 0.00 0.00 2,049.05 0.00 0.00 2,049.05 141.54 11/30/2009 654133 0.00 0.00 0.00 0.00 251.21 30.86 282.07 2,806.60 11/30/2009 654171 0.00 0.00 0.00 134.03 0.00 0.00 134.03 1,333.58 12/14/2009 656221 129.81 0.00 0.00 0.00 0.00 0.00 0.00 1,291.67 12/14/2009 658417 0.00 0.00 0.00 0.00 1,000.56 2,488.64 3,489.20 34,723.27 12/14/2009 658439 0.00 0.00 0.00 635.35 0.00 0.00 635.35 6,352.32 12/28/2009 660681 9,548.50 0.00 0.00 0.00 0.00 10.20 10.20 102,891.66 12/28/2009 662668 0.00 0.00 0.00 0.00 71,015.98 191,236.99 262,252.97 2,609,772.76 12/28/2009 662705 0.00 0.00 0.00 21,133.74 0.00 0.00 21,133.74 176,928.40 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 17,512.00 0.00 0.00 98,277.51 133,552.21 374,054.65 605,884.37 6,949,180.15 CNTRNUM 17,512.00 0.00 0.00 98,277.51 133,552.21 374,054.65 605,884.37 6,949,180.15 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 60 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL --------------------------------------------------------- CONTRACT NUM=5800011 NAME=MORGAN CO BD OF DD ---------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/13/2009 613154 0.00 0.00 0.00 0.00 0.00 0.00 0.00 20.36 07/20/2009 615136 0.00 0.00 0.00 0.00 20.78 3.46 24.24 227.16 07/27/2009 617046 0.00 0.00 0.00 0.00 759.38 1,103.86 1,863.24 20,381.31 08/24/2009 625153 0.00 0.00 0.00 434.25 0.00 0.00 434.25 4,255.24 08/31/2009 627206 0.00 0.00 0.00 556.82 0.00 0.00 556.82 5,171.44 09/08/2009 629163 0.00 0.00 0.00 12.47 0.00 0.00 12.47 122.16 09/28/2009 635377 0.00 0.00 0.00 0.00 2,415.69 5,030.63 7,446.32 73,012.28 09/28/2009 635415 0.00 0.00 0.00 485.02 0.00 0.00 485.02 4,754.06 10/06/2009 637319 0.00 0.00 0.00 0.00 1,174.51 2,516.96 3,691.47 36,759.20 10/06/2009 637356 0.00 0.00 0.00 1,383.24 0.00 0.00 1,383.24 13,763.36 10/13/2009 639399 0.00 0.00 0.00 0.00 735.00 1,740.25 2,475.25 24,636.37 10/19/2009 641641 0.00 0.00 0.00 0.00 7.44 0.00 7.44 0.00 10/19/2009 641685 0.00 0.00 0.00 905.91 0.00 0.00 905.91 7,950.58 11/09/2009 647695 0.00 0.00 0.00 2,337.01 0.00 0.00 2,337.01 3,828.57 11/30/2009 654134 0.00 0.00 0.00 0.00 667.16 1,168.78 1,835.94 18,286.38 11/30/2009 654172 0.00 0.00 0.00 1,914.36 0.00 0.00 1,914.36 18,985.70 12/14/2009 658418 0.00 0.00 0.00 0.00 1,305.73 2,107.43 3,413.16 33,998.28 12/21/2009 660646 0.00 0.00 0.00 2.04 0.00 0.00 2.04 20.36 12/28/2009 662669 0.00 0.00 0.00 0.00 534.07 1,590.13 2,124.20 21,143.06 12/28/2009 662706 0.00 0.00 0.00 61.38 0.00 0.00 61.38 549.72 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 0.00 0.00 0.00 8,092.50 7,619.76 15,261.50 30,973.76 287,865.59 CNTRNUM 0.00 0.00 0.00 8,092.50 7,619.76 15,261.50 30,973.76 287,865.59 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 61 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL --------------------------------------------------------- CONTRACT NUM=5900010 NAME=MORROW CO BD OF DD ---------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 609498 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,108.96 07/06/2009 611239 0.00 0.00 0.00 0.00 0.00 0.00 0.00 16,252.00 07/06/2009 611279 0.00 0.00 0.00 0.00 0.00 0.00 0.00 111.98 07/20/2009 613180 10.50 0.00 0.00 0.00 0.00 0.00 0.00 114.72 07/20/2009 615137 0.00 0.00 0.00 0.00 36.75 17.50 54.25 592.72 07/20/2009 615165 0.00 0.00 0.00 395.85 0.00 0.00 395.85 4,326.50 07/27/2009 617047 0.00 0.00 0.00 0.00 0.00 81.16 81.16 887.14 07/27/2009 617077 0.00 0.00 0.00 14.88 0.00 0.00 14.88 162.88 08/10/2009 619069 579.55 0.00 0.00 0.00 0.00 0.00 0.00 6,334.68 08/10/2009 620938 0.00 0.00 0.00 0.00 1,098.97 4,805.09 5,904.06 64,535.64 08/10/2009 620967 0.00 0.00 0.00 296.11 0.00 0.00 296.11 3,237.24 08/17/2009 623156 0.00 0.00 0.00 709.36 0.00 0.00 709.36 7,217.62 08/24/2009 623188 200.85 0.00 0.00 0.00 0.00 0.00 0.00 1,969.36 08/24/2009 625118 0.00 0.00 0.00 0.00 427.05 1,959.75 2,386.80 23,402.88 08/31/2009 625181 387.68 0.00 0.00 0.00 0.00 0.00 0.00 3,797.99 08/31/2009 627165 0.00 0.00 0.00 0.00 837.30 3,679.02 4,516.32 44,243.91 09/08/2009 629164 0.00 0.00 0.00 228.47 0.00 0.00 228.47 2,239.60 09/14/2009 631425 0.00 0.00 0.00 595.14 0.00 0.00 595.14 5,833.14 09/21/2009 631456 175.50 0.00 0.00 0.00 0.00 9.40 9.40 1,793.47 09/21/2009 632850 0.00 0.00 0.00 0.00 0.00 42.70 42.70 74.97 09/21/2009 633339 0.00 0.00 0.00 0.00 306.30 1,897.35 2,203.65 21,544.43 09/28/2009 635416 0.00 0.00 0.00 15.57 0.00 0.00 15.57 122.16 10/06/2009 635443 209.43 0.00 0.00 0.00 0.00 0.00 0.00 2,081.73 10/06/2009 637320 0.00 0.00 0.00 0.00 802.99 3,180.03 3,983.02 39,600.22 10/13/2009 637390 433.64 0.00 0.00 0.00 0.00 0.00 0.00 4,313.51 10/13/2009 639400 0.00 0.00 0.00 0.00 1,264.35 5,263.30 6,527.65 64,937.15 10/13/2009 639432 0.00 0.00 0.00 1,991.00 0.00 0.00 1,991.00 19,810.28 10/19/2009 641686 0.00 0.00 0.00 135.08 0.00 0.00 135.08 1,343.76 10/26/2009 643690 0.00 0.00 0.00 658.94 0.00 0.00 658.94 5,792.42 11/09/2009 647696 0.00 0.00 0.00 144.25 0.00 0.00 144.25 930.30 11/23/2009 650070 969.74 0.00 0.00 0.00 0.00 0.00 0.00 9,647.22 11/23/2009 652063 0.00 0.00 0.00 0.00 2,662.99 11,849.38 14,512.37 144,376.55 11/23/2009 652092 0.00 0.00 0.00 1,014.77 0.00 0.00 1,014.77 10,129.10 11/30/2009 654173 0.00 0.00 0.00 402.08 0.00 0.00 402.08 3,990.56 12/07/2009 654210 6.15 0.00 0.00 0.00 0.00 0.00 0.00 61.18 12/07/2009 656160 0.00 0.00 0.00 0.00 10.20 57.85 68.05 676.92 12/07/2009 656197 0.00 0.00 0.00 203.57 0.00 0.00 203.57 2,025.82 12/21/2009 658471 432.36 0.00 0.00 0.00 0.00 0.00 0.00 4,302.00 12/21/2009 660612 0.00 0.00 0.00 0.00 85.28 49.95 135.23 1,345.58 12/21/2009 660647 0.00 0.00 0.00 67.52 0.00 0.00 67.52 671.88 12/28/2009 662707 0.00 0.00 0.00 11.10 0.00 0.00 11.10 111.98 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 3,405.40 0.00 0.00 6,883.69 7,532.18 32,892.48 47,308.35 526,052.15 CNTRNUM 3,405.40 0.00 0.00 6,883.69 7,532.18 32,892.48 47,308.35 526,052.15 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 62 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL -------------------------------------------------------- CONTRACT NUM=6000017 NAME=MUSKINGUM CO BD OF DD -------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 611280 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,669.52 07/13/2009 613155 0.00 0.00 0.00 0.00 0.00 0.00 0.00 11,421.96 07/20/2009 615138 0.00 0.00 0.00 0.00 295.83 666.05 961.88 10,525.08 07/20/2009 615166 0.00 0.00 0.00 43.78 0.00 0.00 43.78 223.96 07/27/2009 615197 81.09 0.00 0.00 0.00 0.00 0.00 0.00 885.63 07/27/2009 617048 0.00 0.00 0.00 0.00 618.97 2,605.78 3,224.75 35,227.63 07/27/2009 617078 0.00 0.00 0.00 49.33 0.00 0.00 49.33 539.54 08/04/2009 619003 0.00 0.00 0.00 0.00 138.40 536.30 674.70 7,382.70 08/04/2009 619038 0.00 0.00 0.00 18.62 0.00 0.00 18.62 81.44 08/10/2009 620939 0.00 0.00 0.00 0.00 268.15 842.51 1,110.66 12,153.06 08/17/2009 623157 0.00 0.00 0.00 1,354.71 0.00 0.00 1,354.71 13,580.12 08/24/2009 625119 0.00 0.00 0.00 0.00 0.00 0.60 0.60 5.85 08/24/2009 625154 0.00 0.00 0.00 1,670.42 0.00 0.00 1,670.42 16,369.44 08/31/2009 627166 0.00 0.00 0.00 0.00 167.33 151.27 318.60 3,125.50 08/31/2009 627207 0.00 0.00 0.00 1,971.15 0.00 0.00 1,971.15 14,221.46 09/08/2009 627237 0.60 0.00 0.00 0.00 0.00 0.00 0.00 5.85 09/08/2009 629132 0.00 0.00 0.00 0.00 7.05 30.78 37.83 367.44 09/08/2009 629165 0.00 0.00 0.00 103.90 0.00 0.00 103.90 936.56 09/21/2009 633372 0.00 0.00 0.00 78.95 0.00 0.00 78.95 773.68 09/28/2009 635378 0.00 0.00 0.00 0.00 126.22 73.47 199.69 1,956.29 09/28/2009 635417 0.00 0.00 0.00 86.21 0.00 0.00 86.21 844.94 10/06/2009 635444 234.63 0.00 0.00 0.00 0.00 0.00 0.00 2,337.12 10/06/2009 637321 0.00 0.00 0.00 0.00 1,851.91 6,034.48 7,886.39 78,526.77 10/19/2009 641687 0.00 0.00 0.00 977.04 0.00 0.00 977.04 9,721.90 10/26/2009 641726 2.88 0.00 0.00 0.00 0.00 0.00 0.00 28.62 10/26/2009 643660 0.00 0.00 0.00 0.00 54.39 297.17 351.56 3,498.16 10/26/2009 643691 0.00 0.00 0.00 171.84 0.00 0.00 171.84 977.28 11/02/2009 643719 16.68 0.00 0.00 0.00 0.00 0.00 0.00 166.07 11/02/2009 645674 0.00 0.00 0.00 0.00 200.27 859.32 1,059.59 10,546.23 11/02/2009 645709 0.00 0.00 0.00 131.97 0.00 0.00 131.97 1,313.22 11/09/2009 647697 0.00 0.00 0.00 254.69 0.00 0.00 254.69 2,361.76 11/16/2009 647729 32.89 0.00 0.00 0.00 0.00 0.00 0.00 327.66 11/16/2009 650024 0.00 0.00 0.00 0.00 465.85 1,040.66 1,506.51 15,005.97 11/23/2009 651572 0.00 0.00 0.00 0.00 0.00 5.35 5.35 -6.52 12/21/2009 658472 45.97 0.00 0.00 0.00 0.00 0.00 0.00 457.95 12/21/2009 660613 0.00 0.00 0.00 0.00 443.26 1,036.47 1,479.73 14,742.47 12/21/2009 660648 0.00 0.00 0.00 54.22 0.00 0.00 54.22 539.54 12/28/2009 660682 323.55 0.00 0.00 0.00 0.00 0.00 0.00 3,222.41 12/28/2009 662670 0.00 0.00 0.00 0.00 1,753.63 7,178.03 8,931.66 88,881.22 12/28/2009 662708 0.00 0.00 0.00 367.27 0.00 0.00 367.27 3,827.68 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 738.29 0.00 0.00 7,334.10 6,391.26 21,358.24 35,083.60 368,773.16 CNTRNUM 738.29 0.00 0.00 7,334.10 6,391.26 21,358.24 35,083.60 368,773.16 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 63 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL ---------------------------------------------------------- CONTRACT NUM=6100016 NAME=NOBLE CO BD OF DD ---------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 611240 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,173.66 07/27/2009 617049 0.00 0.00 0.00 