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Grant Related - Renew
GRANT COUNTY COMMISSIONERS AGENDA MEETING REQUEST FORM (Must be submitted to the Clerk of the Board by 12:00pm on Thursday) REQUESTING DEPARTMENT: BOCC REQUEST SUBMITTED BY:Janice Flynn CONTACT PERSON ATTENDING MEETING: Janice Flynn CONFIDENTIAL INFORMATION: ❑YES ®NO DATE: 09/19/2023 PHONE:Ext 2937 Reimbursement request from Renew, in the amount of $19,635.50, for uninsured services provided as part of their American Rescue Plan Act (ARPA) funds previously approved. APPROVED ❑DENIED ❑ TABLE D/DEFERRED/NO ACTION TAKEN: ❑CONTINUED TO DATE: ❑OTHER SEP 2 6 2U23 CONSENT DATE OF ACTION: ❑Agreement / Contract ❑AP Vouchers ❑Appointment / Reappointment ❑ARPA Related ❑ Bids / RFPs / Quotes Award ❑ Bid Opening Scheduled ❑ Boards / Committees ❑ Budget ❑ Computer Related ❑ County Code ❑ Emergency Purchase ❑ Employee Rel. ❑ Facilities Related ❑ Financial ❑ Funds ❑ Hearing ❑ Invoices / Purchase Orders ® Grants — Fed/State/County ❑ Leases ❑ MOA / MOU ❑ Minutes ❑ Ordinances ❑Out of State Travel ❑ Petty Cash ❑ Policies ❑ Proclamations ❑ Request for Purchase ❑ Resolution ❑ Recommendation ❑ Professional Sery/Consultant ❑ Support Letter ❑ Surplus Req. ❑Tax Levies ❑Thank You's ❑Tax Title Property ❑WSLCB Reimbursement request from Renew, in the amount of $19,635.50, for uninsured services provided as part of their American Rescue Plan Act (ARPA) funds previously approved. APPROVED ❑DENIED ❑ TABLE D/DEFERRED/NO ACTION TAKEN: ❑CONTINUED TO DATE: ❑OTHER SEP 2 6 2U23 CONSENT DATE OF ACTION: GRANT COUNTY BOARD OF COUNTY COMMISSIONERS L1J1=ilJ_.•J To: Grant County BOCC 1W From: Janice Flynn, Administrative Services Coordinator Data September 8, 2023 Re: ARPA Renew Uninsured Services Renew is requesting reimbursement for uninsured service expenses for the months of 03/09/21 — 06/06/2023 in the amount of $19,635.50. ARPA funding for Renew Uninsured Services was approved by the BOCC on 11/16/2021 in the amount of $250,000.00 over a five-year period. Their backup documentation is attached for your review. Thank you. reneuy Grant Behavioral Health 6 Wellness PO Box 1057 Moses Lake, WA 98837 Phone (509) 765-9239 BILL TO: Grant County Attention: Janice PO Box 37 Ephrata, WA 98823 DATE: June 20, 2023 SUBTOTAL 19,635.50 TOTAL 19,635.50 THANK YOU FOR YOUR BUSINESS! Insuran Ce Service Service ID Date Service Type SPT CPT Code 1#�vr�i�`ier �ro�r am Location pec it�tiplyee p r1ltrme Client. STATUS Due Client n Due Age ate 31785 3 3/9/2021 Individual ,i 90837 MH GC Office Client Miller, Judy 12532498 0 0 $ 2.3.56 $ 23.56 4/9/2021 5/7/2021 326511 4/6/2021 Individual 90837 MH GC Office Client Miller, Judy 12532498 0 $ 15.70 5/24/202.1 328546 4/13/2021Individua I 90834 MH GC Office Client Miller, Judy 12532498 0 $ 23.56 5/24/2021 331149 4/20/2021Individual 90837 MH GC Office Client Miller, Judy 12532498 0 $ 23.56 5/24/2021 333690 Individual 4/28/2021 Inde 90837 MH GC Office Client Miller, Judy 12532498 0 $ 23.56 6/7/2021 337509 5/11/2021 Individual 90837 MH GC Office Client Miller, Judy 12532498 0 $ 11.81 6/18/2021 339623 5/18/2021 Individual 90832 MH GC Office Client Miller, Judy 12532498 0 $ 19.62 6/18/2021 