Approved Budgets Expenditures can fall into one or more of the following categories: Fee Schedule * ensure RW has a copy Unit Rate * established with.

Ryan White Part A Provider Training

Fiscal InvoicingApril 27, 2012

Approved BudgetsExpenditures can fall into one or more of the following categories:

Fee Schedule * ensure RW has a copy

Unit Rate * established with RW, documentation required one time or based on historical documentation.

Cost Reimbursement * established with RW, documentation required monthly

Cost ReimbursementUse approved budget to complete form

For each service provided, separate Direct Services from Administrative Costs

Provide back-up documentation for each cost reimbursement requested

Financial Re

Backup Documentation

Payroll ledgers, time sheets, mileage reports, invoices, itemized receipts, etc.

Highlight charges applicable to the program

Separate back up documentation by category for Direct and Administrative Services

If you are unsure whether or not the backup you have is acceptable – Ask.

Financial Re

Financial Reports

Report required for each month

Submitted Monthly(10th) – incomplete or late reports will delay payment

Report must include prior Year to Date expenditures

Signed and Dated

Monthly Fiscal Checklist

Ryan White Part A

Fiscal Checklist

Date: ____________________

The following are to be included in your monthly fiscal paperwork:

Cover Sheet, amount requested, signed & dated on company letterhead

Monthly Financial Report Form

Cost Reimbursement: Support documentation for each service provided – DIRECT

Cost Reimbursement: Support documentation for each service provided – ADMINISTRATIVE

Submit via email to [email protected] Or mail hard copy to M. Rodrigo at: CCBH 5550 Venture Dr. Parma, OH 44130

Email subject line to read: Invoice, Provider Name, Date (April 10, 2012)

Cover Sheet:Must be submitted on company letterhead

Provide total amount requested

Provide original signature & date, in BLUE ink, on the day it is completed

Monthly Financial Report Form

Monthly payment request MUST match total on cover letter. All back-up documentation must total amount requested on cover letter

Providers to fill in highlighted areas

Sign & date in lower left corner

MONTHLY FINANCIAL REPORT FORM Mail original and support documentation:  

Due Date: 10th day of the month Ryan White Part A - Fiscal Services  

Health Matters Clinic

5550 Venture Dr. Parma, OH 44130  

A. Service Provider: (Ph) 216-201.2050 ( FAX) 676.1321  

B. Report Period Ending:   D. Subgrantee: CCBH

  Street Address: 5550 Venture Dr.

    City, State Zip: Parma, Oh 44130

C. [ ] Check Box/Marked "F" if Final Report for this Grant. E. Implementing Agency: Health Matters Clinic

  Street Address: 1220 Superior Avenue

Monthly Payment Request:   $21,700.00   City, State Zip: Cleveland, OH 44106

F. BUDGET COST

F. UNIT H. APPROVED I. CURRENT J. PRIOR YTD K. TOTAL YTD L. AVAILABLE

RATE BUDGET EXPENDITURES EXPENDITURES EXPENDITURES

BALANCE

Core Medical Services 

-

-

Outpatient/Ambulatory Medical Care   $70,000.00 $9,000.00 $17,000.00 $26,000.00 $44,000.00

Primary Care Unit$10,000.00

$1,000.00 $2,000.00 $3,000.00 $7,000.00

    Laboratory Fee$60,000.00

$8,000.00 $15,000.00 $23,000.00 $37,000.00

Local AIDS Pharmaceutical Assistance Program Fee$100,000.00

$9,000.00 $10,000.00 $19,000.00 $81,000.00

Oral Health Services Fee $15,000.00 $1,200.00 $8,000.00 $9,200.00 $5,800.00

Medical Case Management CR $30,000.00 $2,500.00 $10,000.00 $12,500.00 $17,500.00

TOTAL COST       $215,000.00 $21,700.00 $45,000.00 $66,700.00 $148,300.00

M. PROGRAM INCOME

     CURRENT PROGRAM

INCOME ACCRUEDYTD PROGRAM INCOME

ACCRUED

* EXPENSES SHOULD BE TRACKED AND DETAILED SUMMARIES WILL BE PROVIDED TO THE GRANTOR AT THE

CLOSE OF THE GRANT YEAR.     