0.00 62.28 62.28 124.56 1,362.96 08/04/2009 619039 0.00 0.00 0.00 2.79 0.00 0.00 2.79 30.54 08/24/2009 625120 0.00 0.00 0.00 0.00 73.34 67.55 140.89 1,381.89 09/14/2009 631426 0.00 0.00 0.00 87.27 0.00 0.00 87.27 855.12 09/21/2009 633340 0.00 0.00 0.00 0.00 175.63 169.84 345.47 3,388.47 10/06/2009 637357 0.00 0.00 0.00 52.15 0.00 0.00 52.15 519.18 10/19/2009 641642 0.00 0.00 0.00 0.00 68.40 68.40 136.80 1,362.96 11/23/2009 652093 0.00 0.00 0.00 294.61 0.00 0.00 294.61 2,931.84 12/07/2009 656161 0.00 0.00 0.00 0.00 83.60 89.30 172.90 1,722.63 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 0.00 0.00 0.00 436.82 463.25 457.37 1,357.44 14,729.25 CNTRNUM 0.00 0.00 0.00 436.82 463.25 457.37 1,357.44 14,729.25 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 64 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL --------------------------------------------------------- CONTRACT NUM=6200015 NAME=OTTAWA CO BD OF DD ---------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/13/2009 613156 0.00 0.00 0.00 0.00 0.00 0.00 0.00 58,300.86 07/27/2009 615198 120.50 0.00 0.00 0.00 0.00 0.00 0.00 1,317.20 07/27/2009 617050 0.00 0.00 0.00 0.00 280.65 2,498.78 2,779.43 30,870.54 07/27/2009 617079 0.00 0.00 0.00 189.88 0.00 0.00 189.88 2,076.72 08/04/2009 619040 0.00 0.00 0.00 130.38 0.00 0.00 130.38 183.24 08/17/2009 620990 122.01 0.00 0.00 0.00 0.00 0.00 0.00 1,195.84 08/17/2009 623136 0.00 0.00 0.00 0.00 420.23 3,217.44 3,637.67 36,299.11 08/24/2009 625121 0.00 0.00 0.00 0.00 0.00 23.24 23.24 227.96 08/24/2009 625155 0.00 0.00 0.00 818.49 0.00 0.00 818.49 8,021.84 08/31/2009 627208 0.00 0.00 0.00 96.72 0.00 0.00 96.72 122.16 09/21/2009 633373 0.00 0.00 0.00 2,625.69 0.00 0.00 2,625.69 25,735.04 10/06/2009 635445 315.56 0.00 0.00 0.00 0.00 0.00 0.00 3,139.00 10/06/2009 637322 0.00 0.00 0.00 0.00 731.05 5,972.93 6,703.98 67,798.76 10/06/2009 637358 0.00 0.00 0.00 4,404.43 0.00 0.00 4,404.43 42,827.26 10/13/2009 639433 0.00 0.00 0.00 409.24 0.00 0.00 409.24 4,072.00 10/19/2009 641688 0.00 0.00 0.00 163.42 0.00 0.00 163.42 356.30 12/07/2009 654211 38.40 0.00 0.00 0.00 0.00 0.00 0.00 382.12 12/07/2009 656162 0.00 0.00 0.00 0.00 0.00 259.47 259.47 2,581.70 12/07/2009 656198 0.00 0.00 0.00 8,254.74 0.00 0.00 8,254.74 83,282.58 12/14/2009 658440 0.00 0.00 0.00 1,855.98 0.00 0.00 1,855.98 19,270.74 12/21/2009 658473 24.72 0.00 0.00 0.00 0.00 0.00 0.00 246.00 12/21/2009 660614 0.00 0.00 0.00 0.00 53.56 165.20 218.76 2,176.40 12/21/2009 660649 0.00 0.00 0.00 17.38 0.00 0.00 17.38 173.06 12/28/2009 662709 0.00 0.00 0.00 108.31 0.00 0.00 108.31 692.24 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 621.19 0.00 0.00 19,074.66 1,485.49 12,137.06 32,697.21 391,348.67 CNTRNUM 621.19 0.00 0.00 19,074.66 1,485.49 12,137.06 32,697.21 391,348.67 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 65 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL -------------------------------------------------------- CONTRACT NUM=6300014 NAME=PAULDING CO BD OF DD --------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 609499 0.00 0.00 0.00 0.00 0.00 0.00 0.00 3,424.05 07/06/2009 611241 0.00 0.00 0.00 0.00 0.00 0.00 0.00 40,531.51 07/27/2009 617051 0.00 0.00 0.00 0.00 0.00 19.03 19.03 208.23 08/04/2009 617103 295.87 0.00 0.00 0.00 0.00 0.00 0.00 3,234.88 08/04/2009 619004 0.00 0.00 0.00 0.00 580.50 1,915.55 2,496.05 27,271.10 08/04/2009 619041 0.00 0.00 0.00 569.80 0.00 0.00 569.80 5,843.32 08/10/2009 619070 64.01 0.00 0.00 0.00 0.00 0.00 0.00 700.41 08/10/2009 620940 0.00 0.00 0.00 0.00 519.00 1,250.79 1,769.79 19,365.39 08/17/2009 623137 0.00 0.00 0.00 0.00 0.00 662.02 662.02 6,495.33 08/31/2009 625182 308.44 0.00 0.00 0.00 0.00 0.00 0.00 3,023.33 08/31/2009 627167 0.00 0.00 0.00 0.00 1,269.03 3,726.21 4,995.24 48,987.73 08/31/2009 627209 0.00 0.00 0.00 740.65 0.00 0.00 740.65 7,258.34 09/08/2009 629166 0.00 0.00 0.00 14.46 0.00 0.00 14.46 132.34 09/14/2009 631427 0.00 0.00 0.00 654.46 0.00 0.00 654.46 6,413.40 09/21/2009 633374 0.00 0.00 0.00 4.15 0.00 0.00 4.15 40.72 10/13/2009 639434 0.00 0.00 0.00 721.24 0.00 0.00 721.24 7,176.90 10/19/2009 639466 412.76 0.00 0.00 0.00 0.00 0.00 0.00 4,108.92 10/19/2009 641643 0.00 0.00 0.00 0.00 1,182.90 3,384.34 4,567.24 45,482.36 10/19/2009 641689 0.00 0.00 0.00 19.12 0.00 0.00 19.12 193.42 11/09/2009 645736 285.63 0.00 0.00 0.00 0.00 0.00 0.00 2,843.49 11/09/2009 647648 0.00 0.00 0.00 0.00 1,056.70 3,024.09 4,080.79 40,634.48 11/09/2009 647698 0.00 0.00 0.00 5.12 0.00 0.00 5.12 40.72 11/23/2009 652064 0.00 0.00 0.00 0.00 0.00 3.80 3.80 37.86 11/23/2009 652094 0.00 0.00 0.00 564.52 0.00 0.00 564.52 5,619.36 11/30/2009 654174 0.00 0.00 0.00 7.16 0.00 0.00 7.16 71.26 12/14/2009 656222 162.51 0.00 0.00 0.00 0.00 0.00 0.00 1,618.25 12/14/2009 658419 0.00 0.00 0.00 0.00 1,385.99 3,350.04 4,736.03 47,163.89 12/14/2009 658441 0.00 0.00 0.00 719.02 0.00 0.00 719.02 7,156.54 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 1,529.22 0.00 0.00 4,019.70 5,994.12 17,335.87 27,349.69 335,077.53 CNTRNUM 1,529.22 0.00 0.00 4,019.70 5,994.12 17,335.87 27,349.69 335,077.53 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 66 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL ---------------------------------------------------------- CONTRACT NUM=6400013 NAME=PERRY CO BD OF DD ---------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/13/2009 611308 0.00 0.00 0.00 0.00 0.00 0.00 0.00 6,020.69 07/13/2009 613134 0.00 0.00 0.00 0.00 0.00 0.00 0.00 74,042.26 07/27/2009 615199 310.69 0.00 0.00 0.00 0.00 0.00 0.00 3,395.85 07/27/2009 617052 0.00 0.00 0.00 0.00 1,086.08 2,402.82 3,488.90 38,134.60 08/17/2009 620991 361.12 0.00 0.00 0.00 0.00 0.00 0.00 3,541.58 08/17/2009 623138 0.00 0.00 0.00 0.00 1,425.24 2,770.25 4,195.49 41,158.31 08/24/2009 625156 0.00 0.00 0.00 1,973.52 0.00 0.00 1,973.52 19,342.00 10/06/2009 635446 268.45 0.00 0.00 0.00 0.00 0.00 0.00 2,673.03 10/06/2009 637323 0.00 0.00 0.00 0.00 867.14 1,593.02 2,460.16 24,501.23 10/19/2009 641690 0.00 0.00 0.00 2,228.38 0.00 0.00 2,228.38 22,172.04 11/09/2009 647699 0.00 0.00 0.00 2,705.07 0.00 0.00 2,705.07 26,966.82 11/30/2009 652127 339.08 0.00 0.00 0.00 0.00 0.00 0.00 3,376.53 11/30/2009 654135 0.00 0.00 0.00 0.00 1,470.90 2,997.23 4,468.13 44,491.52 12/07/2009 654212 373.14 0.00 0.00 0.00 0.00 0.00 0.00 3,715.45 12/07/2009 656163 0.00 0.00 0.00 0.00 1,618.53 3,171.57 4,790.10 47,704.54 12/28/2009 662710 0.00 0.00 0.00 4,568.09 0.00 0.00 4,568.09 45,901.62 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 1,652.48 0.00 0.00 11,475.06 6,467.89 12,934.89 30,877.84 407,138.07 CNTRNUM 1,652.48 0.00 0.00 11,475.06 6,467.89 12,934.89 30,877.84 407,138.07 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 67 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL -------------------------------------------------------- CONTRACT NUM=6500012 NAME=PICKAWAY CO BD OF DD --------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 611281 0.00 0.00 0.00 0.00 0.00 0.00 0.00 417.38 07/13/2009 613157 0.00 0.00 0.00 0.00 0.00 0.00 0.00 9,935.68 07/27/2009 617080 0.00 0.00 0.00 435.79 0.00 0.00 435.79 4,764.24 08/04/2009 619042 0.00 0.00 0.00 116.39 0.00 0.00 116.39 1,272.50 09/21/2009 633375 0.00 0.00 0.00 630.54 0.00 0.00 630.54 6,179.26 10/13/2009 639435 0.00 0.00 0.00 421.59 0.00 0.00 421.59 4,194.16 11/16/2009 650049 0.00 0.00 0.00 543.26 0.00 0.00 543.26 5,996.02 11/23/2009 652095 0.00 0.00 0.00 1,655.47 0.00 0.00 1,655.47 16,827.54 11/30/2009 654175 0.00 0.00 0.00 1.99 0.00 0.00 1.99 20.36 12/14/2009 658442 0.00 0.00 0.00 550.28 0.00 0.00 550.28 5,487.02 12/21/2009 660650 0.00 0.00 0.00 31.72 0.00 0.00 31.72 315.58 12/28/2009 662711 0.00 0.00 0.00 534.11 0.00 0.00 534.11 5,649.90 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 0.00 0.00 0.00 4,921.14 0.00 0.00 4,921.14 61,059.64 CNTRNUM 0.00 0.00 0.00 4,921.14 0.00 0.00 4,921.14 61,059.64 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 68 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL ---------------------------------------------------------- CONTRACT NUM=6600011 NAME=PIKE CO BD OF DD ----------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 611282 0.00 0.00 0.00 0.00 0.00 0.00 0.00 30.54 07/20/2009 613181 78.87 0.00 0.00 0.00 0.00 0.00 0.00 862.58 07/20/2009 615139 0.00 0.00 0.00 0.00 234.17 1,634.33 1,868.50 20,428.01 07/20/2009 615167 0.00 0.00 0.00 35.37 0.00 0.00 35.37 386.84 07/27/2009 615200 7.51 0.00 0.00 0.00 0.00 0.00 0.00 82.16 07/27/2009 617053 0.00 0.00 0.00 0.00 14.02 498.99 513.01 5,609.01 08/04/2009 619043 0.00 0.00 0.00 3.72 0.00 0.00 3.72 40.72 08/10/2009 619071 1,018.00 0.00 0.00 0.00 0.00 0.00 0.00 11,124.38 08/10/2009 620941 0.00 0.00 0.00 0.00 2,290.54 14,595.17 16,885.71 184,552.78 08/10/2009 620968 0.00 0.00 0.00 1,839.43 0.00 0.00 1,839.43 21,673.22 08/17/2009 620992 31.88 0.00 0.00 0.00 0.00 0.00 0.00 312.64 08/17/2009 623139 0.00 0.00 0.00 0.00 65.82 381.51 447.33 4,384.91 08/17/2009 623158 0.00 0.00 0.00 43.63 0.00 0.00 43.63 427.56 08/24/2009 623189 219.17 0.00 0.00 0.00 0.00 0.00 0.00 2,149.32 08/24/2009 625122 0.00 0.00 0.00 0.00 629.80 3,589.50 4,219.30 41,360.35 08/24/2009 625157 0.00 0.00 0.00 55.09 0.00 0.00 55.09 539.54 08/31/2009 625183 148.98 0.00 0.00 0.00 0.00 0.00 0.00 1,460.94 08/31/2009 627168 0.00 0.00 0.00 0.00 569.13 2,046.29 2,615.42 