342098 5/25/2021 Individual 90837 MH GC Office Client Miller, Judy 12532498 0 $ 60.00 1/13/2022 408154 1/5/2022 5 2022 Individual H2O15 MH GC Clnt Home Phone Miller, Judy 12532498 0 $ 23.56 2/15/2022 409842 1/11/2022 Individual 90837 MH GC Office Phone Miller, Judy 12532498 0 $ 23.56 2/28/2022 412199 1/19/2022 Individual 90837 MH GC Office Phone Miller, Judy 12532498 0 $ 23.56 3/4/2022 416639 2/2/2022 Individual 90837 MH GC Office Phone Miller, Judy 12532498 0 $ 23.56 3/30/2022 421349 2/16/2022 Individual 90837 MH GC Office Phone Miller, Judy 12532498 0 $ 23.56 4/5/2022 425456 3/1/2022 Individual 90837 MH GC Office Phone Miller, Judy 12532498 0 $ 23.56 4/18/2022 430255 3/15/2022 Individual 90837 MH GC Office Phone Miller, Judy 12532498 0 $ 23.56 5/3/2022 434741 3/29/2022 Individual 90837 GT MH GC Telehealth Client Miller, Judy 12532498 439877 4/12/2022 Individual 90837 MH GC Telehealth Phone Miller, Judy 12532498 0 $ 23.56 5/20/2022 444718 4/26/2022 Individual 90837 MH GC Office Phone Miller, Judy 12532498 0 $ 23.56 6/1/2022 12532498 Total $ 436.97 395555 11/19/2021 PeerSup Svc H0038 U8 WISe ML School Client Napiontek, Tyler 12532857 0 $ 12.30 12/16/2021 12532857 Total $ 12.30 506758 10/31/2022 intake 90791 MH ML Office Client Shoemake, Carol 12533027 0 $ 25.00 12/2/2022 509705 11/7/2022 Individual 90834 MH ML Office Client Serrano Castrellon, 12533027 0 $ 25.00 12/20/2022 512116 11/14/2022 Individual 90834 MH ML Office Client Serrano Castrellon, 12533027 0 $ 25.00 12/30/2022 515027 11/21/2022 Individual 90834 MH ML Office Client Serrano Castrellon, 12533027 0 $ 25.00 12/30/2022 517704 11/30/2022 Individual 90834 MH ML Clnt Home Client Serrano Castrellon, 12533027 0 $ 10.47 12/30/2022 12533027 Total $ 110.47 487315 8/31/2022 Individual 90834 MH ML Office Client Alcott, Megan 12533237 0 $ 10.00 9/29/2022 12533237 Total $ 10.00 516030 11/28/2022 Intake H0031 MH ML Office Client Shoemake, Carol 12533450 0 $ 30.00 12/27/2022 520001 12/7/2022 Individual 90837 MH EP Telehealth Client Anderson, Bobbie J 12533450 0 $ 30.00 1/6/2023 534491 1/19/2023 Individual 90837 MH Telehealth Hom Client Anderson, Bobbie J 12533450 0 $ 30.00 2/6/2023 12533450 Total $ 90.00 513275 11/16/2022 Individual 90834 MH ML Office Client Serrano Castrellon, 12533549 0 $ 20.00 12/30/2022 522921 12/13/2022 Individual 90834 MH ML Office Client Serrano Castrellon, 12533549 0 $ 20.00 1/26/2023 532396 1/11/2023 Individual 90834 MH ML Office Client Serrano Castrellon, 12533549 0 $ 25.00 2/15/2023 546902 2/21/2023 Individual 90834 MH ML Office Client Serrano Castrellon, 1253354910 $ 25.00 3/23/2023 12533549 Total $ 90.00 411360 1/13/2022 Individual 90837 MH EP Office Client Pinckard, Devin 12534174 0 $ 43.21 4/8/2022 416932 2/2/2022 Individual 90837 MH EP Office Client Pinckard, Devin 12534174 0 $ 240.00 4/8/2022 4320271_3/21/2022 Individual 90837 IMH EP Office Client Pinckard, Devin 12534174 0 $ 240.00 4/8/2022 Service CPTInsurance Service ID Date Service Type CPT Code ` i ioa t, ler Program Lt �a#� R ,p Mot Employee n e Client ID STATUS Due Client Due Age Date 476735 7/27/2022 Individual 90837 MH EP Office Client Pinckard, Devin 12534174 0 $ 240.00 7/30/2022 490666 9/12/2022 