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{"sheet":"Instructions ","index":0,"n_rows":73,"n_cols":22,"rows_kept":73,"cut":false,"hidden":false,"merged":[[10,0,10,6],[6,0,6,6],[57,0,57,6],[72,0,72,6],[64,0,64,6],[66,0,66,6],[62,0,62,6],[71,0,71,7],[61,0,61,5],[22,7,22,21],[64,9,64,15],[18,0,18,6],[16,0,16,6],[19,0,19,6],[41,0,41,6],[0,0,0,6],[2,0,2,6],[3,0,3,6],[4,0,4,6],[5,0,5,6]]}
["ACBHD Claim Correction Form (CCF) Instructions"]
[]
["All forms must be signed or it will be returned for a signature."]
["Contact the CCF Coordinator by secure email at CCFCoordinator@acgov.org if you have any questions.     "]
["All information for original services must exactly match data originally entered into SmartCare.  "]
["Please fill in all columns. Do not copy and/or paste data into formatted fields"]
["*Do not combine SUD & MHS on the same CCF form."]
[]
[]
[]
["All information must exactly match data originally entered into SmartCare"]
["For each service, enter:"]
["Service Program Type: Choose from MHS (Mental Health Services) or SUD (Substance Use Disorder).",null,null,null,null,null,null,"Service Program Type (MHS/SUD)","Client Last Name & First Name","Client SmartCare ID #","Claim Correction Reason"]
["Client Last name and First name: Clients full name.",null,null,null,null,null,null,"MHS","Doe, John","099999999","1"]
["Client SmartCare ID # : Please match to client name & include preceeding zeros for a total of 9 digits."]
["Claim Correction Reason Code : Choose from dropdown list. Refer to Claim Correction Reason Code Key  "]
["   If appropriate code is not listed, use reason code 11 and provide a detailed description in the comments column."]
[]
["ORIGINAL SERVICE ENTERED (as shown in SmartCare)"]
["All information must exactly match data originally entered into SmartCare"]
[]
["For each service, enter the below information which is found on the Services (My Office) screen:"]
[null,null,null,null,null,null,null,"ORIGINAL SERVICE ENTERED"]
["Service ID: Hover over the \"i\" in the title bar on the service screen.",null,null,null,null,null,null,"Service ID","Service Start Date ","Service Start Time ","Program Name \n(as listed in SmartCare) ","Clinician Last \n& First Name","Attending Clinician Last & First Name \n (if applicable) ","Primary Proc. Code","Duration Type Units/Mins/Days","Total Duration","Location","Mode of Delivery ","Add-On Proc. Code (if Applicable)","Add-On Proc. Code Duration Type Units/Mins/Days","Add-On Proc. Total Duration","Primary Billing Diagnosis Code"]
["Service Start Date: Enter the date the service(s) was rendered. (MM/DD/YYYY)",null,null,null,null,null,null,null,"MM/DD/YYYY","12:00am",null,null,null,null,"Units",null,1,"Other",null,"Units"]
["Service Start Time: Enter the start time service(s) was rendered. "]
["Program Name (as listed in SmartCare): Enter complete name as shown in SmartCare. "]
["Clinician Last Name & First Name"]
["Attending Clinician Last Name & First Name (if applicable) "]
["Primary Procedure Code: Use code for main service performed."]
["Duration Type Units/Mins/Days: Select from Units/Minutes/Days."]
["Total Duration: Should be numeric (e.g. 1 Units/45 mins/7 Days)."]
["Location: Choose from dropdown list. Refer to Location Code Key. "]
["Mode of delivery: Choose from Other/Telephone/Video Conference. "]
["Add-On Proc. Code: Found on Add-On Codes Tab (if Applicable)."]
["Add-On Proc. Code Duration Type: Choose Units/Mins/Days."]
["Add-On Proc. Total Duration: Should be numeric (e.g. 1 Units/45 mins/7 Days)."]
["Billing Diagnosis Code: Use #1 billing diagnosis code (e.g. ICD/DSM Code: Z55.9)."]