25,090.23 08/31/2009 627210 0.00 0.00 0.00 30.12 0.00 0.00 30.12 295.22 09/14/2009 629198 130.12 0.00 0.00 0.00 0.00 0.00 0.00 1,276.04 09/14/2009 631390 0.00 0.00 0.00 0.00 227.05 1,758.45 1,985.50 19,461.41 09/21/2009 631457 401.42 0.00 0.00 0.00 0.00 0.00 0.00 3,936.89 09/21/2009 633341 0.00 0.00 0.00 0.00 936.87 6,213.52 7,150.39 70,096.89 09/28/2009 635418 0.00 0.00 0.00 687.79 0.00 0.00 687.79 6,739.16 10/06/2009 637359 0.00 0.00 0.00 78.94 0.00 0.00 78.94 -71.26 10/13/2009 639401 0.00 0.00 0.00 0.00 85.61 315.59 401.20 3,991.54 10/13/2009 639436 0.00 0.00 0.00 992.76 0.00 0.00 992.76 9,874.60 10/19/2009 641691 0.00 0.00 0.00 660.61 0.00 0.00 660.61 6,474.48 10/26/2009 641727 263.13 0.00 0.00 0.00 0.00 0.00 0.00 2,618.34 10/26/2009 643661 0.00 0.00 0.00 0.00 665.38 3,719.39 4,384.77 43,628.48 10/26/2009 643692 0.00 0.00 0.00 800.98 0.00 0.00 800.98 8,164.36 11/02/2009 645710 0.00 0.00 0.00 79.79 0.00 0.00 79.79 407.20 11/09/2009 645737 467.98 0.00 0.00 0.00 0.00 0.00 0.00 4,659.33 11/09/2009 647649 0.00 0.00 0.00 0.00 988.94 7,261.22 8,250.16 82,139.50 11/09/2009 647700 0.00 0.00 0.00 525.66 0.00 0.00 525.66 2,417.46 11/16/2009 647730 0.43 0.00 0.00 0.00 0.00 0.95 0.95 1.09 11/16/2009 650025 0.00 0.00 0.00 0.00 549.14 609.10 1,158.24 11,524.42 11/23/2009 651619 0.00 0.00 0.00 0.00 0.00 91.51 91.51 6.79 11/30/2009 652128 237.12 0.00 0.00 0.00 0.00 2.35 2.35 2,383.54 11/30/2009 653664 0.00 0.00 0.00 0.00 0.00 10.86 10.86 99.01 11/30/2009 654136 0.00 0.00 0.00 0.00 844.92 4,075.90 4,920.82 48,963.73 11/30/2009 654176 0.00 0.00 0.00 1,252.21 0.00 0.00 1,252.21 12,602.84 12/07/2009 654213 172.93 0.00 0.00 0.00 0.00 0.00 0.00 1,722.33 12/07/2009 656164 0.00 0.00 0.00 0.00 397.12 2,356.36 2,753.48 27,429.17 12/14/2009 658443 0.00 0.00 0.00 928.80 0.00 0.00 928.80 9,243.44 12/21/2009 658474 311.22 0.00 0.00 0.00 0.00 0.00 0.00 3,097.00 12/21/2009 660615 0.00 0.00 0.00 0.00 733.00 4,967.14 5,700.14 56,739.82 12/21/2009 660651 0.00 0.00 0.00 4.09 0.00 0.00 4.09 40.72 12/28/2009 662712 0.00 0.00 0.00 5.12 0.00 0.00 5.12 50.90 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 3,488.76 0.00 0.00 8,024.11 9,231.51 54,128.13 71,383.75 760,530.17 CNTRNUM 3,488.76 0.00 0.00 8,024.11 9,231.51 54,128.13 71,383.75 760,530.17 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 69 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL --------------------------------------------------------- CONTRACT NUM=6700010 NAME=PORTAGE CO BD OF DD --------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 609500 0.00 0.00 0.00 0.00 0.00 0.00 0.00 698.86 07/06/2009 611242 0.00 0.00 0.00 0.00 0.00 0.00 0.00 105,021.10 07/06/2009 611283 0.00 0.00 0.00 0.00 0.00 0.00 0.00 16,267.64 07/27/2009 615201 205.09 0.00 0.00 0.00 0.00 0.00 0.00 5,134.08 07/27/2009 617054 0.00 0.00 0.00 0.00 5,035.14 10,434.65 15,469.79 168,954.78 07/27/2009 617081 0.00 0.00 0.00 3,720.86 0.00 0.00 3,720.86 41,900.88 08/04/2009 618554 0.00 0.00 0.00 0.00 0.00 10.83 10.83 -15.65 08/04/2009 619044 0.00 0.00 0.00 66.13 0.00 0.00 66.13 183.24 08/31/2009 625184 170.85 0.00 0.00 0.00 0.00 0.00 0.00 3,621.65 08/31/2009 627169 0.00 0.00 0.00 0.00 2,368.41 3,899.47 6,267.88 61,432.72 08/31/2009 627211 0.00 0.00 0.00 1,993.28 0.00 0.00 1,993.28 19,789.92 09/08/2009 629167 0.00 0.00 0.00 40.22 0.00 0.00 40.22 325.76 09/14/2009 629199 337.26 0.00 0.00 0.00 0.00 0.00 0.00 7,446.76 09/14/2009 631391 0.00 0.00 0.00 0.00 6,924.92 15,478.31 22,403.23 219,743.03 09/21/2009 633376 0.00 0.00 0.00 3,411.58 0.00 0.00 3,411.58 33,624.54 09/28/2009 635379 0.00 0.00 0.00 0.00 19.24 11.83 31.07 304.50 10/13/2009 637391 363.03 0.00 0.00 0.00 0.00 0.00 0.00 3,613.11 10/13/2009 639402 0.00 0.00 0.00 0.00 5,227.88 10,475.18 15,703.06 156,281.74 10/19/2009 639467 397.01 0.00 0.00 0.00 0.00 0.00 0.00 5,979.34 10/19/2009 641645 0.00 0.00 0.00 0.00 2,679.44 4,979.65 7,659.09 76,207.60 10/19/2009 641692 0.00 0.00 0.00 3,176.31 0.00 0.00 3,176.31 31,843.04 11/02/2009 645675 0.00 0.00 0.00 0.00 0.00 197.40 197.40 1,963.78 11/02/2009 645711 0.00 0.00 0.00 2,387.69 0.00 0.00 2,387.69 24,340.38 11/09/2009 647701 0.00 0.00 0.00 226.13 0.00 0.00 226.13 1,038.36 11/16/2009 647731 661.26 0.00 0.00 0.00 0.00 0.00 0.00 11,515.86 11/16/2009 650026 0.00 0.00 0.00 0.00 8,350.87 16,588.50 24,939.37 248,201.20 11/23/2009 652065 0.00 0.00 0.00 0.00 68.49 112.98 181.47 1,805.42 11/23/2009 652096 0.00 0.00 0.00 2,902.20 0.00 0.00 2,902.20 29,247.14 11/30/2009 654137 0.00 0.00 0.00 0.00 14.56 11.65 26.21 261.00 11/30/2009 654177 0.00 0.00 0.00 63.42 0.00 0.00 63.42 20.36 12/07/2009 655712 0.00 0.00 0.00 0.00 0.00 3.90 3.90 39.40 12/21/2009 658475 649.44 0.00 0.00 0.00 0.00 0.00 0.00 9,475.70 12/21/2009 660616 0.00 0.00 0.00 0.00 4,149.44 5,576.67 9,726.11 96,770.48 12/21/2009 660652 0.00 0.00 0.00 455.23 0.00 0.00 455.23 4,581.00 12/28/2009 662215 0.00 0.00 0.00 0.00 0.00 3.96 3.96 19.70 12/28/2009 662671 0.00 0.00 0.00 0.00 0.00 2.82 2.82 28.00 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 2,783.94 0.00 0.00 18,443.05 34,838.39 67,787.80 121,069.24 1,387,666.42 CNTRNUM 2,783.94 0.00 0.00 18,443.05 34,838.39 67,787.80 121,069.24 1,387,666.42 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 70 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL --------------------------------------------------------- CONTRACT NUM=6800019 NAME=PREBLE CO BD OF DD ---------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 609501 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2,006.00 07/06/2009 611243 0.00 0.00 0.00 0.00 0.00 0.00 0.00 52,388.78 08/24/2009 623190 210.71 0.00 0.00 0.00 0.00 0.00 0.00 2,066.02 08/24/2009 625123 0.00 0.00 0.00 0.00 800.79 4,072.27 4,873.06 47,780.74 09/14/2009 629200 471.77 0.00 0.00 0.00 0.00 0.00 0.00 4,623.98 09/14/2009 631392 0.00 0.00 0.00 0.00 1,076.41 5,799.88 6,876.29 67,413.75 10/06/2009 637360 0.00 0.00 0.00 1,677.02 0.00 0.00 1,677.02 16,685.02 10/13/2009 637392 302.94 0.00 0.00 0.00 0.00 0.00 0.00 3,015.55 10/13/2009 639403 0.00 0.00 0.00 0.00 913.91 4,537.15 5,451.06 54,245.21 11/02/2009 643720 370.37 0.00 0.00 0.00 0.00 0.00 0.00 3,687.56 11/02/2009 645676 0.00 0.00 0.00 0.00 1,251.24 5,138.59 6,389.83 63,588.88 11/02/2009 645712 0.00 0.00 0.00 987.36 0.00 0.00 987.36 9,884.78 11/23/2009 652097 0.00 0.00 0.00 1,462.05 0.00 0.00 1,462.05 14,567.58 12/07/2009 654214 355.52 0.00 0.00 0.00 0.00 0.00 0.00 3,539.68 12/07/2009 656165 0.00 0.00 0.00 0.00 1,201.32 5,059.60 6,260.92 62,305.42 12/14/2009 658444 0.00 0.00 0.00 664.02 0.00 0.00 664.02 6,606.82 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 1,711.31 0.00 0.00 4,790.45 5,243.67 24,607.49 34,641.61 414,405.77 CNTRNUM 1,711.31 0.00 0.00 4,790.45 5,243.67 24,607.49 34,641.61 414,405.77 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 71 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL --------------------------------------------------------- CONTRACT NUM=6900018 NAME=PUTMAN CO BD OF DD ---------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/13/2009 613158 0.00 0.00 0.00 0.00 0.00 0.00 0.00 20,248.02 11/30/2009 652129 2,609.16 0.00 0.00 0.00 0.00 0.00 0.00 25,951.25 11/30/2009 654138 0.00 0.00 0.00 0.00 7,211.42 20,604.16 27,815.58 276,719.69 11/30/2009 654178 0.00 0.00 0.00 2,096.27 0.00 0.00 2,096.27 20,858.82 12/07/2009 654215 360.73 0.00 0.00 0.00 0.00 0.00 0.00 3,588.39 12/07/2009 656166 0.00 0.00 0.00 0.00 586.42 2,863.98 3,450.40 34,328.83 12/07/2009 656199 0.00 0.00 0.00 478.79 0.00 0.00 478.79 4,764.24 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 2,969.89 0.00 0.00 2,575.06 7,797.84 23,468.14 33,841.04 386,459.24 CNTRNUM 2,969.89 0.00 0.00 2,575.06 7,797.84 23,468.14 33,841.04 386,459.24 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 72 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL -------------------------------------------------------- CONTRACT NUM=7000015 NAME=RICHLAND CO BD OF DD --------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 609502 0.00 0.00 0.00 0.00 0.00 0.00 0.00 4,781.03 07/06/2009 611244 0.00 0.00 0.00 0.00 0.00 0.00 0.00 105,172.00 07/06/2009 611284 0.00 0.00 0.00 0.00 0.00 0.00 0.00 57,547.54 07/13/2009 611309 0.00 0.00 0.00 0.00 0.00 0.00 0.00 4,789.08 07/13/2009 613135 0.00 0.00 0.00 0.00 0.00 0.00 0.00 121,337.91 07/13/2009 613159 0.00 0.00 0.00 0.00 0.00 0.00 0.00 49,393.36 08/10/2009 619072 916.69 0.00 0.00 0.00 0.00 0.00 0.00 10,024.49 08/10/2009 620942 0.00 0.00 0.00 0.00 7,097.32 14,763.28 21,860.60 239,045.68 08/17/2009 620993 360.83 0.00 0.00 0.00 0.00 0.00 0.00 3,533.95 08/17/2009 623140 0.00 0.00 0.00 0.00 60.45 407.42 467.87 4,584.82 09/08/2009 627238 1,218.75 0.00 0.00 0.00 0.00 214.50 214.50 7,743.60 09/08/2009 629133 0.00 0.00 0.00 0.00 4,860.02 9,894.30 14,754.32 141,913.82 09/08/2009 629168 0.00 0.00 0.00 4,794.33 0.00 0.00 4,794.33 46,980.70 09/14/2009 631393 0.00 0.00 0.00 0.00 122.41 71.40 193.81 1,900.16 09/14/2009 631428 0.00 0.00 0.00 4,875.22 0.00 0.00 4,875.22 48,670.58 10/06/2009 635447 2,098.82 0.00 0.00 0.00 0.00 0.00 0.00 20,876.00 10/06/2009 637324 0.00 0.00 0.00 0.00 10,020.78 21,587.74 31,608.52 314,352.72 10/19/2009 639468 537.60 0.00 0.00 0.00 0.00 63.23 63.23 4,946.17 10/19/2009 641646 0.00 0.00 0.00 0.00 2,416.21 4,655.67 7,071.88 68,035.93 10/19/2009 641693 0.00 0.00 0.00 4,476.18 0.00 0.00 4,476.18 44,537.50 