individual 90837 MH EP Office Client Pinckard, Devin 12534174 0 $ 240.00 9/15/2022 500053 10/10/2022 Individual 90837 MH EP Office Client Pinckard, Devin 12534174 0 $ 240.00 10/13/2022 12534174 Total $ 11243.21 535149 1/10/2023 Group 96165 SUD ML NonResSUDFc Client Vertrees, Katherine 12534191 0 $ 27.50 1/21/2023 536232 1/24/2023 SUD Svcs 90832 SUD ML NonResSUDFc Client Pinckard, Heidi 12534191 0 $ 80.00 1/25/2023 537074 1/24/2023 Group 96165 SUD ML NonResSUDFc Client Pinckard, Heidi _ _ . 12534191 0 $ 70.00 1/27/2023 537073 1/24/2023 Group 96164 SUD ML NonResSUDFc Client Pinckard, Heidi 12534191 0 $ 35.00 1/27/2023 542174 2/7/2023 Group 96164 SUD ML NonResSUDFc Client Lopez, Maleena 12534191 0 $ 35.00 2/10/2023 542175 2/7/2023 Group 96165 SUD ML NonResSUDFc Client Lopez, Maleena 125341.91 0 $ 70.00 2/10/2.023 546860 2/21/2023 Group 96165 SUD ML NonResSUDFc Client Lopez, Maleena 12534191 0 $ 70.00 2/23/2023 546859 2/21/2023 Group 96164 SUD ML NonResSUDFc Client Lopez, Maleena 12534191 0 $ 35.00 2/23/2023 555827 3/14/2023 Group 96164 SUD ML NonResSUDFc Client Lopez, Maleena 12534191 0 $ 35.00 3/17/2023 555828 3/14/2023 Group 96165 SUD ML NonResSUDFc Client Lopez, Maleena 12534191 0 $ 70.00 3/17/2023 559863 3/23/2023 SUD Svcs 90832 SUD ML NonResSUDFc Client Lopez, Maleena 12534191 0 $ 80.00 3/28/2023 12534191 Total $ 607.50 335932 5/6/2021 Individual 90832 MH GC Office Client Becker-Smoger, Dai 12535680 0 $ 11.64 5/28/2021 12535680 Total $ 11.64 544717 2/14/2023 Intake H0001 SUD ML NonResSUDFc Client Cloyd, Megan 12537554 0 $ 187.50 2/18/2023 560986 3/28/2023 SUD Svcs 90832 SUD ML NonResSUDFc Client Cloyd, Megan 12537554 0 $ 80.00 4/1/2023 582990 5/22/2023 Discharge H0004 SUD ML NonResSUDFc Client Cloyd, Megan 12537554 0 $ 80.00 5/31/2023 12537554 Total $ 347.50 317969 3/9/2021 Individual 90834 MH ML Office Client Alcott, Megan 12537862 0 $ 10.00 4/8/2021 320567 3/18/2021 Individual 90834 MH ML Office Client Alcott, Megan 12537862 0 $ 10.00 4/8/2021 338704 5/14/2021 Individual 90834 MH ML Office Client Alcott, Megan 12537862 0 $ 10.00 6/7/2021 346600 6/9/2021 Individual 90834 MH ML Office Client Alcott, Megan 12537862 0 $ 10.00 7/6/2021 352437 6/29/2021 Individual 90832 MH ML Office Phone Alcott, Megan 12537862 0 $ 10.00 7/26/2021 363804 8/6/2021 Individual 90834 MH ML Office Phone Alcott, Megan* 12537862 0 $ 10.00 9/3/2021 12537862 Total $ 60.00 318481 3/11/2021 Individual 90837 GT MH RC Telehealth Client Escamilla, Reina 12537980 0 $ 20.00 4/2/2021 334472 4/30/2021 Individual 90834 MH RC Office Client Guerrero, Conne 12537980 0 $ 20.00 5/24/2021 343207 5/28/2021 Individual 90834 GT MH RC Telehealth Client Guerrero, Conne 12537980 0 $ 20.00 6/18/2021 12537980 Total $ 60.00 332601 4/26/2021 Individual 90834 MH GC Office Client Becker-Smoger, Dal 12S38316F 0 $ 144.00 7/9/2021 12538316 Total $ 144.00 519177 12/6/2022 RcrdFeeCln RECFEECLN MH ML Office Parent Sharrah, Kathleen ( 12538392 0 $ 7.00 12/13/2022 12538392 Total $ 7.00 406232 12/28/2021 Individual 90837 MH EP Office Client Pinckard, Devin 12538427 0 $ 40.00 5/11/2022 433957 3/25/2022 Individual 90832 MH EP School Client Pinckard, Devin 12538427 0 $ 40.00 5/3/2022 445244 4/27/2022 Individual 90834 MH EP School Client Pinckard, Devin 12538427 L 0 $ 40.00 6/1/2022 452785 5/18/2022 Individual 90834 MH EP Office Client Pinckard, Devin 12538427 0 $ 40.00 7/1 /2022 .....