MED/PSYCH DIAGNOSTIC & TREATMENT:

• A.Optional (add to the required text of B):

  • Payment for adjunct services provided on (fill in blank) as ordered by Doctor (fill in blank).

• B.Required for Medical Service authorizations, Durable Goods, and Prosthesis > $2000.00:

  • If there are any other participating assurers, VR will pay this individuals remaining portion, up to the lower of the Nebraska Medicaid Rate Total or Assurers Allowed Total. Bill VR by CPT Code as last assurer and include all E.O.B. copies.

• C.Required for Drugs:

  • Provide generic drugs if available and allowed by prescribing Doctor. If there are any other participating assurers, VR will pay this individuals remaining portion up to the lower of the Nebraska Medicaid Rate Total or Assurers Allowed Total. Bill VR by the National Drug Code and Metric Decimal Equivalency as last assurer, and include all E.O.B. copies.

• D.Optional (Assessment):

  • Report must accompany invoice for prompt payment.

ASSISTIVE TECHNOLOGY (Goods, Exams, Services):

• A.Optional Hearing Aid Text (add to required text B):

  • Vocational Rehabilitation makes formal exception to the Medicaid Fee Schedule for purchase of these specific options at your cost: (fill in blank). The Recipient will need to pay for all other Non-Medicaid options.

• B.Required for all Hearing Aid authorizations:

  • If there are any other participating assurers, VR will pay this individuals remaining portion, up to the lower of the Nebraska Medicaid Rate Total or Assurers Allowed Total. Bill VR as last assurer by CPT Code, and include all E.O.B. copies. A copy of your provider’s invoice for all “V” Code items is required, and must be provided with your invoice.

• C.Optional Eyewear Text, (add to required text D):

  • Vocational Rehabilitation makes formal exception to the Medicaid Fee Schedule for purchase of these specific options at your invoice cost: (fill in blank). The Recipient will need to pay for all other Non-Medicaid options.

• D.Required for all Eyewear authorizations:

  • If there are other participating assurers, VR Will pay this individuals remaining portion, up to the lower of the Nebraska Medicaid Rate Total or Assurers Allowed Total. Bill VR by CPT Code as last assurer, and include all E.O.B. copies. A copy of your provider’s invoice is required for all “V” Code items, except V2623 – V2629.

• E.Required for Prosthetics/Orthotics, and Durable Medical Goods < $2000.00:

  • (Authorize only to ATP for these services: Payment for services as per your estimated cost. For Prosthesis > $2000.00 Use Text B.

• G.Required for Modification of vehicles and dwellings:

  • Items must be installed in accordance with manufacturer’s specifications.

TRAINING SERVICES:

• A.Required for College, Technical Training, or Skill Building to be paid to a provider (Credit hour basis):

  • Tuition and related Fees not to exceed $(fill in blank) for payment or partial payment of (fill in blank) credit hours. Your invoice must specify the number of hours provided, your rate per hour, and a listing of fees charged.

• B.Required for College, Technical Training, or Skill Building to be paid to a provider (Clock hour basis):

  • Tuition and related Fees not to exceed $(fill in blank) for payment or partial payment of (fill in blank) clock hours. Your invoice must specify the number of hours provided, your rate per hour, and a listing of fees charged.

• C.Required for College, Technical, or Skill Building Books & Supplies:

  • Textbooks and Supplies for registered classes only. Your itemized Invoice must include the name of individual books. Used books are preferred if in reasonable condition.

• D.Optional for a Post Secondary Cash Advance:

  • VR Payments to you will be dependent upon your presenting to us, a copy of your next registration, along with a copy of your previous term official grade report. *E.Required for On-Job-Training Fees paid to any entity:
  • See specific terms and conditions of this training in the On-Job-Training letter from us. You are required to employ and pay this person. Authorized units of service or ending dates may not be changed without prior consent from Voc Rehab.

• F.Required for all Job Coaching, Job Readiness, and Skill Building authorizations:

  • This authorization is limited in both units of service and time. Authorized units of service or ending dates may not be changed without prior consent from Voc Rehab.

• G.Required for SE Services under an agreement:

  • Supported Employment Services beginning (fill in blank) in accordance with the Service Agreement, and your providing necessary services, reports, and invoices.

MAINTENANCE (Authorizations for specific situations):

• A.Required for Deposits (assumes advanced payment of deposit):

  • This deposit can be used for damages or unpaid rent from (fill in blank) to (fill in blank). The person receiving this service will be responsible for any costs after the period described or any costs exceeding this amount.

• B.Required for Client Reimbursements:

  • Please complete the enclosed invoice form, showing each item you purchased and the cost for each item. Then sign your name, attach your original paid receipts, and return to our office for payment.

• C.Required for Clothing or miscellaneous items:

  • Provide only items specifically authorized, and do not exceed each individually specified amount shown, unless prior arrangements are made. Interview Clothing not to exceed $150.00 Work Clothing & Uniforms not to exceed $200.00 Safety Boots or Shoes not to exceed $130.00. Non-safety Work Boots or shoes not to exceed $75.00 Casual Shoes not to exceed $55.00

• D.Optional:

  • Recipient is responsible for any items or amounts exceeding this authorization.

CASH ADVANCES:

• A check will be mailed to you within approximately 10 days for all cash advance payments.