11/09/2009 647702 0.00 0.00 0.00 494.30 0.00 0.00 494.30 183.24 11/23/2009 650071 613.49 0.00 0.00 0.00 0.00 0.00 0.00 6,109.20 11/23/2009 652066 0.00 0.00 0.00 0.00 2,590.09 4,723.79 7,313.88 72,830.86 11/23/2009 652098 0.00 0.00 0.00 5,176.91 0.00 0.00 5,176.91 53,383.92 11/30/2009 654179 0.00 0.00 0.00 16.35 0.00 0.00 16.35 162.88 12/14/2009 656223 741.87 0.00 0.00 0.00 0.00 0.00 0.00 7,374.82 12/14/2009 658420 0.00 0.00 0.00 0.00 3,518.33 7,556.87 11,075.20 110,106.10 12/21/2009 658476 1,185.16 0.00 0.00 0.00 0.00 0.00 0.00 11,790.69 12/21/2009 660617 0.00 0.00 0.00 0.00 5,738.31 12,200.95 17,939.26 178,465.42 12/21/2009 660653 0.00 0.00 0.00 6,078.96 0.00 0.00 6,078.96 61,354.86 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 7,673.21 0.00 0.00 25,912.25 36,423.92 76,139.15 138,475.32 1,801,929.03 CNTRNUM 7,673.21 0.00 0.00 25,912.25 36,423.92 76,139.15 138,475.32 1,801,929.03 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 73 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL ---------------------------------------------------------- CONTRACT NUM=7100014 NAME=ROSS CO BD OF DD ----------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 611245 0.00 0.00 0.00 0.00 0.00 0.00 0.00 12,586.56 07/20/2009 615168 0.00 0.00 0.00 160.20 0.00 0.00 160.20 570.08 08/04/2009 619005 0.00 0.00 0.00 0.00 109.57 956.75 1,066.32 11,650.06 08/10/2009 620969 0.00 0.00 0.00 3,737.63 0.00 0.00 3,737.63 41,697.00 08/24/2009 623191 45.84 0.00 0.00 0.00 0.00 0.00 0.00 449.52 08/24/2009 625124 0.00 0.00 0.00 0.00 666.59 5,773.93 6,440.52 63,157.56 09/14/2009 629201 68.76 0.00 0.00 0.00 0.00 0.00 0.00 674.28 09/14/2009 631394 0.00 0.00 0.00 0.00 532.89 1,573.84 2,106.73 20,659.19 09/21/2009 633377 0.00 0.00 0.00 2,447.83 0.00 0.00 2,447.83 24,001.20 09/28/2009 635380 0.00 0.00 0.00 0.00 93.59 1,086.79 1,180.38 11,575.14 10/19/2009 641694 0.00 0.00 0.00 2,613.71 0.00 0.00 2,613.71 26,014.86 11/02/2009 645677 0.00 0.00 0.00 0.00 109.04 1,379.92 1,488.96 14,834.16 11/09/2009 647703 0.00 0.00 0.00 222.94 0.00 0.00 222.94 83.86 11/16/2009 647732 63.92 0.00 0.00 0.00 0.00 0.00 0.00 636.82 11/16/2009 650027 0.00 0.00 0.00 0.00 611.00 1,735.24 2,346.24 23,375.04 12/14/2009 658421 0.00 0.00 0.00 0.00 169.20 1,062.20 1,231.40 12,268.15 12/21/2009 658477 58.28 0.00 0.00 0.00 0.00 0.00 0.00 580.63 12/21/2009 660618 0.00 0.00 0.00 0.00 748.24 2,872.64 3,620.88 36,073.98 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 236.80 0.00 0.00 9,182.31 3,040.12 16,441.31 28,663.74 300,888.09 CNTRNUM 236.80 0.00 0.00 9,182.31 3,040.12 16,441.31 28,663.74 300,888.09 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 74 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL -------------------------------------------------------- CONTRACT NUM=7200013 NAME=SANDUSKY CO BD OF DD --------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 10/19/2009 639469 4,606.24 0.00 0.00 0.00 0.00 0.00 0.00 45,826.51 10/19/2009 641647 0.00 0.00 0.00 0.00 2,005.71 81,621.10 83,626.81 831,799.28 10/19/2009 641695 0.00 0.00 0.00 25,762.06 0.00 0.00 25,762.06 256,373.12 11/02/2009 643721 497.63 0.00 0.00 0.00 0.00 0.00 0.00 4,951.22 11/02/2009 645678 0.00 0.00 0.00 0.00 244.47 11,950.92 12,195.39 121,320.32 11/23/2009 652099 0.00 0.00 0.00 3,692.73 0.00 0.00 3,692.73 36,749.80 11/30/2009 654180 0.00 0.00 0.00 90.07 0.00 0.00 90.07 895.84 12/21/2009 658478 436.14 0.00 0.00 0.00 0.00 0.00 0.00 4,339.18 12/21/2009 660619 0.00 0.00 0.00 0.00 167.04 11,289.01 11,456.05 113,967.61 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 5,540.01 0.00 0.00 29,544.86 2,417.22 104,861.03 136,823.11 1,416,222.88 CNTRNUM 5,540.01 0.00 0.00 29,544.86 2,417.22 104,861.03 136,823.11 1,416,222.88 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 75 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL --------------------------------------------------------- CONTRACT NUM=7300012 NAME=SCIOTO CO BD OF DD ---------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 611285 0.00 0.00 0.00 0.00 0.00 0.00 0.00 4,377.40 07/13/2009 613136 0.00 0.00 0.00 0.00 0.00 0.00 0.00 51,790.63 08/04/2009 619006 0.00 0.00 0.00 0.00 505.79 2,669.82 3,175.61 34,687.96 08/10/2009 620943 0.00 0.00 0.00 0.00 438.87 2,506.77 2,945.64 32,178.14 09/08/2009 629169 0.00 0.00 0.00 2,134.46 0.00 0.00 2,134.46 20,919.90 09/21/2009 633342 0.00 0.00 0.00 0.00 695.65 5,177.61 5,873.26 57,580.61 09/28/2009 633404 119.64 0.00 0.00 0.00 0.00 0.00 0.00 1,172.90 09/28/2009 635381 0.00 0.00 0.00 0.00 1,165.91 7,833.48 8,999.39 88,236.70 10/06/2009 635448 71.45 0.00 0.00 0.00 0.00 0.00 0.00 711.74 10/06/2009 637325 0.00 0.00 0.00 0.00 372.34 2,750.70 3,123.04 31,105.09 10/06/2009 637361 0.00 0.00 0.00 1,950.06 0.00 0.00 1,950.06 19,403.08 10/13/2009 639404 0.00 0.00 0.00 0.00 0.00 2.17 2.17 21.50 10/26/2009 641728 67.81 0.00 0.00 0.00 0.00 0.00 0.00 674.66 10/26/2009 643662 0.00 0.00 0.00 0.00 573.94 4,493.86 5,067.80 50,423.30 11/02/2009 645713 0.00 0.00 0.00 1,980.77 0.00 0.00 1,980.77 19,708.48 11/16/2009 647733 133.07 0.00 0.00 0.00 0.00 0.00 0.00 1,323.44 11/16/2009 650028 0.00 0.00 0.00 0.00 564.74 4,321.22 4,885.96 48,613.95 11/30/2009 652130 73.32 0.00 0.00 0.00 0.00 0.00 0.00 730.47 11/30/2009 654139 0.00 0.00 0.00 0.00 404.24 2,818.87 3,223.11 32,103.22 12/14/2009 658445 0.00 0.00 0.00 2,187.50 0.00 0.00 2,187.50 21,764.84 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 465.29 0.00 0.00 8,252.79 4,721.48 32,574.50 45,548.77 517,528.01 CNTRNUM 465.29 0.00 0.00 8,252.79 4,721.48 32,574.50 45,548.77 517,528.01 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 76 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL --------------------------------------------------------- CONTRACT NUM=7400011 NAME=SENECA CO BD OF DD ---------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 10/19/2009 641696 0.00 0.00 0.00 2,926.35 0.00 0.00 2,926.35 29,114.80 11/09/2009 645738 1,645.70 0.00 0.00 0.00 0.00 0.00 0.00 16,364.04 11/09/2009 647650 0.00 0.00 0.00 0.00 928.85 11,887.64 12,816.49 127,400.80 11/09/2009 647704 0.00 0.00 0.00 4,474.54 0.00 0.00 4,474.54 44,517.14 11/23/2009 650072 1,017.60 0.00 0.00 0.00 0.00 0.00 0.00 10,133.60 11/23/2009 652067 0.00 0.00 0.00 0.00 1,075.20 16,767.36 17,842.56 177,682.16 12/07/2009 654216 822.36 0.00 0.00 0.00 0.00 0.00 0.00 8,177.19 12/07/2009 656167 0.00 0.00 0.00 0.00 480.29 5,833.49 6,313.78 62,763.84 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 3,485.66 0.00 0.00 7,400.89 2,484.34 34,488.49 44,373.72 476,153.57 CNTRNUM 3,485.66 0.00 0.00 7,400.89 2,484.34 34,488.49 44,373.72 476,153.57 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 77 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL --------------------------------------------------------- CONTRACT NUM=7500010 NAME=SHELBY CO BD OF DD ---------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/20/2009 613182 392.71 0.00 0.00 0.00 0.00 0.00 0.00 4,292.88 07/20/2009 615140 0.00 0.00 0.00 0.00 1,598.63 3,631.45 5,230.08 57,168.35 07/20/2009 615169 0.00 0.00 0.00 39.10 0.00 0.00 39.10 427.56 07/27/2009 615202 133.00 0.00 0.00 0.00 0.00 0.00 0.00 1,453.12 07/27/2009 617055 0.00 0.00 0.00 0.00 929.71 1,561.00 2,490.71 27,213.74 07/27/2009 617082 0.00 0.00 0.00 306.38 0.00 0.00 306.38 3,349.22 08/04/2009 619045 0.00 0.00 0.00 18.63 0.00 0.00 18.63 91.62 08/17/2009 620994 207.18 0.00 0.00 0.00 0.00 0.00 0.00 2,029.50 08/17/2009 623141 0.00 0.00 0.00 0.00 121.68 388.99 510.67 5,002.16 09/08/2009 627239 37.05 0.00 0.00 0.00 0.00 0.00 0.00 363.28 09/08/2009 629134 0.00 0.00 0.00 0.00 158.04 3.90 161.94 1,586.91 09/14/2009 629202 201.43 0.00 0.00 0.00 0.00 0.00 0.00 1,973.25 09/14/2009 631395 0.00 0.00 0.00 0.00 971.27 2,367.29 3,338.56 32,704.20 09/21/2009 631458 109.20 0.00 0.00 0.00 0.00 0.00 0.00 1,070.72 09/21/2009 633343 0.00 0.00 0.00 0.00 692.25 1,394.25 2,086.50 20,458.40 09/21/2009 633378 0.00 0.00 0.00 72.54 0.00 0.00 72.54 173.06 09/28/2009 633405 156.00 0.00 0.00 0.00 0.00 0.00 0.00 1,529.60 09/28/2009 635382 0.00 0.00 0.00 0.00 144.81 402.44 547.25 5,361.87 09/28/2009 635419 0.00 0.00 0.00 4,858.08 0.00 0.00 4,858.08 47,611.86 10/19/2009 641697 0.00 0.00 0.00 43.17 0.00 0.00 43.17 386.84 10/26/2009 641729 678.45 0.00 0.00 0.00 0.00 0.00 0.00 6,750.04 10/26/2009 643663 0.00 0.00 0.00 0.00 4,010.82 7,466.36 11,477.18 114,181.55 10/26/2009 643693 0.00 0.00 0.00 2,518.88 0.00 0.00 2,518.88 25,307.48 11/02/2009 643722 0.00 0.00 0.00 0.00 1.92 13.39 15.31 95.60 11/02/2009 645679 0.00 0.00 0.00 0.00 325.54 91.99 417.53 2,932.34 11/02/2009 645714 0.00 0.00 0.00 1,432.60 0.00 0.00 1,432.60 13,508.86 11/09/2009 647705 0.00 0.00 0.00 2,798.04 0.00 0.00 2,798.04 3,305.92 11/30/2009 652131 599.21 0.00 0.00 0.00 0.00 21.46 21.46 5,810.31 11/30/2009 654140 0.00 0.00 0.00 0.00 3,913.80 5,428.16 9,341.96 92,180.82 11/30/2009 654181 0.00 0.00 0.00 2,078.02 0.00 0.00 2,078.02 20,573.78 12/07/2009 656168 0.00 0.00 0.00 0.00 104.07 0.00 104.07 1,035.47 12/07/2009 656200 0.00 0.00 0.00 61.38 0.00 0.00 61.38 610.80 12/14/2009 658446 0.00 0.00 0.00 2.04 0.00 0.00 2.04 30.54 12/21/2009 658479 284.79 0.00 0.00 0.00 0.00 0.00 0.00 2,832.58 12/21/2009 660620 0.00 0.00 0.00 0.00 1,109.48 2,636.93 3,746.41 37,247.91 12/21/2009 660654 0.00 0.00 0.00 2.04 0.00 0.00 2.04 20.36 12/28/2009 660683 7.29 0.00 0.00 0.00 0.00 