__._. ._ . _ insurance .. .. Service Service ISD Date Service Type CPT CPT Code iVJ'odi�fer . Pro rare g Location Recipient ' Ern loyee Name Elient iD STATUS Due Client ►f��ue Age Date 484178 8/19/20221ndividua1 90837 MH EP Office Client Pinckard, Devin 12538427 0 0 $ $ 40.00 40.00 9/22/2022 10/26/2022 495563 9/27/2022 Individual 90832 MH EP Office Client Pinckard, Devin 12538427 0 $ 40.00 12/20/2022 507881 11/1/2022 Individual 90837 MH EP School Client Pinckard, Devin 12538427 0 $ 25.00 2/23/2023 532658 1/12/2023 Individual 90832 MH EP School Client Pinckard, Devin 12538427 0 $ 60.00 2/3/2023 538977 1/25/2023 Discharge H2O15 MH EP Clnt Home Phone Pinckard, Devin 12538427 12538427 Total $ 365.00 5370331/25/2023 IOP 90853 SUD IOP ML NonResSUDFc Client Weaver, Dale 12539131 0 0 $ $ 10.75 21.00 2/14/2023 2/14/2023 539312 1/31/2023 IOP 90853 SUD IOP ML NonResSUDFc Client Weaver, Dale 12539131 0 $ 21.00 2/14/2023 5399052/1/2023 IOP 90853 SUD IOP ML NonResSUDFc Client Weaver, Dale 12539131 0 $ 12.00 2/14/2023 540149 2/2/2023 IOP -Ind 90834 SUD IOP ML NonResSUDFc Client Cloyd, Megan 12539131 0 $ 21.00 2/14/2023 540426 2/2/2023 IOP 90853 SUD IOP ML NonResSUDFc Client Weaver, Dale 12539131 0 $ 21.00 2/14/2023 542052 2/7/2023 IOP 90853 SUD IOP ML NonResSUDFc Client Weaver, Dale 12539131 0 $ 21.00 2/14/2023 5 42442 2/8/2023 IOP 90853 SUD IOP ML NonResSUDFc Client Cloyd, Megan 12539131 0 $ 21.00 2/14/2023 543081 2/9/2023 IOP 90853 SUD IOP ML NonResSUDFc. Client Cloyd, Megan 12539131 0 $ 21.00 3/9/2023 544573 2/14/2023 IOP 90853 SUD IOP ML NonResSUDFc Client Cloyd, Megan 12539131 0 $ 21.00 3/9/2023 545070 2/15/2023 IOP 90853 SUD IOP ML NonResSUDFc Client Cloyd, Megan 12539131 0 $ 21.00 3/9/2023 547393 2/22/2023 IOP 90853 SUD IOP ML NonResSUDFc Client Cloyd, Megan 12539131 0 $ 21.00 3/9/2023 548055 2/23/2023 IOP 90853 SUD IOP ML NonResSUDFc Client Cloyd, Megan 12539131 549829 2/28/2023 IOP 90853 SUD IOP ML NonResSUDFc Client Cloyd, Megan 12539131 0 $ 21.00 3/9/2023 550402 3/1/2023 IOP 90853 SUD IOP ML NonResSUDFc Client Cloyd, Megan 125391311 0 $ 21.00 3/9/2023 12539131 Total $ 274.75 509843 11/8/2022 Individual 90834 MH EP Office Client Anderson, Bobbie J 12539778 0 $ 10.00 12/20/2022 12539778 Total $ 10.00 331919 4/22/2021 Med Man 99213 MH EP Clnt Home Client Sander, Darcy 12539892 0 $ 7.83 6/7/2021 12539892 Total $ 7.83 470851 7/12/2022 Individual 90834 MH ML Office Client Crittendon, Lacey 12539901 0 $ 120.00 8/29/2022 476114 7/26/2022 Individual 90837 MH ML Office Client Crittendon, Lacey 12539901 0 $ 124.00 8/29/2022 480502 8/9/2022 Individual 90834 MH ML Office Client Crittendon, Lacey 12539901 0 $ 72.00 9/27/2022 486441 8/29/2022 Individual 90834 MH ML Office Client Crittendon, Lacey 12539901 0 $ 72.00 9/29/2022 507708 11/1/2022 Individual 90834 MH ML Office Client Crittendon, Lacey 12539901 0 $ 72.00 12/20/2022 512329 11/15/2022 Individual 90834 MH ML Office Client Crittendon, Lacey 12539901 0 $ 72.00 1/5/2023 516948 11/29/2022 Individual 90834 MH ML Office Client Crittendon, Lacey 12539901 0 $ 72.00 1/5/2023 525847 12/22/2022 Discharge 90834 MH ML Office Client. Crittendon, Lacey 12539901 0 $ 72.00 1/24/2023 125.39901 Total $ 676.00 402794 12/14/2021 Individual 90834 MH ML Office Client . Crawford, Matt 12540216 0 $ 12.62 2/1/2022 12540216 Total $ 12.62 339294 5/11/2021 Intake 90791 MH GC Office Client Garza, Irene 125403201. 