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 VT Community Email | July 28, 2011 


2011 - 2012 Fall Start up Checklist

If you Google™ the phrase "getting off to a good start", you will find thousands of ideas and methods that will lead to great outcomes. Nothing is better than a fresh start with the opportunity to do it better than we did the last time!


Each school year brings a fresh start for many things and school-based Medicaid is no exception. Together, we are looking for our quickest start ever!  Please review action items and deadlines below. It is important for districts to complete tasks by the deadlines indicated to ensure there is no lapse in billing for the new school year.

Please submit the following items by 9/15/11:   
  1. District Information form. Click to download form. 
  2. Out-of-District School calendar for any student attending an out-of-district facility.
  3. Updated Sped Roster for Medicaid eligible students to include Last Name, First Name, DOB, Gender, UID or SSN, current placement and case manager and current physician. Please submit your roster to MSB ( by 9/15/11.  For Case-e clients - please have your student information complete to include the aforementioned  data updated in Case-e by 9/15/11.
  4. Release of Information for new students and Release of Information for 18-year-old students who become their own guardian.  Send MSB ( copies upon receipt to expedite obtaining Physician Authorization. Click on the links to read more about ROI and Age 18 ROI.
  5. Provider Certification Agreement and licensing for new staff who will be providing Medicaid billable services at a professional rate (Speech, OT, PT, Nursing, Counseling, etc.) and updated licensing for any staff whose license has expired. Provider Certification agreements and licensing are not required for those billing as paraprofessionals. Click to download the Provider Certification form.
  6. Out-of-District Provider Certification Agreements for students attending out-of-district programs. Click for to download the OOD form.
  7. New and updated IEPs along with applicable amendment forms.  If you are a Case-e client, we have the ability to access the IEPs directly from the software. If we see that an IEP has been amended, we will request the appropriate amendment form (5b or 7a). An amended IEP is not a Medicaid-compliant document without an attached amendment form.
  8. Unscheduled School Days form. Must be submitted at the end of each billing period. Click to download form.   Should your school calendar be updated during the school year, it is important to notify MSB to insure we remain compliant in billing for the appropriate amount of school days each billing period.

Revised State Forms

  • 3 Yr. Special Education Reevaluation (Pink Form) - Must use revised form beginning 8/15/11.  Click to download form.
  • Annual IEP (Blue Form) - Must use revised form beginning 8/15/11. Click to download form.
  • Personal Care Verification Form (PCVF) - The new PCVF must be used for all new IEPs written after 8/15/11 from which Personal Care will be billed.  This form can also be used for IEPs written prior to this date. (Detailed training will be provided on how to complete the new version of the Personal Care Verification Form at the Department of Education's September Clerk's meeting.) Click to download form.
  • Many billing opportunities are missed due to lack of timely submission of blue and pink forms - please remind case managers to complete a blue form for each annual IEP renewal (claim amount $422.00) and a pink form for every 3-year re-evaluation (claim amount $743.00). 
IMPORTANT REMINDERS for Service Providers


Completed service  documentation logs are due to MSB two weeks after the close of the billing period. Please submit any ESY service logs by September 15, 2011.  Aug/Sept logs should be submitted no later than October 14, 2011,October logs by November 11, 2011, etc. 
  • Any handwritten changes, including cross-outs, must be initialed.
  • Do not use ditto marks, arrows, pencil or white out when filling out service logs.
  • Developmental and Assistive Therapy (DATlogs under section "IEP ACTIVITY" must be recorded exactly as it is listed on the Service page of IEP. 
  • Signatures must be dated on or after the end of the billing period.  
  • Quarterly progress notes for Related Services (OT, PT, Speech, etc.) will be due at the close of each marking period. Progress notes are not required for DAT or Personal Care.  Case-e clients, please record progress in Case-e and we can download the progress notes directly at the designated progress dates.
FY12 Grant Report Payment Schedule 

 FY12 VT

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MSB is looking forward to a fantastic fall start up this year, and we look forward to working with you in 2011-2012!
Kelly Bilodeau, Claims Analyst
Phone Number: 800.618.3111 x106 MSB Fax Number: 603.692.0857 
Mailing Address: MSB, 97 High Street, Somersworth, NH 03878