0.00 0.00 72.50 12/28/2009 662672 0.00 0.00 0.00 0.00 88.29 26.08 114.37 1,136.76 12/28/2009 662713 0.00 0.00 0.00 11.26 0.00 0.00 11.26 50.90 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 2,806.31 0.00 0.00 14,242.16 14,170.31 25,433.69 53,846.16 541,932.66 CNTRNUM 2,806.31 0.00 0.00 14,242.16 14,170.31 25,433.69 53,846.16 541,932.66 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 78 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL ---------------------------------------------------------- CONTRACT NUM=7600019 NAME=STARK CO BD OF DD ---------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 609503 0.00 0.00 0.00 0.00 0.00 0.00 0.00 457.41 07/06/2009 611246 0.00 0.00 0.00 0.00 0.00 0.00 0.00 9,998.04 07/06/2009 611286 0.00 0.00 0.00 0.00 0.00 0.00 0.00 17,692.84 07/13/2009 613137 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,851.14 07/27/2009 615203 146.77 0.00 0.00 0.00 0.00 0.00 0.00 1,604.30 07/27/2009 617056 0.00 0.00 0.00 0.00 3,576.69 5,485.93 9,062.62 99,047.42 08/04/2009 617105 24.71 0.00 0.00 0.00 0.00 0.00 0.00 270.34 08/04/2009 619008 0.00 0.00 0.00 0.00 773.20 1,025.65 1,798.85 19,676.89 08/04/2009 619046 0.00 0.00 0.00 95.92 0.00 0.00 95.92 1,048.54 08/10/2009 620970 0.00 0.00 0.00 19.56 0.00 0.00 19.56 213.78 08/17/2009 620995 265.95 0.00 0.00 0.00 0.00 0.00 0.00 2,606.85 08/17/2009 623142 0.00 0.00 0.00 0.00 7,474.18 7,876.06 15,350.24 150,463.52 08/24/2009 623192 340.72 0.00 0.00 0.00 0.00 0.00 0.00 3,340.17 08/24/2009 625125 0.00 0.00 0.00 0.00 4,120.87 5,900.03 10,020.90 98,239.57 08/31/2009 625185 1,148.17 0.00 0.00 0.00 0.00 0.00 0.00 11,256.60 08/31/2009 627170 0.00 0.00 0.00 0.00 17,283.09 21,453.38 38,736.47 379,719.24 09/08/2009 628811 0.00 0.00 0.00 0.00 0.00 26.63 26.63 7.78 09/14/2009 631429 0.00 0.00 0.00 9.35 0.00 0.00 9.35 91.62 09/21/2009 631459 131.25 0.00 0.00 0.00 0.00 0.00 0.00 1,286.49 09/21/2009 633344 0.00 0.00 0.00 0.00 5,239.09 8,554.80 13,793.89 135,229.83 09/21/2009 633379 0.00 0.00 0.00 112.17 0.00 0.00 112.17 1,099.44 09/28/2009 633406 65.01 0.00 0.00 0.00 0.00 0.00 0.00 1,063.81 09/28/2009 635383 0.00 0.00 0.00 0.00 1,434.57 185.49 1,620.06 15,881.90 10/06/2009 635449 1,395.82 0.00 0.00 0.00 0.00 0.00 0.00 13,887.88 10/06/2009 637326 0.00 0.00 0.00 0.00 22,406.20 29,331.47 51,737.67 514,783.24 10/13/2009 639437 0.00 0.00 0.00 14.33 0.00 0.00 14.33 142.52 10/19/2009 639470 1,953.71 0.00 0.00 0.00 0.00 0.00 0.00 20,109.27 10/19/2009 641648 0.00 0.00 0.00 0.00 36,370.57 43,741.35 80,111.92 796,853.27 10/19/2009 641698 0.00 0.00 0.00 654.20 0.00 0.00 654.20 3,715.70 10/26/2009 641730 27.54 0.00 0.00 0.00 0.00 0.00 0.00 274.23 10/26/2009 643664 0.00 0.00 0.00 0.00 339.38 74.05 413.43 4,115.86 11/02/2009 645341 0.00 0.00 0.00 0.00 0.00 19.40 19.40 193.10 11/09/2009 645739 2,769.06 0.00 0.00 0.00 0.00 0.00 0.00 28,784.13 11/09/2009 647651 0.00 0.00 0.00 0.00 26,352.89 35,292.85 61,645.74 613,255.42 12/07/2009 656169 0.00 0.00 0.00 0.00 6.00 16.20 22.20 220.89 12/07/2009 656201 0.00 0.00 0.00 12,722.28 0.00 0.00 12,722.28 127,565.58 12/21/2009 658480 3,234.62 0.00 0.00 0.00 0.00 0.00 0.00 32,738.42 12/21/2009 660621 0.00 0.00 0.00 0.00 42,000.46 40,765.54 82,766.00 823,633.78 12/21/2009 660655 0.00 0.00 0.00 15,464.41 0.00 0.00 15,464.41 154,624.02 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 11,503.33 0.00 0.00 29,092.22 167,377.19 199,748.83 396,218.24 4,087,044.83 CNTRNUM 11,503.33 0.00 0.00 29,092.22 167,377.19 199,748.83 396,218.24 4,087,044.83 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 79 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL --------------------------------------------------------- CONTRACT NUM=7700018 NAME=SUMMIT CO BD OF DD ---------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 609504 0.00 0.00 0.00 0.00 0.00 0.00 0.00 6,087.62 07/06/2009 611247 0.00 0.00 0.00 0.00 0.00 0.00 0.00 486,420.36 07/06/2009 611287 0.00 0.00 0.00 0.00 0.00 0.00 0.00 209,616.38 07/13/2009 613138 0.00 0.00 0.00 0.00 0.00 0.00 0.00 10,272.39 07/20/2009 613183 82.92 0.00 0.00 0.00 0.00 0.00 0.00 905.16 07/20/2009 615141 0.00 0.00 0.00 0.00 1,419.76 2,121.04 3,540.80 38,672.88 07/27/2009 617083 0.00 0.00 0.00 476.76 0.00 0.00 476.76 5,212.16 08/04/2009 619009 0.00 0.00 0.00 0.00 216.41 341.25 557.66 6,094.11 08/04/2009 619047 0.00 0.00 0.00 19,595.95 0.00 0.00 19,595.95 215,622.58 08/10/2009 619073 1,416.11 0.00 0.00 0.00 0.00 0.00 0.00 15,469.58 08/10/2009 620944 0.00 0.00 0.00 0.00 14,361.13 35,378.28 49,739.41 543,418.27 08/17/2009 623143 0.00 0.00 0.00 0.00 887.16 839.30 1,726.46 16,937.23 08/17/2009 623159 0.00 0.00 0.00 881.78 0.00 0.00 881.78 10,475.22 08/31/2009 625186 40.20 0.00 0.00 0.00 0.00 0.00 0.00 394.00 08/31/2009 627171 0.00 0.00 0.00 0.00 80.40 102.51 182.91 1,792.70 09/08/2009 627240 1,674.47 0.00 0.00 0.00 0.00 0.00 0.00 16,423.37 09/08/2009 629135 0.00 0.00 0.00 0.00 14,724.89 38,034.58 52,759.47 503,537.73 09/08/2009 629170 0.00 0.00 0.00 21,784.07 0.00 0.00 21,784.07 213,505.14 09/14/2009 629203 251.25 0.00 0.00 0.00 0.00 0.00 0.00 2,462.50 09/14/2009 631396 0.00 0.00 0.00 0.00 331.65 311.55 643.20 6,304.00 09/21/2009 631460 227.27 0.00 0.00 0.00 0.00 0.00 0.00 2,229.37 09/21/2009 633345 0.00 0.00 0.00 0.00 3,116.02 3,556.95 6,672.97 63,117.49 10/06/2009 635450 627.66 0.00 0.00 0.00 0.00 0.00 0.00 6,244.90 10/06/2009 637327 0.00 0.00 0.00 0.00 3,094.74 6,223.14 9,317.88 92,708.20 10/06/2009 637362 0.00 0.00 0.00 19,747.62 0.00 0.00 19,747.62 196,494.36 10/13/2009 637393 1,911.36 0.00 0.00 0.00 0.00 0.00 0.00 19,019.70 10/13/2009 639405 0.00 0.00 0.00 0.00 18,586.06 47,368.89 65,954.95 656,352.05 10/19/2009 639471 87.06 0.00 0.00 0.00 0.00 0.00 0.00 866.54 10/19/2009 641649 0.00 0.00 0.00 0.00 2,681.69 3,015.33 5,697.02 54,808.91 10/19/2009 641699 0.00 0.00 0.00 337.60 0.00 0.00 337.60 3,359.40 10/26/2009 641731 255.42 0.00 0.00 0.00 0.00 0.00 0.00 2,541.30 10/26/2009 643665 0.00 0.00 0.00 0.00 3,391.74 7,789.32 11,181.06 111,245.90 11/02/2009 643723 516.78 0.00 0.00 0.00 0.00 0.00 0.00 5,141.70 11/02/2009 645680 0.00 0.00 0.00 0.00 6,294.42 13,911.48 20,205.90 201,038.50 11/02/2009 645715 0.00 0.00 0.00 19,126.53 0.00 0.00 19,126.53 191,363.64 11/09/2009 645740 1,230.80 0.00 0.00 0.00 0.00 0.00 0.00 12,245.88 11/09/2009 647652 0.00 0.00 0.00 0.00 14,146.38 30,691.50 44,837.88 446,117.77 11/09/2009 647706 0.00 0.00 0.00 22.51 0.00 0.00 22.51 40.72 11/16/2009 647734 2,048.67 0.00 0.00 0.00 0.00 0.00 0.00 20,387.51 11/16/2009 650029 0.00 0.00 0.00 0.00 16,342.09 43,860.59 60,202.68 599,154.00 11/16/2009 650050 0.00 0.00 0.00 3,102.65 0.00 0.00 3,102.65 30,641.80 11/23/2009 650073 545.10 0.00 0.00 0.00 0.00 0.00 0.00 5,424.00 11/23/2009 652068 0.00 0.00 0.00 0.00 5,198.45 8,241.99 13,440.44 133,732.48 11/30/2009 652132 1,991.45 0.00 0.00 0.00 0.00 0.00 0.00 19,817.90 11/30/2009 654141 0.00 0.00 0.00 0.00 15,878.40 41,264.39 57,142.79 568,689.07 11/30/2009 654182 0.00 0.00 0.00 20,060.37 0.00 0.00 20,060.37 201,879.58 12/07/2009 656170 0.00 0.00 0.00 0.00 65.88 82.40 148.28 1,475.74 12/21/2009 658481 1,914.66 0.00 0.00 0.00 0.00 0.00 0.00 19,049.90 12/21/2009 660622 99.00 0.00 0.00 0.00 17,952.66 40,374.18 58,326.84 581,307.60 12/28/2009 662673 0.00 0.00 0.00 0.00 188.01 0.00 188.01 1,418.40 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 14,920.18 0.00 0.00 105,135.84 138,957.94 323,508.67 567,602.45 6,557,537.69 CNTRNUM 14,920.18 0.00 0.00 105,135.84 138,957.94 323,508.67 567,602.45 6,557,537.69 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 80 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL -------------------------------------------------------- CONTRACT NUM=7800017 NAME=TRUMBULL CO BD OF DD --------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 609505 0.00 0.00 0.00 0.00 0.00 0.00 0.00 4,265.12 07/06/2009 611248 0.00 0.00 0.00 0.00 0.00 0.00 0.00 219,895.95 07/06/2009 611288 0.00 0.00 0.00 0.00 0.00 0.00 0.00 81.44 07/13/2009 613160 0.00 0.00 0.00 0.00 0.00 0.00 0.00 10,577.02 07/20/2009 615171 0.00 0.00 0.00 8,104.65 0.00 0.00 8,104.65 87,721.06 07/27/2009 615204 11.16 0.00 0.00 0.00 0.00 0.00 0.00 122.00 07/27/2009 617057 0.00 0.00 0.00 0.00 387.27 1,344.16 1,731.43 18,923.97 08/04/2009 617106 70.61 0.00 0.00 0.00 0.00 0.00 0.00 772.40 08/04/2009 619010 0.00 0.00 0.00 0.00 877.53 6,669.32 7,546.85 82,550.25 08/04/2009 619048 0.00 0.00 0.00 6,717.27 0.00 0.00 6,717.27 74,548.14 08/10/2009 619074 60.02 0.00 0.00 0.00 0.00 0.00 0.00 656.54 08/10/2009 620945 0.00 0.00 0.00 0.00 776.92 6,076.09 6,853.01 74,961.42 08/10/2009 620971 0.00 0.00 0.00 74.51 0.00 0.00 74.51 71.26 08/24/2009 623193 255.77 0.00 0.00 0.00 0.00 0.00 0.00 2,508.32 08/24/2009 625126 0.00 0.00 0.00 0.00 1,391.32 9,641.06 11,032.38 108,133.81 08/24/2009 625158 0.00 0.00 0.00 23.91 0.00 0.00 23.91 234.14 08/31/2009 627172 0.00 0.00 0.00 0.00 37.63 185.74 223.37 1,993.78 08/31/2009 627214 0.00 0.00 0.00 68.55 0.00 0.00 68.55 671.88 09/08/2009 629136 0.00 0.00 0.00 0.00 1.97 0.00 1.97 19.31 09/14/2009 629204 146.30 0.00 0.00 0.00 0.00 0.00 0.00 1,434.72 09/14/2009 631397 0.00 0.00 0.00 0.00 210.02 3,062.34 3,272.36 32,072.34 09/14/2009 631430 0.00 0.00 0.00 7,044.92 0.00 0.00 7,044.92 69,458.14 09/21/2009 633380 0.00 0.00 0.00 88.50 0.00 0.00 88.50 152.70 09/28/2009 635384 0.00 0.00 0.00 0.00 44.71 410.17 454.88 4,457.22 