0 $ 10.00 7/26/2021 12540320 Total $ 10.00 435258 3/29/2022 Individual 90834 MH ML Office Client Crawford, Matt 125403251 0 $ 7.75 5/3/2022 12540325 Total $ 7.75 4693601_7/7/2022 Group 96164 SUD ML NonResSUDFc Client 1weaver, Dale 125411231 0 $ 35.00 7/8/2022 Service Service Type e Service ID Date yp CPT CPT Code '6Vlor�i ie�° Programo Location Peck i nt Employee Name Client 10 STATUS Insurance Due Client Due Age Date 469361 7/7/2022 Group 96165 SUD ML NonResSUDFc Client Weaver, Dale .12541123 0 $ 70.00 7/8/2022 470552 7/11/2022 Discharge H0004 SUD ML NonResSUDFc Client Pinckard, Heidi 125411231 0 $ 120.00 7/15/2022 12541123 Total $ 225.00 429351 3/11/2022 individual 90832 MH ML School Client Crittendon, Lacey 12541183 0 $ 11.81 4/13/2022 12541183 Total $ 11.81 442128 4/19/2022 SUD Svcs 90834 SUD ML NonResSUDFc Client Pinckard, Heidi 12541416 0 $ 15.28 3/23/2023 452540 5/18/2022 SUD Svcs 90834 SUD ML NonResSUDFc Client Pinckard, Heidi 12541416 0 $ 20.68 1/13/2023 459089 6/7/2022 SUD Svcs 90832 SUD ML NonResSUDFc Client Pinckard, Heidi 12541416 0 $ 78.76 7/8/2022 468899 7/5/20.22 Group 90853 SUD ML NonResSUDFc Client Vertrees, Katherine 12541416 0 $ 105.00 8/11/2022 474395 7/19/2022 Group 90853 SUD ML NonResSUDFc Client Pinckard, Heidi 12541416 0 $ 105.00 9/6/2022 475952 7/26/2022 Group 90853 SUD ML NonResSUDFc Client Lopez, Maleena 12541416 0 $ 105.00 9/6/2022 478928 8/2/2022 Group 90853 SUD ML NonResSUDFc Client Pinckard, Heidi 12541416 0 $ 105.00 9/12/2022 481090 8/9/2022 Group 90853 SUD ML NonResSUDFc Client Pinckard, Heidi 12541416 0 $ 99.17 9/22/2022 4837318/16/2022 Group 90853 SUD ML NonResSUDFc Client Pinckard, Heidi 12541416 0 $ 21.00 9/22/2022 484667 8/23/2022 SUD Svcs 90832 SUD ML NonResSUDFc Client Pinckard, Heidi 12541416 0 $ 15.75 9/29/2022 487068 8/30/2022 Group 90853 SUD ML NonResSUDFc Client Pinckard, Heidi 12541416 0 $ 21.00 9/29/2022 490491 9/6/2022 Group 90853 SUD ML NonResSUDFc Client Pinckard, Heidi 12541416 0 $ 21.00 10/12/2022 491096 9/13/2022 Group 90853 SUD ML NonResSUDFc Client Pinckard, Heidi 12541416 0 $ 21.00 10/26/2022 495001 9/20/2022 Group 90853 SUD ML NonResSUDFc Client Pinckard, Heidi 12541416 0 $ 21.00 10/26/2022 497503 9/27/2022 Discharge H0004 SUD ML NonResSUDFc Client Pinckard, Heidi 125414161 0 $ 15.75 11/10/2022 12541416 Total $ 770.39 430224 3/15/2022 Individual 90837 MH ML Office Client Pineda, Ambar 12541461 0 $ 20.00 4/13/2022 432335 3/22/2022 Individual 90837 MH ML Office Client Pineda, Ambar 12541461 0 $ 20.00 4/18/2022 440303 4/12/2022 Individual 90837 MH ML Office Client Pineda, Ambar 12541461 0 $ 20.00 5/11/2022 463675 6/21/2022 Individual 90837 MH ML Office Client Pineda, Ambar 12541461 0 $ 20.00 7/25/2022 469086 7/6/2022 Individual 90837 MH ML Office Client Pineda, Ambar 12541461 0 $ 20.00 8/3/2022 12541461 Total $ 100.00 554041 