Documents/Forms

Reference materials for Providers and Administrative Staff are listed below offering information and guidance on the implementation and administration of the School Based Child Health (SBCH) Program:

CT-SBCH Program Dates and Deadlines
Connecticut iC MMIS Provider Manual
Fee For Service Interim Rates (Effective 1/1/2019)
RMTS User Guide
RMTS Power Point Summary
CT-SBCH Participant Management Guide
CT-SBCH Work Schedule Calendar Guide
CT-SBCH Participant Quick Reference Guide
SBCH User Guide (Revised January 2019)
Technical Notes and System Requirements FY20

Administrative Activity Claim (ACC) Information

SBCH Admin Claiming Training Video (MP4)

SBCH Administrative Claiming reimburses for RMTS participants administrative efforts (as determined by Time Study result) applied to salaries and fringe benefits. Additional expenses available include capital costs (buildings, fixed assets, and major moveable equipment) and non-personnel costs (i.e. supplies) pertaining to Medicaid Administrative functions. Medicaid Administrative functions support Medicaid eligibility determination process, Medicaid outreach, or supports SBCH covered services as described in the State Plan Amendment. Administrative claiming is submitted on a quarterly basis.

Administrative Activity Claiming Guide
Administrative Activity Claiming Instruction Guide
Administrative Activity Claiming Webinar Q&A
Example Certification with Direct Admin Identified
Quick Step-by-Step Overview
SBCH CC Upload Template

Cost Report Information

Cost Report Instructional Manual
Direct Medical Services and Transportation Cost Report Instruction

Medicaid Service Information (MSI)

Claim Submission to DAS Guidelines
Claim Resolution Guide to Understanding EOB Codes
MSI Claim Form In-District (Effective 1/1/2019)
MSI Claim Form Out-of-District (Effective 1/1/2019)
MSI Claim Form Out-of-District with Comments (Effective 1/1/2019)
MSI Form Part 2 (Revised 2/17/2017)