09/28/2009 635420 0.00 0.00 0.00 112.20 0.00 0.00 112.20 1,099.44 10/06/2009 635451 178.02 0.00 0.00 0.00 0.00 0.00 0.00 1,771.80 10/06/2009 637328 0.00 0.00 0.00 0.00 2,127.69 16,895.19 19,022.88 189,314.74 10/13/2009 639406 0.00 0.00 0.00 0.00 3.88 0.00 3.88 38.62 10/13/2009 639438 0.00 0.00 0.00 897.23 0.00 0.00 897.23 8,927.86 10/19/2009 639472 61.30 0.00 0.00 0.00 0.00 0.00 0.00 610.00 10/19/2009 641650 0.00 0.00 0.00 0.00 651.50 4,668.90 5,320.40 52,921.26 10/19/2009 641700 0.00 0.00 0.00 1,592.95 0.00 0.00 1,592.95 7,716.44 10/26/2009 641732 27.46 0.00 0.00 0.00 0.00 0.00 0.00 273.28 10/26/2009 643666 0.00 0.00 0.00 0.00 530.71 3,151.52 3,682.23 36,639.12 10/26/2009 643694 0.00 0.00 0.00 161.66 0.00 0.00 161.66 1,608.44 11/02/2009 645716 0.00 0.00 0.00 14.30 0.00 0.00 14.30 71.26 11/16/2009 647735 326.76 0.00 0.00 0.00 0.00 0.00 0.00 3,251.91 11/16/2009 650030 0.00 0.00 0.00 0.00 1,828.36 15,632.27 17,460.63 173,735.11 11/16/2009 650051 0.00 0.00 0.00 16,064.98 0.00 0.00 16,064.98 147,813.60 11/30/2009 654142 0.00 0.00 0.00 0.00 812.97 4,235.65 5,048.62 50,222.67 11/30/2009 654183 0.00 0.00 0.00 7,604.55 0.00 0.00 7,604.55 75,555.96 12/07/2009 654217 442.34 0.00 0.00 0.00 0.00 0.00 0.00 4,401.56 12/07/2009 656171 0.00 0.00 0.00 0.00 1,583.74 14,551.74 16,135.48 160,558.66 12/07/2009 656202 0.00 0.00 0.00 291.54 0.00 0.00 291.54 3,043.82 12/14/2009 658422 0.00 0.00 0.00 0.00 814.00 4,698.58 5,512.58 54,840.58 12/14/2009 658447 0.00 0.00 0.00 3,663.68 0.00 0.00 3,663.68 36,556.38 12/21/2009 658482 3.88 0.00 0.00 0.00 0.00 0.00 0.00 38.62 12/21/2009 660623 0.00 0.00 0.00 0.00 0.00 158.67 158.67 1,579.24 12/21/2009 660656 0.00 0.00 0.00 62.41 0.00 0.00 62.41 620.98 12/28/2009 660684 487.39 0.00 0.00 0.00 0.00 0.00 0.00 4,849.44 12/28/2009 662674 0.00 0.00 0.00 0.00 1,924.12 17,976.61 19,900.73 198,007.68 12/28/2009 662714 0.00 0.00 0.00 3,651.64 0.00 0.00 3,651.64 34,184.44 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 2,071.01 0.00 0.00 56,239.45 14,004.34 109,358.01 179,601.80 2,046,535.84 CNTRNUM 2,071.01 0.00 0.00 56,239.45 14,004.34 109,358.01 179,601.80 2,046,535.84 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 81 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL ------------------------------------------------------- CONTRACT NUM=7900016 NAME=TUSCARAWAS CO BD OF DD -------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 609506 0.00 0.00 0.00 0.00 0.00 0.00 0.00 9,833.25 07/06/2009 611249 0.00 0.00 0.00 0.00 0.00 0.00 0.00 68,195.93 07/06/2009 611289 0.00 0.00 0.00 0.00 0.00 0.00 0.00 17,794.64 07/20/2009 615142 0.00 0.00 0.00 0.00 1.71 0.00 1.71 18.73 07/20/2009 615172 0.00 0.00 0.00 18.62 0.00 0.00 18.62 203.60 08/04/2009 617107 540.13 0.00 0.00 0.00 0.00 0.00 0.00 6,855.18 08/04/2009 619011 0.00 0.00 0.00 0.00 1,085.44 3,182.24 4,267.68 46,618.97 08/17/2009 620996 500.94 0.00 0.00 0.00 0.00 0.00 0.00 5,700.62 08/17/2009 623144 0.00 0.00 0.00 0.00 2,130.42 4,797.52 6,927.94 67,923.27 08/24/2009 625159 0.00 0.00 0.00 2,522.98 0.00 0.00 2,522.98 25,592.52 08/31/2009 627020 0.00 0.00 0.00 0.00 0.00 22.92 22.92 16.69 08/31/2009 627215 0.00 0.00 0.00 13.51 0.00 0.00 13.51 81.44 09/14/2009 629205 538.10 0.00 0.00 0.00 0.00 0.00 0.00 6,175.19 09/14/2009 631398 0.00 0.00 0.00 0.00 1,616.89 4,625.94 6,242.83 61,205.54 09/14/2009 631431 0.00 0.00 0.00 3,137.85 0.00 0.00 3,137.85 31,435.84 09/21/2009 631461 0.00 0.00 0.00 0.00 0.00 30.41 30.41 112.38 09/21/2009 633346 0.00 0.00 0.00 0.00 95.75 0.00 95.75 206.03 09/28/2009 633407 221.56 0.00 0.00 0.00 0.00 0.00 0.00 2,416.17 09/28/2009 635385 0.00 0.00 0.00 0.00 573.00 1,447.78 2,020.78 19,816.34 09/28/2009 635421 0.00 0.00 0.00 2,600.79 0.00 0.00 2,600.79 25,735.04 10/06/2009 635452 244.41 0.00 0.00 0.00 0.00 14.54 14.54 3,671.08 10/06/2009 637329 0.00 0.00 0.00 0.00 2,110.74 5,157.44 7,268.18 72,129.23 10/13/2009 639439 0.00 0.00 0.00 28.04 0.00 0.00 28.04 61.08 10/19/2009 639473 650.54 0.00 0.00 0.00 0.00 -1.55 -1.55 6,859.13 10/19/2009 641651 0.00 0.00 0.00 0.00 1,517.63 4,392.49 5,910.12 58,806.54 10/19/2009 641701 0.00 0.00 0.00 2,399.09 0.00 0.00 2,399.09 24,258.94 10/26/2009 641733 515.70 0.00 0.00 0.00 0.00 0.00 0.00 5,999.34 10/26/2009 643667 0.00 0.00 0.00 0.00 1,433.72 4,216.37 5,650.09 56,212.94 11/02/2009 643724 1,451.49 0.00 0.00 0.00 0.00 3.77 3.77 15,747.87 11/02/2009 645681 0.00 0.00 0.00 0.00 2,283.59 5,750.05 8,033.64 79,969.58 11/23/2009 650074 48.88 0.00 0.00 0.00 0.00 0.00 0.00 767.93 11/23/2009 652069 0.00 0.00 0.00 0.00 821.60 872.38 1,693.98 16,875.73 11/23/2009 652100 0.00 0.00 0.00 3,539.94 0.00 0.00 3,539.94 35,324.60 11/30/2009 652133 593.64 0.00 0.00 0.00 0.00 9.47 9.47 6,999.02 11/30/2009 654143 0.00 0.00 0.00 0.00 2,096.93 3,995.75 6,092.68 60,623.16 11/30/2009 654184 0.00 0.00 0.00 168.92 0.00 0.00 168.92 1,109.62 12/07/2009 654218 100.37 0.00 0.00 0.00 0.00 0.00 0.00 1,510.62 12/07/2009 656172 0.00 0.00 0.00 0.00 94.45 65.34 159.79 1,590.67 12/21/2009 660657 0.00 0.00 0.00 2,619.22 0.00 0.00 2,619.22 26,915.92 12/28/2009 660685 257.33 0.00 0.00 0.00 0.00 7.53 7.53 3,816.94 12/28/2009 662675 0.00 0.00 0.00 0.00 2,137.41 2,896.54 5,033.95 50,141.95 12/28/2009 662715 0.00 0.00 0.00 263.36 0.00 0.00 263.36 2,239.60 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 5,663.09 0.00 0.00 17,312.32 17,999.28 41,486.93 76,798.53 927,568.86 CNTRNUM 5,663.09 0.00 0.00 17,312.32 17,999.28 41,486.93 76,798.53 927,568.86 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 82 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL ---------------------------------------------------------- CONTRACT NUM=8000013 NAME=UNION CO BD OF DD ---------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 609507 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,190.11 07/06/2009 611250 0.00 0.00 0.00 0.00 0.00 0.00 0.00 15,393.39 07/06/2009 611290 0.00 0.00 0.00 0.00 0.00 0.00 0.00 91.62 07/20/2009 613184 44.75 0.00 0.00 0.00 0.00 0.00 0.00 487.75 07/20/2009 615143 0.00 0.00 0.00 0.00 230.42 542.82 773.24 8,447.83 07/20/2009 615173 0.00 0.00 0.00 44.69 0.00 0.00 44.69 488.64 07/27/2009 617058 0.00 0.00 0.00 0.00 708.62 0.00 708.62 7,742.71 08/04/2009 617108 166.30 0.00 0.00 0.00 0.00 0.00 0.00 2,614.34 08/04/2009 619012 0.00 0.00 0.00 0.00 1,135.29 1,746.12 2,881.41 31,477.40 08/10/2009 619075 427.50 0.00 0.00 0.00 0.00 0.00 0.00 4,671.07 08/10/2009 620946 0.00 0.00 0.00 0.00 1,398.37 2,992.27 4,390.64 47,980.66 08/10/2009 620972 0.00 0.00 0.00 5.59 0.00 0.00 5.59 61.08 08/24/2009 623194 131.62 0.00 0.00 0.00 0.00 0.00 0.00 1,290.42 08/24/2009 625127 0.00 0.00 0.00 0.00 91.66 207.99 299.65 2,936.61 08/24/2009 625160 0.00 0.00 0.00 40.51 0.00 0.00 40.51 397.02 09/08/2009 629137 0.00 0.00 0.00 0.00 0.00 15.93 15.93 156.21 09/28/2009 633408 296.51 0.00 0.00 0.00 0.00 0.00 0.00 3,589.84 09/28/2009 635386 0.00 0.00 0.00 0.00 1,022.79 1,433.52 2,456.31 24,082.51 09/28/2009 635422 0.00 0.00 0.00 73.73 0.00 0.00 73.73 722.78 10/06/2009 635453 250.88 0.00 0.00 0.00 0.00 0.00 0.00 2,985.03 10/06/2009 637330 0.00 0.00 0.00 0.00 727.16 981.96 1,709.12 17,012.72 10/19/2009 639474 1,682.57 0.00 0.00 0.00 0.00 0.00 0.00 22,327.03 10/19/2009 641652 0.00 0.00 0.00 0.00 3,225.19 6,452.61 9,677.80 96,291.84 10/19/2009 641702 0.00 0.00 0.00 129.98 0.00 0.00 129.98 600.62 10/26/2009 641734 264.75 0.00 0.00 0.00 0.00 0.00 0.00 2,635.11 10/26/2009 643668 0.00 0.00 0.00 0.00 611.12 428.41 1,039.53 10,345.28 10/26/2009 643695 0.00 0.00 0.00 4,460.98 0.00 0.00 4,460.98 48,965.80 11/02/2009 643725 182.28 0.00 0.00 0.00 0.00 -5.56 -5.56 2,755.17 11/02/2009 645682 0.00 0.00 0.00 0.00 760.48 1,922.76 2,683.24 26,709.19 11/02/2009 645717 0.00 0.00 0.00 63.44 0.00 0.00 63.44 91.62 11/09/2009 647707 0.00 0.00 0.00 3,450.32 0.00 0.00 3,450.32 2,131.43 11/23/2009 650075 380.24 0.00 0.00 0.00 0.00 0.00 0.00 4,448.28 11/23/2009 652070 0.00 0.00 0.00 0.00 736.96 1,340.64 2,077.60 20,680.60 11/30/2009 652134 253.20 0.00 0.00 0.00 0.00 13.62 13.62 2,793.39 11/30/2009 654144 0.00 0.00 0.00 0.00 723.04 928.51 1,651.55 16,387.68 11/30/2009 654185 0.00 0.00 0.00 1,977.34 0.00 0.00 1,977.34 20,105.50 12/07/2009 656173 0.00 0.00 0.00 0.00 105.55 12.57 118.12 1,175.58 12/28/2009 660686 332.01 0.00 0.00 0.00 0.00 7.27 7.27 4,288.82 12/28/2009 662676 0.00 0.00 0.00 0.00 1,057.86 2,121.35 3,179.21 31,645.91 12/28/2009 662716 0.00 0.00 0.00 1,276.38 0.00 0.00 1,276.38 12,704.64 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 4,412.61 0.00 0.00 11,522.96 12,534.51 21,142.79 45,200.26 500,903.23 CNTRNUM 4,412.61 0.00 0.00 11,522.96 12,534.51 21,142.79 45,200.26 500,903.23 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 83 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL -------------------------------------------------------- CONTRACT NUM=8100012 NAME=VAN WERT CO BD OF DD --------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 609508 0.00 0.00 0.00 0.00 0.00 0.00 0.00 4,442.06 07/06/2009 611251 0.00 0.00 0.00 0.00 0.00 0.00 0.00 63,271.63 07/06/2009 611291 0.00 0.00 0.00 0.00 0.00 0.00 0.00 3,949.84 07/20/2009 613185 295.94 0.00 0.00 0.00 0.00 0.00 0.00 3,237.03 07/20/2009 615144 0.00 0.00 0.00 0.00 1,064.04 1,448.01 2,512.05 27,486.36 07/20/2009 615174 0.00 0.00 0.00 64.23 0.00 0.00 64.23 702.42 08/04/2009 617109 37.64 0.00 0.00 0.00 0.00 0.00 0.00 411.30 08/04/2009 