3/9/2023 Individual 90834 MH ML Office Client Crittendon, Lacey 12541592 0 $ 25.00 4/17/2023 574557 4/28/2023 Individual 90834 MH ML Office Client Crittendon, Lacey 12541592 0 $ 25.00 5/31/2023 12541592 Total $ 50.00 444996 4/27/2022 CM H2O15 MH ML Office Client Marston, Paula 12541857 0 $ 23.00 4/27/2022 454117 5/24/2022 CM H2O15 MH ML Office Client Escamilla, Bethany 12541857 0 $ 36.00 5/24/2022 464414 6/23/2022 CM H2O15 MH ML Office Client Escamilla, Bethany 12541857 0 $ 36.00 6/23/2022 477063 7/29/2022 CM H2O15 MH ML OthrCommSet Phone Escamilla, Bethany 12541857 0 $ 12.00 7/29/2022 483227 8/18/2022 CM H2O15 MH ML Office Client Escamilla, Bethany 12541857 0 $ 24.00 8/18/2022 494895 9/26/2022 CM H2O15 MH Telehealth Horn Phone Escamilla, Bethany 12541857 0 $ 12.00 9/26/2022 500906 10/13/2022 CM H0046 MH ML Office Oth Agency Escamilla, Bethany 12541857 0 $ 12.00 10/13/2022 506309 10/28/2022 CM H2O15 MH ML Office Client Escamilla, Bethany 125418571 0 $ 48.00 10/28/2022 12541857 Total $ 203.00 433398 3/24/2022 SUD Svcs 90832 SUD ML NonResSUDFc Client Lopez, Maleena 12541930 0 $ 19.20 2/2/2023 448016 4/28/2022 IOP 90853 SUD IOP ML NonResSUDFc Client Vertrees, Katherin 12541930 0 $ 108.00 6/27/2022 _ _ - -- . insurance Service CST Date Service Type CPT Code Modifier Program �aieci LOCOtion itttaee fVae �'iie.nt ID STATUS Die Client Due Age Dote Service ID 90853 SUD IOP ML NonResSUDFc Client Pinckard, Heidi 12541930 0 $ 168.00 6/27/2022 447408 5/2/ 10P 90853 SUD IOP ML NonResSUDFc Client Pinckard, Heidi 12541930 0 $ 168.00 7/5/2022 447932 5/4/2022 IOP 90853 SUD IOP ML NonResSUDFc Client Vertrees, Katherine 12541930 0 $ 168.00 6/27/2022 448489 5/5/2022 IOP 5/9/2022 IOP 90853 SUD IOP ML NonResSUDFc Client Bates, Sarah 12541930 0 $ 50.40 7/12/2022 449558 450089 5/11/2022 IOP 90 853 SUD IOP ML NonResSUDFc Client Vertrees, Katherine 12541930 0 0 $ $ 168.00 154.00 7/5/2022 7/5/2022 450978 5/12/2022 IOP 9 0853 SUD IOP ML NonResSUDFc Client Vertrees, Katherine12541930 $ 168.00 7/11/2022 452558 5/18/2022 IOP 90853 SUD IOP ML NonResSUDFc Client Vertrees, Katherinep 12541930 0 $ 33.60 7/12/ 2022 453001 5/19/2022 IOP 90853 SUD IOP ML NonResSUDFc Client Vertrees, Katherine12541930 0 $ 163.80 7/12/2022 454239 5/23/202210P 90853 SUD IOP ML NonResSUDFc Client Vertrees, Katherine 12541930 0 $ 47.25 8/2/2022 455117 5/25/2022 IOP 90853 SUD IOP ML NonResSUDFc Client Bates, Sarah 12541930 0 $ 50.40 7/19/2022 455393 5/26/2022 IOP 90853 SUD IOP ML NonResSUDFc Client Vertrees, Katherine 12541930 0 $ 168.00 7/11/2022 457106 6/1/202210 P 90853 SUD IOP ML NonResSUDFc Client Vertrees, Katherine 12541930 0 $ 50.40 7/12/2022 458025 6/2/2022 IOP 90853 SUD IOP ML NonResSUDFc Client Vertrees, Katherine 12541930 0 $ 168.00 7/11/2022 458492 6/6/2022 IOP 90853 SUD IOP ML NonResSUDFc Client Vertrees, Katherine 12541930 0 $ 50.40 8/2/2022 459709 6/8/2022 IOP 90853 SUD IOP ML NonResSUDFc Client Vertrees, Katherine 12541930 0 $ 50.40 7/12/2022 460320 6/9/2022 IOP 90853 SUD IOP ML NonResSUDFc Client Vertrees, Katherine 12541930 0 $ 30.00 7/15/2022 461753 6/13/2022 IOP -Ind 90837 SUD IOP ML NonResSUDFc Client Vertrees, Katherine12541930 0 $ 50.40 8/16/2022 462148 6/13/2022 IOP 90853 SUD