PROGRAM INCOME 1,200.00

1,200.00

-

I CERTIFY THAT ALL TRANSACTIONS REPORTED ABOVE HAVE BEEN MADE IN COMPLIANCE WITH ALL APPLICABLE STATUTES AND REGULATIONS AND IN ACCORDANCE WITH THE APPROVED CONTRACT.

Report Reviewed and Approved By Internal Use Only:Signature:           Phone No.:  

            Fax No.:  

Date:           e-mail:    

Typed Name and Title:           Mail    

            Payment:    

Direct Services Admin ServicesRyan White Part A

Medical Case Management- Direct Services

Mercy Medical Center

Reporting Month:  

Mercy Medical CenterOperating Agency: Program:

Medical Case Management

Contract Time of Performance:

Cost Categories on approved budget

Approved Budget Cost incurred This Month

Costs Incurred to Date

Available Balance

Personnel $

- $ -

$ -

$ -

Program Materials $

- -

-

-

Office Supplies $

- -

-

-

Overhead (Phones) $

- -

-

-

Travel $

- -

-

-

Other (Postage/Copies) $

- -

-

-

Total $

- $ -

$ -

$ -

Documentation SamplesService Summary ChartPersonnel - Payroll documentation for staff (monthly).Supplies - Provide documentation of costs incurred receipts/chargebacks (monthly).Overhead Phones - Provide bills and receipts or chargebacks (monthly).Travel - Provide a Travel summary for costs incurred (monthly)Other Postage/copies - Provide bills and receipts or chargebacks of costs incurred (monthly).

Ryan White Part AMedical Case Management- Administrative Services

Mercy Medical Center

Reporting Month:  

Mercy Medical CenterOperating Agency: Program:Medical Case Management

Contract Time of Performance:

Cost Categories on approved budget

Approved Budget Cost incurred This Month

Costs Incurred to Date

Available Balance

Personnel $ -

$ -

$ -

$ -

Program Materials $ -

-

-

-

Office Supplies $ -

-

-

-

Overhead (Phones) $ -

-

-

-

Travel $ -

-

-

-

Other (Postage/Copies) $ -

-

-

-

Total $ -

$ -

$ -

$ -

Documentation SamplesService Summary ChartPersonnel - Payroll documentation for staff (monthly).Supplies - Provide documentation of costs incurred receipts/chargebacks (monthly).Overhead Phones - Provide bills and receipts or chargebacks (monthly).Travel - Provide a Travel summary for costs incurred (monthly)Other Postage/copies - Provide bills and receipts or chargebacks of costs incurred (monthly).

Submitting Monthly Invoices & Paperwork

Submit via email: In PDF: Cover Page, signed Financial Report, signed Support Documents – payroll, proof of payment bills, etc. If you submit any hard copy, the same documents are required,

attention M. Rodrigo

In (1) EXCEL FILE: Invoice Support & Data

Email all documents to [email protected]

Email subject line should read:

Invoice, Provider Name, Date(April 10, 2012)

3 Fiscal Monitoring Visits60 day site visit

Annual monitoring visit

120 days before end of grant cycle

Fiscal Reminders:

Invoice Data Tracking

Purpose:•Documentation of monthly activities•Uniformity among data collection methods•Unduplicated data collection across service categories

Important Items to Remember:

• Agencies must submit a data tracking sheet for each service listed on the monthly financial report.

• Each service category must be recorded on its own service tab.

• At minimum your data must include the information listed on the approved data tracking sheet.

Agency A

Agency A

Agency A

CD Table of Contents Invoice Data Tracking File (agency-specific)

RW Provider Monthly Financial Report Form (agency-specific)

Presentation: Ryan White Part A Provider Training: Fiscal Invoicing

Federal Resources Folder National HIV/AIDS Strategy National Monitoring Standards

Local Resources Folder Part A Service Definitions Funding Exclusions and Restrictions Audit Tools Folders: Program, Fiscal, and Quality Management Agency Responsibilities CCBH Grants Administration Manual

Questions?

Ryan White Part A Program Contacts: Melissa Rodrigo – Program Supervisor

[email protected] (216)201-2001 x1507

Kate Burnett – Program Manager [email protected] (216)201-2001 x1502

Molly Kirsch - Program Manager [email protected] (216)201-2001 x1523

Jen Astronskas – Fiscal Clerk [email protected] (216)201-2001

x1525