619013 0.00 0.00 0.00 0.00 1,055.85 674.82 1,730.67 18,912.23 08/04/2009 619050 0.00 0.00 0.00 395.72 0.00 0.00 395.72 4,326.50 08/10/2009 619076 632.17 0.00 0.00 0.00 0.00 0.00 0.00 6,908.91 08/10/2009 620947 0.00 0.00 0.00 0.00 2,735.39 3,605.08 6,340.47 69,308.86 08/31/2009 625187 220.02 0.00 0.00 0.00 0.00 0.00 0.00 2,158.02 08/31/2009 627173 0.00 0.00 0.00 0.00 1,046.06 1,499.61 2,545.67 24,968.67 08/31/2009 627217 0.00 0.00 0.00 882.93 0.00 0.00 882.93 8,653.00 09/14/2009 629206 320.08 0.00 0.00 0.00 0.00 0.00 0.00 3,140.98 09/14/2009 631399 0.00 0.00 0.00 0.00 2,702.84 3,404.07 6,106.91 59,898.47 09/14/2009 631432 0.00 0.00 0.00 15.60 0.00 0.00 15.60 152.70 09/21/2009 633239 0.00 0.00 0.00 0.00 0.00 36.67 36.67 140.16 09/21/2009 633347 0.00 0.00 0.00 0.00 7.72 2.59 10.31 36.27 09/28/2009 635423 0.00 0.00 0.00 577.60 0.00 0.00 577.60 5,660.08 10/06/2009 635454 311.44 0.00 0.00 0.00 0.00 0.00 0.00 3,101.64 10/06/2009 637331 0.00 0.00 0.00 0.00 2,592.28 3,248.51 5,840.79 58,145.91 10/06/2009 637363 0.00 0.00 0.00 28.65 0.00 0.00 28.65 285.04 10/19/2009 639475 281.25 0.00 0.00 0.00 0.00 0.00 0.00 2,801.58 10/19/2009 641653 0.00 0.00 0.00 0.00 1,874.53 2,297.51 4,172.04 41,530.90 10/19/2009 641703 0.00 0.00 0.00 787.89 0.00 0.00 787.89 7,838.60 10/26/2009 641735 553.72 0.00 0.00 0.00 0.00 0.00 0.00 5,514.36 10/26/2009 643669 0.00 0.00 0.00 0.00 2,800.66 3,797.45 6,598.11 65,702.87 10/26/2009 643696 0.00 0.00 0.00 433.81 0.00 0.00 433.81 4,316.32 11/02/2009 645718 0.00 0.00 0.00 823.80 0.00 0.00 823.80 8,021.84 11/09/2009 647708 0.00 0.00 0.00 2,282.72 0.00 0.00 2,282.72 3,021.80 11/16/2009 650052 0.00 0.00 0.00 697.75 0.00 0.00 697.75 6,942.76 11/30/2009 654186 0.00 0.00 0.00 586.83 0.00 0.00 586.83 5,649.90 12/07/2009 654219 1,099.18 0.00 0.00 0.00 0.00 0.00 0.00 10,949.31 12/07/2009 656174 0.00 0.00 0.00 0.00 4,649.00 5,775.57 10,424.57 103,799.18 12/07/2009 656203 0.00 0.00 0.00 773.54 0.00 0.00 773.54 8,021.84 12/21/2009 658483 15.20 0.00 0.00 0.00 0.00 0.00 0.00 151.44 12/21/2009 660624 0.00 0.00 0.00 0.00 594.70 459.80 1,054.50 10,506.15 12/21/2009 660658 0.00 0.00 0.00 151.40 0.00 0.00 151.40 1,506.64 12/28/2009 662717 0.00 0.00 0.00 79.80 0.00 0.00 79.80 753.32 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 3,766.64 0.00 0.00 8,582.27 21,123.07 26,249.69 55,955.03 656,326.89 CNTRNUM 3,766.64 0.00 0.00 8,582.27 21,123.07 26,249.69 55,955.03 656,326.89 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 84 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL --------------------------------------------------------- CONTRACT NUM=8200011 NAME=VINTON CO BD OF DD ---------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/13/2009 613139 0.00 0.00 0.00 0.00 0.00 0.00 0.00 31,018.04 07/20/2009 615175 0.00 0.00 0.00 24.21 0.00 0.00 24.21 264.68 07/27/2009 617059 0.00 0.00 0.00 0.00 43.32 143.07 186.39 2,037.50 08/10/2009 620973 0.00 0.00 0.00 421.78 0.00 0.00 421.78 4,611.54 08/17/2009 623145 0.00 0.00 0.00 0.00 475.59 1,415.31 1,890.90 18,542.70 08/17/2009 623160 0.00 0.00 0.00 207.76 0.00 0.00 207.76 2,036.00 08/31/2009 625188 34.38 0.00 0.00 0.00 0.00 0.00 0.00 337.14 08/31/2009 627174 0.00 0.00 0.00 0.00 584.46 636.03 1,220.49 11,968.47 09/21/2009 633348 0.00 0.00 0.00 0.00 456.05 1,012.15 1,468.20 14,393.42 09/28/2009 635387 0.00 0.00 0.00 0.00 46.33 0.00 46.33 454.40 09/28/2009 635424 0.00 0.00 0.00 1.04 0.00 0.00 1.04 10.18 10/13/2009 637394 56.40 0.00 0.00 0.00 0.00 0.00 0.00 561.90 10/13/2009 639407 0.00 0.00 0.00 0.00 443.68 360.96 804.64 8,016.44 10/19/2009 641704 0.00 0.00 0.00 12.27 0.00 0.00 12.27 20.36 10/26/2009 643670 0.00 0.00 0.00 0.00 84.24 14.28 98.52 979.80 10/26/2009 643697 0.00 0.00 0.00 212.42 0.00 0.00 212.42 1,394.66 11/02/2009 645719 0.00 0.00 0.00 27.57 0.00 0.00 27.57 223.96 11/09/2009 647709 0.00 0.00 0.00 1,372.75 0.00 0.00 1,372.75 495.14 11/16/2009 647736 86.29 0.00 0.00 0.00 0.00 0.00 0.00 858.80 11/16/2009 650031 0.00 0.00 0.00 0.00 1,383.78 1,948.03 3,331.81 33,156.55 11/30/2009 652135 295.70 0.00 0.00 0.00 0.00 0.00 0.00 2,944.10 11/30/2009 654145 0.00 0.00 0.00 0.00 3,114.38 2,973.29 6,087.67 60,606.04 11/30/2009 654187 0.00 0.00 0.00 223.06 0.00 0.00 223.06 2,219.24 12/07/2009 656204 0.00 0.00 0.00 10.33 0.00 0.00 10.33 61.08 12/14/2009 658423 0.00 0.00 0.00 0.00 61.91 1.98 63.89 635.38 12/14/2009 658448 0.00 0.00 0.00 734.07 0.00 0.00 734.07 7,349.96 12/28/2009 662718 0.00 0.00 0.00 51.99 0.00 0.00 51.99 519.18 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 472.77 0.00 0.00 3,299.25 6,693.74 8,505.10 18,498.09 205,716.66 CNTRNUM 472.77 0.00 0.00 3,299.25 6,693.74 8,505.10 18,498.09 205,716.66 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 85 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL --------------------------------------------------------- CONTRACT NUM=8300010 NAME=WARREN CO BD OF DD ---------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/27/2009 617084 0.00 0.00 0.00 3,302.01 0.00 0.00 3,302.01 36,250.98 08/04/2009 618910 0.00 0.00 0.00 0.00 0.00 580.57 580.57 6,345.00 08/04/2009 619051 0.00 0.00 0.00 5,959.01 0.00 0.00 5,959.01 66,577.20 09/08/2009 629172 0.00 0.00 0.00 12,367.90 0.00 0.00 12,367.90 121,213.26 09/28/2009 635274 0.00 0.00 0.00 0.00 499.80 0.00 499.80 4,900.00 10/19/2009 641526 351.75 0.00 0.00 0.00 100.50 0.00 100.50 4,500.00 11/09/2009 647710 0.00 0.00 0.00 5,101.61 0.00 0.00 5,101.61 48,059.36 12/07/2009 654220 1,306.63 0.00 0.00 0.00 0.00 0.00 0.00 12,997.88 12/07/2009 656175 0.00 0.00 0.00 0.00 6,634.41 32,927.83 39,562.24 393,632.30 12/07/2009 656205 0.00 0.00 0.00 821.63 0.00 0.00 821.63 8,215.26 12/14/2009 658449 0.00 0.00 0.00 5,506.90 0.00 0.00 5,506.90 54,856.98 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 1,658.38 0.00 0.00 33,059.06 7,234.71 33,508.40 73,802.17 757,548.22 CNTRNUM 1,658.38 0.00 0.00 33,059.06 7,234.71 33,508.40 73,802.17 757,548.22 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 86 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL ------------------------------------------------------- CONTRACT NUM=8400019 NAME=WASHINGTON CO BD OF DD -------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 609509 0.00 0.00 0.00 0.00 0.00 0.00 0.00 3,017.14 07/06/2009 611252 0.00 0.00 0.00 0.00 0.00 0.00 0.00 25,948.81 07/06/2009 611292 0.00 0.00 0.00 0.00 0.00 0.00 0.00 18,415.62 07/13/2009 613140 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,109.16 07/13/2009 613161 0.00 0.00 0.00 0.00 0.00 0.00 0.00 4,723.52 07/20/2009 615176 0.00 0.00 0.00 111.76 0.00 0.00 111.76 447.92 07/27/2009 615205 361.60 0.00 0.00 0.00 0.00 0.00 0.00 3,950.07 07/27/2009 617060 0.00 0.00 0.00 0.00 164.27 118.32 282.59 3,087.67 07/27/2009 617085 0.00 0.00 0.00 773.77 0.00 0.00 773.77 8,561.38 08/04/2009 617110 87.43 0.00 0.00 0.00 0.00 0.00 0.00 1,816.81 08/04/2009 619014 0.00 0.00 0.00 0.00 1,069.99 1,448.60 2,518.59 27,514.37 08/10/2009 620974 0.00 0.00 0.00 82.85 0.00 0.00 82.85 906.02 08/17/2009 623161 0.00 0.00 0.00 9.35 0.00 0.00 9.35 71.26 08/24/2009 623195 1,209.70 0.00 0.00 0.00 0.00 0.00 0.00 15,730.40 08/24/2009 625128 0.00 0.00 0.00 0.00 5,293.50 9,088.11 14,381.61 141,011.67 08/31/2009 625189 0.00 0.00 0.00 0.00 0.00 7.64 7.64 18.73 08/31/2009 627084 0.00 0.00 0.00 0.00 0.00 201.49 201.49 1,220.72 08/31/2009 627175 0.00 0.00 0.00 0.00 332.70 844.64 1,177.34 7,108.69 08/31/2009 627218 0.00 0.00 0.00 2,460.51 0.00 0.00 2,460.51 21,887.00 09/14/2009 629207 334.20 0.00 0.00 0.00 0.00 0.00 0.00 4,544.78 09/14/2009 631400 0.00 0.00 0.00 0.00 1,832.89 2,797.39 4,630.28 45,403.25 09/21/2009 633382 0.00 0.00 0.00 275.74 0.00 0.00 275.74 1,231.78 09/28/2009 635425 0.00 0.00 0.00 1,788.75 0.00 0.00 1,788.75 17,591.04 10/06/2009 635455 491.94 0.00 0.00 0.00 0.00 0.00 0.00 7,093.12 10/06/2009 637332 0.00 0.00 0.00 0.00 2,533.39 4,039.77 6,573.16 65,394.67 10/06/2009 637364 0.00 0.00 0.00 11.26 0.00 0.00 11.26 111.98 10/13/2009 637395 590.37 0.00 0.00 0.00 0.00 0.00 0.00 8,803.10 10/13/2009 639408 0.00 0.00 0.00 0.00 2,780.61 3,878.61 6,659.22 66,341.66 10/19/2009 639476 0.00 0.00 0.00 0.00 0.00 9.30 9.30 93.65 10/19/2009 641552 0.00 0.00 0.00 0.00 0.00 43.70 43.70 449.52 10/19/2009 641654 0.00 0.00 0.00 0.00 49.32 25.45 74.77 767.93 10/19/2009 641705 0.00 0.00 0.00 1,883.66 0.00 0.00 1,883.66 16,450.88 11/02/2009 645683 0.00 0.00 0.00 0.00 0.00 11.28 11.28 112.38 11/02/2009 645720 0.00 0.00 0.00 1,571.36 0.00 0.00 1,571.36 16,226.92 11/30/2009 652136 692.60 0.00 0.00 0.00 0.00 0.00 0.00 8,845.39 11/30/2009 654058 0.00 0.00 0.00 0.00 0.00 3.76 3.76 18.73 11/30/2009 654146 0.00 0.00 0.00 0.00 2,553.71 5,364.95 7,918.66 78,783.85 11/30/2009 654188 0.00 0.00 0.00 3,146.00 0.00 0.00 3,146.00 31,354.40 12/21/2009 658484 137.34 0.00 0.00 0.00 0.00 0.00 0.00 1,367.29 12/21/2009 660625 0.00 0.00 0.00 0.00 453.08 1,058.60 1,511.68 15,058.92 12/21/2009 660659 0.00 0.00 0.00 1,836.33 0.00 0.00 1,836.33 19,912.08 12/28/2009 660687 0.00 0.00 0.00 0.00 0.00 3.76 3.76 18.73 12/28/2009 662596 0.00 0.00 0.00 0.00 0.00 9.40 9.40 18.73 12/28/2009 662677 0.00 0.00 0.00 0.00 7.52 0.00 7.52 37.46 12/28/2009 662719 0.00 0.00 0.00 465.43 0.00 0.00 465.43 2,809.68 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 3,905.18 0.00 0.00 14,416.77 17,070.98 28,954.77 60,442.52 695,388.88 CNTRNUM 3,905.18 0.00 0.00 14,416.77 17,070.98 