[]
[]
[]
["DUPLICATE SERVICE ID INFORMATION"]
[]
["Duplicate Services ID: This should be the Service ID from the service that you want billed. You must go into that service and hover over the \"i\" in the title bar.",null,null,null,null,null,null,"Duplicate Service ID"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["Comments =  If appropriate reason code is not listed, use reason code 11 and provide a detailed description in the comments column.",null,null,null,null,null,null,"Comments"]
[]
["Provider Name: Your legal entity name as listed with the state."]
["Date = Date submitted."]
["Prepared by = Person preparing CCF.                     Phone # = Preparer's Phone Number "]
["Contact name = Person to contact for questions.     Phone # = Contact Phone Number"]
["Contact Email = Contact person's email address."]
["Authorized Approver : Signature and printed name of person who is authorized to approve CCF. This will be verified with the most current Signature Authorization Form on file."]
[]
["DO NOT:"]
["* Combine services from different fiscal years."]
["* Re-submit corrections previously submitted, unless asked to do so by the CCF Coordinator"]
["* Use this CCF form in place of completing any Denial Correction Report's (DCR) sent to you."]
[]
["CCF Forms Submitted Via Secure Email Will Only Be Accepted In Excel Format"]
["** If the CCF form is not completed correctly, it will be returned for correction.  Once corrections have been made re-submit the form. **"]

{"sheet":"CCF Form","index":1,"n_rows":38,"n_cols":22,"rows_kept":38,"cut":false,"hidden":false,"merged":[[3,2,3,4],[37,0,37,16],[3,6,3,19]]}
[]
[]
[]
[null,null,null,null,null,null,"ORIGINAL SERVICE ENTERED"]
["Line #","Service Program Type (MHS/SUD)","Client Last Name & First Name","Client SmartCare ID #","Claim Correction Reason","Service ID","Service Start Date ","Service Start Time ","Program Name \n(as listed in SmartCare) ","Clinician Last \n& First Name","Attending Clinician Last & First Name \n (if applicable) ","Primary Proc. Code","Duration Type Units/Mins/Days","Total Duration","Location","Mode of Delivery ","Add-On Proc. Code (if Applicable)","Add-On Proc. Code Duration Type Units/Mins/Days","Add-On Proc. Total Duration","Primary Billing Diagnosis Code(s)","Duplicate Service ID","Comments"]
["ex.","MHS","Doe, John","099999999","1",null,"MM/DD/YYYY","12:00am",null,null,null,null,"Units",null,1,"Other",null,"Units"]
[1]
[2]
[3]
[4]
[5]
[6]
[7]
[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15]
[]
[]
["Provider Name : _________________________________"]
["Date : ________________"]
["Prepared by : _______________________________",null,null,null,null,null,null,null,"Phone # : _______________________"]
["Contact Name : _____________________________",null,null,null,null,null,null,null,"Phone # : _______________________"]
["Contact Email : _____________________________"]
["Authorized Approver : __________________________________          _________________________________"]
[null,null,null,null,"(Signature)",null,null,null,"(Print Name)"]
[]
[]
["created : 1/01/2026"]
["modified : 01/2026 v1.0"]
[]
[]
[]
["Confidential Notice : This electronic mail transmission may contain privileged and/or confidential information only for use by the intended recipients.  Any usage, distribution, copying or disclosure by any other person, other than the intended recipient(s), is strictly prohibited and may be subjected to civil action and/or criminal penalties.  If you received this transmission in error, please notify the sender by reply e-mail or by telephone and delete the transmission."]

