DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1013 (10/08)
STATE OF WISCONSIN
FORWARDHEALTH
NURSE AIDE TRAINING AND COMPETENCY TEST REIMBURSEMENT REQUEST
The information on this reimbursement request is required for the reimbursement of Medicaid-certified long term care facilities, nursing facilities (NFs), for a certified nursing assistant's (CNA's) training and/or testing. This reimbursement is only available for CNAs who are employed by an NF. Providers may submit this completed form by mail to ForwardHealth, 6406 Bridge Road, Madison, WI 53784-0002. Instructions: Type or print clearly. Before completing this form, read the Nurse Aide Training and Competency Test Reimbursement Request Completion Instructions, F-1013A. Reference the Wisconsin Nurse Aide Registry Web site at www.forwardhealth.wi.gov prior to submitting this reimbursement request to obtain/verify certification information. Do a "Search by Number," Social Security number (SSN), to verify the SSN and the competency test date. Inclusion Date is the competency test date for newly certified CNAs. A reimbursement request will deny if either the SSN or the competency test date do not match what is on the Registry. Per 42 CFR Part 431 and s. 483.152(c), NFs are eligible to seek reimbursement when they have incurred testing and/or training costs for an employee or when they have hired a CNA who incurred training and testing costs within 365 days of their employment by the NF. ForwardHealth has established a maximum amount that CNAs have to be reimbursed. Nursing facilities receive a percentage of that maximum amount based on their Medicaid utilization, number of Medicaid patient days divided by their total patient days. ForwardHealth implemented this reimbursement methodology on October 1, 1997. It ensures that CNA training and testing costs are properly allocated between ForwardHealth, Medicare, and private pay residents. Name -- NF (Physical Name, not Corporate Name) POP ID National Provider Identifier -- NF
Last Name -- CNA
First Name -- CNA
SSN -- CNA
Registration Number -- CNA
Date of Hire (Required)
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Training Completion Date* Competency Test Date* Inclusion Date
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/ K K K
CNA CNA Yes
/ K K K
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NF NF No
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Training and Testing Questions -- Check the box for the applicable answer for questions 1-3. 1. Who incurred the training cost? 2. Who incurred the testing cost? 3. Is this a recertification?
CERTIFICATION This is to certify that the foregoing information is true, accurate, and complete. I understand that payment and satisfaction of this reimbursement request is from federal and state funds, and any false claims, statements, documents, or concealment of material fact may be prosecuted under applicable federal or state laws. Name and Telephone Number -- NF Contact
SIGNATURE -- Provider
Date Signed -- Provider
* To obtain reimbursement for both the training and the test, dates must be entered in both the Training Completion Date and Competency Test Date elements of this form.
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