28,954.77 60,442.52 695,388.88 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 87 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL ---------------------------------------------------------- CONTRACT NUM=8500018 NAME=WAYNE CO BD OF DD ---------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 611253 0.00 0.00 0.00 0.00 0.00 0.00 0.00 53,209.08 07/06/2009 611293 0.00 0.00 0.00 0.00 0.00 0.00 0.00 234.14 07/13/2009 611310 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2,284.51 07/13/2009 613141 0.00 0.00 0.00 0.00 0.00 0.00 0.00 184,486.89 07/13/2009 613162 0.00 0.00 0.00 0.00 0.00 0.00 0.00 31,934.66 07/20/2009 615177 0.00 0.00 0.00 30.73 0.00 0.00 30.73 223.96 07/27/2009 616988 0.00 0.00 0.00 0.00 0.00 0.00 0.00 88.65 08/24/2009 623196 513.68 0.00 0.00 0.00 0.00 0.00 0.00 5,037.28 08/24/2009 625129 0.00 0.00 0.00 0.00 1,772.93 18,876.27 20,649.20 202,490.47 08/24/2009 625161 0.00 0.00 0.00 2,891.68 0.00 0.00 2,891.68 28,341.12 08/31/2009 625190 742.29 0.00 0.00 0.00 0.00 0.00 0.00 7,278.96 08/31/2009 627176 0.00 0.00 0.00 0.00 1,678.12 18,837.89 20,516.01 201,184.38 08/31/2009 627219 0.00 0.00 0.00 2,686.25 0.00 0.00 2,686.25 25,022.44 09/14/2009 629208 1,095.99 0.00 0.00 0.00 0.00 0.00 0.00 10,742.73 10/06/2009 635456 643.30 0.00 0.00 0.00 0.00 0.00 0.00 6,398.54 10/06/2009 637333 0.00 0.00 0.00 0.00 1,202.88 15,711.60 16,914.48 168,252.47 10/06/2009 637365 0.00 0.00 0.00 3,341.53 0.00 0.00 3,341.53 33,247.88 10/13/2009 639409 0.00 0.00 0.00 0.00 0.24 333.96 334.20 3,324.93 10/13/2009 639440 0.00 0.00 0.00 53.19 0.00 0.00 53.19 529.16 10/19/2009 641655 0.00 0.00 0.00 0.00 6.18 0.00 6.18 59.10 10/19/2009 641706 0.00 0.00 0.00 14.27 0.00 0.00 14.27 142.52 11/02/2009 643726 712.08 0.00 0.00 0.00 0.00 0.00 0.00 7,082.76 11/02/2009 645684 0.00 0.00 0.00 0.00 1,293.94 17,377.59 18,671.53 185,718.91 11/02/2009 645721 0.00 0.00 0.00 2,793.04 0.00 0.00 2,793.04 27,811.76 11/09/2009 647711 0.00 0.00 0.00 250.69 0.00 0.00 250.69 40.72 11/23/2009 652071 0.00 0.00 0.00 0.00 5.08 234.71 239.79 2,385.99 11/30/2009 654147 0.00 0.00 0.00 0.00 198.48 0.00 198.48 1,604.43 12/21/2009 658485 678.61 0.00 0.00 0.00 0.00 0.00 0.00 6,749.93 12/21/2009 660626 0.00 0.00 0.00 0.00 2,527.39 17,961.65 20,489.04 203,797.08 12/21/2009 660660 0.00 0.00 0.00 3,376.27 0.00 0.00 3,376.27 32,576.00 12/28/2009 662720 0.00 0.00 0.00 2.04 0.00 0.00 2.04 20.36 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 4,385.95 0.00 0.00 15,439.69 8,685.24 89,333.67 113,458.60 1,432,301.81 CNTRNUM 4,385.95 0.00 0.00 15,439.69 8,685.24 89,333.67 113,458.60 1,432,301.81 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 88 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL -------------------------------------------------------- CONTRACT NUM=8600017 NAME=WILLIAMS CO BD OF DD --------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 609510 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,897.72 07/06/2009 611254 0.00 0.00 0.00 0.00 0.00 0.00 0.00 38,908.52 07/06/2009 611294 0.00 0.00 0.00 0.00 0.00 0.00 0.00 458.10 07/27/2009 617061 0.00 0.00 0.00 0.00 10.59 0.00 10.59 115.86 08/04/2009 619052 0.00 0.00 0.00 1,378.20 0.00 0.00 1,378.20 14,526.86 08/10/2009 619077 206.10 0.00 0.00 0.00 0.00 0.00 0.00 2,253.04 08/10/2009 620948 0.00 0.00 0.00 0.00 1,134.92 2,930.44 4,065.36 44,438.72 08/24/2009 623197 14.80 0.00 0.00 0.00 0.00 0.00 0.00 145.00 08/24/2009 625130 0.00 0.00 0.00 0.00 0.00 3.90 3.90 38.24 08/24/2009 625162 0.00 0.00 0.00 1,254.77 0.00 0.00 1,254.77 12,297.44 08/31/2009 625191 234.57 0.00 0.00 0.00 0.00 0.00 0.00 2,298.90 08/31/2009 627177 0.00 0.00 0.00 0.00 1,372.72 3,058.76 4,431.48 43,431.30 08/31/2009 627220 0.00 0.00 0.00 35.21 0.00 0.00 35.21 305.40 09/08/2009 629173 0.00 0.00 0.00 1,028.66 0.00 0.00 1,028.66 10,068.02 09/14/2009 631401 0.00 0.00 0.00 0.00 0.00 44.76 44.76 438.73 09/28/2009 633409 188.20 0.00 0.00 0.00 0.00 0.00 0.00 1,844.34 09/28/2009 635388 0.00 0.00 0.00 0.00 1,328.92 3,018.19 4,347.11 42,604.61 11/02/2009 643727 188.58 0.00 0.00 0.00 0.00 0.00 0.00 1,876.24 11/02/2009 645685 0.00 0.00 0.00 0.00 1,281.65 2,793.55 4,075.20 40,545.21 11/09/2009 647712 0.00 0.00 0.00 3,713.45 0.00 0.00 3,713.45 17,660.41 11/16/2009 650053 0.00 0.00 0.00 611.55 0.00 0.00 611.55 6,026.56 11/30/2009 654189 0.00 0.00 0.00 9.21 0.00 0.00 9.21 91.62 12/21/2009 658486 225.34 0.00 0.00 0.00 0.00 0.00 0.00 2,242.08 12/21/2009 660627 0.00 0.00 0.00 0.00 1,335.32 2,990.32 4,325.64 43,035.82 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 1,057.59 0.00 0.00 8,031.05 6,464.12 14,839.92 29,335.09 327,548.74 CNTRNUM 1,057.59 0.00 0.00 8,031.05 6,464.12 14,839.92 29,335.09 327,548.74 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 89 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL ---------------------------------------------------------- CONTRACT NUM=8700016 NAME=WOOD CO BD OF DD ----------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/27/2009 617005 0.00 0.00 0.00 0.00 0.00 0.00 0.00 27,051.27 08/17/2009 623146 0.00 0.00 0.00 0.00 232.56 0.00 232.56 2,280.00 08/24/2009 623198 310.90 0.00 0.00 0.00 0.00 0.00 0.00 3,047.79 08/24/2009 625131 0.00 0.00 0.00 0.00 1,156.18 7,076.65 8,232.83 80,705.47 08/24/2009 625163 0.00 0.00 0.00 2,404.71 0.00 0.00 2,404.71 23,566.70 09/21/2009 631462 313.14 0.00 0.00 0.00 0.00 0.00 0.00 3,069.61 09/21/2009 633349 0.00 0.00 0.00 0.00 856.45 5,906.89 6,763.34 66,301.50 09/21/2009 633383 0.00 0.00 0.00 21.82 0.00 0.00 21.82 213.78 10/06/2009 635457 174.60 0.00 0.00 0.00 0.00 0.00 0.00 1,737.90 10/06/2009 637334 0.00 0.00 0.00 0.00 686.76 1,513.20 2,199.96 21,897.54 10/13/2009 637396 565.13 0.00 0.00 0.00 0.00 0.00 0.00 5,622.68 10/13/2009 639410 0.00 0.00 0.00 0.00 1,601.31 7,575.00 9,176.31 91,300.31 10/13/2009 639441 0.00 0.00 0.00 5,735.58 0.00 0.00 5,735.58 57,069.08 11/09/2009 645741 38.75 0.00 0.00 0.00 0.00 0.00 0.00 385.52 11/09/2009 647653 0.00 0.00 0.00 0.00 45.02 692.49 737.51 7,340.20 11/09/2009 647713 0.00 0.00 0.00 161.66 0.00 0.00 161.66 1,068.90 11/16/2009 647737 573.91 0.00 0.00 0.00 0.00 0.00 0.00 5,709.67 11/16/2009 650032 0.00 0.00 0.00 0.00 1,486.38 7,098.80 8,585.18 85,417.05 11/16/2009 650054 0.00 0.00 0.00 2,853.61 0.00 0.00 2,853.61 28,392.02 11/23/2009 650076 544.99 0.00 0.00 0.00 0.00 0.00 0.00 5,422.64 11/23/2009 652072 0.00 0.00 0.00 0.00 1,743.64 7,117.50 8,861.14 88,163.37 11/23/2009 652101 0.00 0.00 0.00 2,744.14 0.00 0.00 2,744.14 27,404.56 12/21/2009 658487 547.94 0.00 0.00 0.00 0.00 0.00 0.00 5,451.95 12/21/2009 660628 0.00 0.00 0.00 0.00 1,628.70 7,073.94 8,702.64 86,588.26 12/21/2009 660661 0.00 0.00 0.00 2,277.53 0.00 0.00 2,277.53 23,271.48 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 3,069.36 0.00 0.00 16,199.05 9,437.00 44,054.47 69,690.52 748,479.25 CNTRNUM 3,069.36 0.00 0.00 16,199.05 9,437.00 44,054.47 69,690.52 748,479.25 1 DEPARTMENT OF DEVELOPMENTAL DISABILITIES 11:32 Tuesday, January 26, 2010 90 DIVISION OF INFORMATION SYSTEMS (EFMAP_QUARTERLY) MEDICAID BILLING SYSTEM QUARTERLY REPORT OF eFMAP PAYMENTS TO COUNTY BOARDS CLAIMED DURING 2009 WITH ENHANCED FFP DETAIL --------------------------------------------------------- CONTRACT NUM=8800015 NAME=WYANDOT CO BD OF DD --------------------------------------------------------- POSTABLE VOUCHER VOUCHER eFMAP REIMBURSED RUN DATE NUMBER MARTIN eFMAP Sermak eFMAP XICF eFMAP TCM eFMAP LEVEL1 eFMAP I/O eFMAP (IO/LV1/TCM) AMOUNT 07/06/2009 609511 0.00 0.00 0.00 0.00 0.00 0.00 0.00 750.48 07/06/2009 611255 0.00 0.00 0.00 0.00 0.00 0.00 0.00 33,684.40 07/06/2009 611295 0.00 0.00 0.00 0.00 0.00 0.00 0.00 5,344.50 07/13/2009 613163 0.00 0.00 0.00 0.00 0.00 0.00 0.00 -10.18 07/20/2009 615096 0.00 0.00 0.00 0.00 0.00 0.00 0.00 15.90 07/27/2009 615206 114.42 0.00 0.00 0.00 0.00 0.00 0.00 1,250.61 07/27/2009 617062 0.00 0.00 0.00 0.00 350.23 3,825.86 4,176.09 45,641.01 08/10/2009 619078 127.97 0.00 0.00 0.00 0.00 0.00 0.00 1,398.87 08/10/2009 620949 0.00 0.00 0.00 0.00 439.28 3,860.31 4,299.59 46,989.67 08/10/2009 620975 0.00 0.00 0.00 32.60 0.00 0.00 32.60 356.30 09/08/2009 627241 107.84 0.00 0.00 0.00 0.00 0.00 0.00 1,058.07 09/08/2009 629139 0.00 0.00 0.00 0.00 394.55 3,653.02 4,047.57 39,702.76 09/14/2009 631433 0.00 0.00 0.00 283.72 0.00 0.00 283.72 2,779.14 11/02/2009 643728 123.39 0.00 0.00 0.00 0.00 0.00 0.00 1,229.04 11/02/2009 645686 0.00 0.00 0.00 0.00 379.83 3,291.27 3,671.10 36,557.71 11/09/2009 647714 0.00 0.00 0.00 275.31 0.00 0.00 275.31 2,738.42 11/30/2009 652137 148.85 0.00 0.00 0.00 0.00 0.00 0.00 1,482.69 11/30/2009 654148 0.00 0.00 0.00 0.00 494.14 3,937.51 4,431.65 44,131.56 12/07/2009 656206 0.00 0.00 0.00 321.40 0.00 0.00 321.40 3,196.52 12/21/2009 658488 144.56 0.00 0.00 0.00 0.00 0.00 0.00 1,440.06 12/21/2009 660629 0.00 0.00 0.00 0.00 440.76 4,153.85 4,594.61 45,754.94 12/28/2009 662721 0.00 0.00 0.00 280.36 0.00 0.00 280.36 2,789.32 ---------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- -------------- CNTRNAME 767.03 0.00 0.00 1,193.39 2,498.79 22,721.82 26,414.00 318,281.79 CNTRNUM 767.03 0.00 0.00 1,193.39 2,498.79 22,721.82 26,414.00 318,281.79 ============== ============== ============== ============== ============== ============== ============== ============== 485,989.30 0.00 4,705.15 1,847,906.08 2,487,563.53 6,279,222.60 10,614,692.21 118,215,513.92