IOP ML NonResSUDFc Client Vertrees, Katherine 12541930 462989 6/15/2022 IOP 90853 SUD IOP ML NonResSUDFc Client Vertrees, Katherine 12541930 0 $ 50.40 8/16/2022 463138 6/16/2022 IOP 90853 SUD IOP ML NonResSUDFc Client Vertrees, Katherine 12541930 0 $ 50.40 8/16/2022 465870 6/23/2022 IOP 90853 SUD IOP ML NonResSUDFc Client Vertrees, Katherine 12541930 0 $ 50.40 8/16/2022 468025 6/27/2022 IOP 90853 SUD IOP- ML NonResSUDFc Client Vertrees, Katherine 12541930 0 $ 50.40 8/16/2022 467478 6/29/2022 IOP 90853 SUD IOP ML NonResSUDFc Client Vertrees, Katherine 12541930 0 $ 50.40 8/16/2022 468386 6/30/2022 IOP 90853 SUD IOP ML NonResSUDFc Client Vertrees, Katherine 12541930 0 $ 50.40 8/30/2022 469036 7/6/2022 IOP 90853 SUD IOP ML NonResSUDFc Client Vertrees, Katherine 12541930 0 $ 50.40 8/30/2022 469894 7/7/2022 IOP 90853 SUD IOP ML NonResSUDFc Client Vertrees, Katherine 12541930 0 $ 50.40 9/1/2022 470572 7/11/2022 IOP 90853 SUD IOP ML NonResSUDFc Client Vertrees, Katherine 12541930 0 $ 50.40 9/7/2022 471559 7/13/2022 IOP 90853 SUD IOP ML NonResSUDFc Client Vertrees, Katherine 12541930 0 $ 50.40 9/7/2022 472109 7/14/2022 IOP 90853 SUD IOP ML NonResSUDFc Client Vertrees, Katherine 12541930 0 $ 50.40 9/7/2022 473360 7/18/2022 IOP 90853 SUD IOP ML NonResSUDFc Client Vertrees, Katherine 12541930 0 $ 30.00 9/22/2022 474335 7/20/2022 IOP 90853 SUD IOP ML NonResSUDFc Client Vertrees, Katherine 12541930 0 $ 50.40 9/19/2022 476459 7/21/2022 IOP 90853 SUD IOP ML NonResSUDFc Client Vertrees, Katherine 12541930 0 $ 50.40 9/19/2022 475161 7/25/2022 IOP 90853 SUD IOP ML NonResSUDFc Client Vertrees, Katherine 12541930 0 $ 50.40 9/19/2022 476228 7/27/2022 IOP 90853 SUD IOP ML NonResSUDFc Client Vertrees, Katherine 12541930 0 $ 50.40 9/19/2022 477103 7/28/2022 IOP 90853 SUD IOP ML NonResSUDFc Client Vertrees, Katherine 12541930 0 $ 50.40 9/19/2022 484903 8/23/2022 Group 90853 SUD ML NonResSUDFc Client Pinckard, Heidi 12541930 0 $ 25.20 10/12/2022 489841 9/6/2022 Group 90853 SUD ML NonResSUDFc Client Vertrees, Katherine 12541930 0 $ 25.20 11/21/2022 493322 9/13/2022 Group 90853 SUD ML NonResSUDFc Client Vertrees, Katherine 12541930 0 $ 25.20 11/21/2022 496003 9/27/2022 Group 90853 SUD ML NonResSUDFc Client Vertrees, Katherine 12541930 0 $ 25.20 11/21/2022 498300 10/4/2022 Group 90853 SUD ML NonResSUDFc Client Alamos, Dard 12541930 0 $ 21.00 2/7/2023 503744 10/11/2022 Group 90853 SUD ML NonResSUDFc Client Vertrees, Katherine,12541930 0 $ 25.20 12/27/2022 Service CPT Insurance Service ID Date Service Type Code Modifier CPT Co f Program g ,�aatit�t Recpientplye Name. Client ID STATUS Due Client Due Age Date 508632 10/18/2022 SUD Svcs 90837 SUD ML NonResSUDFc Client Vertrees, Katherine 12541930 0 $ 38.40 12/27/2022 508995 10/25/2022 Group 90853 SUD ML NonResSUDFc Client Vertrees, Katherine 12541930 0 $ 25.20 12/27/2022 517039 11/15/2022 Group 90853 SUD ML NonResSUDFc Client Vertrees, Katherine 12541930 0 $ 25.20 3/1/2023 517819 11/22/2022 Group 90853 SUD ML NonResSUDFc Client Vertrees, Katherine 12541930 0 $ 12.60 3/1/2023 518409 11/29/2022 Group 90853 SUD ML NonResSUDFc Client Vertrees, Katherine 12541930 0 $ 25.20 3/1/2023 520117 12/6/2022 Group 90853 SUD ML NonResSUDFc