{"sheet":"Location List","index":2,"n_rows":40,"n_cols":2,"rows_kept":40,"cut":false,"hidden":true,"merged":[]}
["LocationCode"]
[1,"Age-Specific Community Center"]
[2,"Comm Mental Health Center"]
[3,"Court"]
[4,"Crisis Field"]
[5,"Crisis Mobile Unit-Service"]
[6,"Emergency Room (Hospital)"]
[7,"Faith Based,Field"]
[8,"FQHC,Group/Board and Care Home"]
[9,"Group/Board and Care Home"]
[10,"Health/Primary Care"]
[11,"Homeless/ER Shelter"]
[12,"Inpatient (Non-Psych) Hosp"]
[13,"IP Hosp Psychiatric"]
[14,"Location Unknown/Other"]
[15,"MH Psych Residnl Tx Cntr-Adult"]
[16,"MH Psych Residnl Tx Cntr-Child"]
[17,"NonTraditnl Serv LOC"]
[18,"Office (Primary)"]
[19,"Office (Satellite)"]
[20,"Other Community Loc"]
[21,"Patient's Home"]
[22,"Patient's Work Site"]
[23,"Phone (Patient in home)"]
[24,"Phone (Patient not home)"]
[25,"Prison/Correctional Facility"]
[26,"Psych Fac - IMD"]
[27,"MHRC Hosp"]
[28,"Psych Fac-Partial Hosp (PHF)"]
[29,"Public Health Clinic"]
[30,"School"]
[31,"Skilled Nursing Facility"]
[32,"SUD Non-Residnl Opioid Tx Fac"]
[33,"SUD Outpt Substance Abuse Fac"]
[34,"SUD Psych Residnl Tx Cntr"]
[35,"SUD Residnl Substance Fac"]
[36,"Telehealth (Patient in home)"]
[37,"Telehealth (Patient not  home)"]
[38,"Temporary Lodging"]
[39,"Urgent Care Facility"]

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{"sheet":"Data Validation","index":4,"n_rows":38,"n_cols":5,"rows_kept":38,"cut":false,"hidden":true,"merged":[]}
["Reason \nCode ","Pregnancy \nIndicator","Emergency Indicator (if Applicable) ","Mode \nof Delivery ","Location "]
[null,"Y","Y","Other ","Age-Specific Community Center "]
["DUPLICATE SERVICE","N",null,"Telephone","Comm Mental Health Center "]
["INCORRECT PROCEDURE CODE",null,null,"Video Conference ","Court "]
["INCORRECT DATE OF SERVICE",null,null,null,"Crisis Field"]
["INCORRECT UNIT/TIME",null,null,null,"Crisis Mobile Unit-Service "]
["INCORRECT CLIENT",null,null,null,"Emergency Room (Hospital) "]
["INCORRECT STAFF #",null,null,null,"Faith Based "]
["SERVICE NEVER RENDERED ",null,null,null,"Field"]
["CLIENT NOT ELIGIBLE",null,null,null,"FQHC"]
["NO MEDICAL NECESSITY",null,null,null,"Group/Board and Care Home "]
["DOCUMENTATION ISSUE - (No active plan/Missing progress note)",null,null,null,"Health/Primary Care "]
["ATTENDING CLINICIAN MISSING ",null,null,null,"Homeless / ER Shelter "]
["OTHER (Comments required)",null,null,null,"Inpatient (Non-Psych) Hosp"]
[null,null,null,null,"IP Hosp Psychiatric "]
[null,null,null,null,"Location Unknown/Other"]
[null,null,null,null,"MH Psych Residnl Tx Cntr-Adult"]
[null,null,null,null,"MH Psych Residnl Tx Cntr-Child "]
[null,null,null,null,"NonTraditnal Serv LOC"]
[null,null,null,null,"Office (Primary) "]
[null,null,null,null,"Office (Satellite) "]
[null,null,null,null,"Other Community Loc "]
[null,null,null,null,"Patient's Work Site "]
[null,null,null,null,"Phone (Patient in Home)"]
[null,null,null,null,"Phone (Patient not home) "]
[null,null,null,null,"Psych Fac IMD, MHRC Hosp"]
[null,null,null,null,"Psych Fac-Partial Hosp (PHF)"]
[null,null,null,null,"Public Health Clinic "]
[null,null,null,null,"School"]
[null,null,null,null,"Skilled Nursing Facility "]
[null,null,null,null,"SUD Non-Residnl Opioid Tx Fac"]
[null,null,null,null,"SUD Outpt Substance Abuse Fac"]
[null,null,null,null,"SUD Psych Residnl Tx Cntr"]
[null,null,null,null,"SUD Residnl Substance Fac"]
[null,null,null,null,"Telehealth (Patient in Home) "]
[null,null,null,null,"Telehealth (Patient not Home) "]
[null,null,null,null,"Temporary Lodging"]
[null,null,null,null,"Urgent Care Facility"]