Client Vertrees, Katherine 12541930 0 $ 25.20 3/7/2023 526262 12/13/2022 Group 90853 SUD ML NonResSUDFc Client Vertrees, Katherine 12541930 0 $ 25.20 3/7/2023 525107 12/20/2022 Group 90853 SUD ML NonResSUDFc Client Vertrees, Katherine 12541930 0 $ 25.20 3/7/2023 527721 12/27/2022 Group 90853 SUD ML NonResSUDFc Client Vertrees, Katherine 12541930 0 $ 25.20 3/7/2023 528512 1/3/2023 Group 90853 SUD ML NonResSUDFc Client Vertrees, Katherine 12541930 0 $ 84.00 3/20/2023 533329 1/10/2023 Group 90853 SUD ML NonResSUDFc Client Vertrees, Katherine 12541930 0 $ 84.00 3/20/2023 534907 1/20/2023 Discharge H0004 SUD ML NonResSUDFc Client Vertrees, Katherine 12541930 0 $ 120.00 1/21/2023 12541930 Total $ 3,533.05 425084 2/28/2022 Intake 90791 MH ML Office Client Shoemake, Carol 12541950 0 $ 40.00 4/5/2.022 437202 4/4/2022 Individual 90834 MH ML Office Client Skjervold, Karli 12541950 0 $ 40.00 5/11/2022 440660 4/13/2022 Individual 90834 MH ML Office Client Skjervold, Karli 12541950 0 $ 40.00 5/20/2022 453366 5/19/2022 Individual 90834 MH ML Office Client Skjervold, Karli 125419501 0 $ 36.47 7/1/2022 12541950 Total $ 156.47 431652 3/21/2022 Intake 90791 MH ML Office Client Wilkinson, Barbara 12542019 0 $ 40.48 5/5/2022 442866 4/20/2022 Individual 90834 MH ML Office Fam+Client Alcott, Megan 12542019 0 $ 26.18 6/1/2022 452323 5/17/2022 Individual 90834 MH ML Office Fam+Client Alcott, Megan 125420191 0 $ 26.18 7/1/2022 469973 7/8/2022 Individual 90834 MH ML Office Client Alcott, Megan 125420191 0 $ 180.00 8/16/2022 12542019 Total $ 272.84 534532 1/19/2023 Individual 90837 MH QU Office Client Guerrero, Conne 12542069 0 $ 192.00 5/16/2023 537590 1/26/2023 Individual 90834 MH QU Office Client Guerrero, Conne 12542069 0 $ 144.00 5/16/2023 540400 2/2/2023 Individual 90837 MH QU Office Client Guerrero, Conne 12542069 0 $ 164.00 5/17/2023 543372 2/9/2023 Individual 90837 MH QU Office Client Guerrero, Conne 12542069 0 $ 24.00 5/17/2023 545803 2/16/2023 Individual 90837 MH QU Office Client Guerrero, Conne 12542069 0 $ 24.00 5/17/2023 547664 2/21/2023 Med Intake 90792 MH ML Telehealth Fam+Client Dick, Michelle 12542069 0 $ 40.00 3/21/2023 547960 2/23/2023 Individual 90837 MH QU Office Client Guerrero, Conne 12542069 0 $ 24.00 5/17/2023 551093 3/2/2023 Individual 90837 MH QU Office Client Guerrero, Conne 12542069 0 $ 24.00 5/17/2023 554790 3/13/2023 Individual 90837 MH QU Office Client Guerrero, Conne 12542069 0 $ 24.00 5/17/2023 12542069 Total $ 660.00 556511 3/15/2023 Intake H0001 SUD ML NonResSUDFc Client Garcia, Noemi 12542249 0 $ 250.00 3/22/2023 560098 3/23/2023 SUD Svcs 90832 SUD ML NonResSUDFc Client Garcia, Noemi 12542249 0 $ 80.00 3/28/2023 12542249 Total $ 330.00 454474 5/24/2022 Intake H0031 MH EP Office Client Wilkinson, Barbara 12542287 0 $ 250.00 6/2/2022 463434 6/21/2022 Individual 90837 MH EP Office Client Westermann, Cath 12542287 0 $ 240.00 6/28/2022 466557 6/28/2022 Individual 90834 MH EP Clnt Home Phone Westermann, Cath 12542287 0 $ 180.00 6/30/2022 479356 8/5/2022 Individual 90837 MH EP Office Client Westermann, Cath 12542287 0 $ 240.00 8/9/2022 483879 8 19/2022 Individual 90837 MH EP Office Client Westermann, Cath 12542287 0 $ 240.00 8/23/2022