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["(delete this text) *PRINT ON LGA LETTER HEAD* (delete this text)"]
["COUNTY BASED MEDI-CAL ADMINISTRATIVE ACTIVITIES (CMAA) - SUMMARY INVOICE"]
[]
["Local Governmental Agency:",null,null,"ABC County",null,null,null,"Program/Department:",null,"Public Health"]
[]
["Contract Number:",null,null,"14-85697",null,null,null,"Claiming Unit:",null,"Outreach Program"]
[]
["Period of Service:",null,null,"07/01/2016 - 09/30/2016",null,null,null,"Invoice Number:",null,"16/17-1"]
[]
["COST CATEGORIES",null,null,null,null,{"$f":"IF(ISNUMBER(SEARCH(\"R\",J8)), \"Original Inv. Amt.\", \" \")","v":" "},null,null,null,{"$f":"IF(ISNUMBER(FIND(\"R\",J8)), \"Revised Inv. Amt.\", \" \")","v":" "}]
[null,"Total Amount to be Reimbursed at 50%",null,null,null,null,null,{"$f":"'Invoice - Claim Calculation'!E74","v":40561.761086405342},null,{"$f":"IF(F11>=1,F11-H11,\" \")","v":" "}]
[]
[null,"Total Amount to be Reimbursed at 75%",null,null,null,null,null,{"$f":"'Invoice - Claim Calculation'!F74","v":7697.7045953759944},null,{"$f":"IF(F13>=1, F13-H13, \" \")","v":" "}]
[]
[null,"Total amount of Fed. Govt. Reimbursement",null,null,null,null,null,{"$f":"'Invoice - Claim Calculation'!D74","v":48259.465681781337},null,{"$f":"IF(F15>=1, F15-H15, \" \")","v":" "},{"$f":"IF(J15<=-1,\"Due to the State\",\" \")","v":" "}]
[null,null,null,null,null,null,{"$f":"IF('Invoice - Claim Calculation'!B74=\"NON-COMPLIANT\", \"CPE RESTRICTED\", \" \")","v":" "}]
["I HEREBY CERTIFY under penalty of perjury that:\n\n1) I am the official responsible for the administration, examination, and settlement of accounts concerning Medicaid Administrative Activities for the above-named agency and am authorized to make this certification on behalf of the agency.\n\n2) To the best of my knowledge and belief each expenditure is in all respects true, correct, and in accordance with state and federal law, and regulation, including Section 1903(a) of the Social Security Act and 42 C.F.R. Section 433.51.\n\n3) The expenditures certified are based on actual, total expenditures of public funds that have been made to eligible Medicaid beneficiaries pursuant to all applicable requirements of federal law and regulation.\n\n4) The expenditures certified are allowable Medicaid costs in accordance with all applicable requirements of federal law and regulation.\n\n5) The expenditures certified have not previously been, nor will they be, certified at any other time to receive federal financial participation under Medicaid or any other program (unless being resubmitted under correction or revision).\n\n6) The costs certified in this invoice have not been paid in an all-inclusive or capitation rate.\n\nI understand that the State of California must deny payment of any invoice submitted if it determines the certification is not adequately supported for purposes of claiming federal financial participation.  I have notice that this information is to be used for filing of a claim with the federal government for federal financial participation and that a knowing misrepresentation constitutes a violation of the federal and state False Claims Acts."]
["Jim Morrison"]
["Printed Name of Signer",null,null,null,null,null,null,null,"Signature"]
["LGA MAA/TCM Coordinator"]
["Title",null,null,null,null,null,null,null,"Date"]
["For DHCS Program use only"]
["I hereby certify to the best of my knowledge and belief that the claims submitted and attached herein, are claims for the Medicaid program under Title XIX of the Social Security Act (the Act), and as applicable, under the State Children's Health Insurance Program (SCHIP) under Title XXI of the Act, and are allowable in accordance with applicable implementing federal, state, and local statutes, regulations, policies, and the state plan (including any approved waivers of the state plan) approved by the Secretary and in effect at the corresponding time commensurate with the claims aforementioned and furthermore, I certify that federal matching funds are not being claimed for any expenditure under any Medicaid and/or SCHIP state plan amendment that was submitted after January 2, 2001, and that has not been approved by the Secretary effective for the applicable quarter associated with the claims aforementioned.  Further, I direct the Accounting section to process the attached claims for payment certifying to the best of my knowledge and belief that the payee has met the contractual conditions for such payment(s) and the following Accounting codes are appropriate for such payment(s).  This invoice has been checked against our records and found to be the original one presented for payment and has not previously been paid.  We have recorded this payment so as to prevent a later duplicate payment."]
[null,null,null,null,null,null,null,null,null,"SSM I"]
["Signature",null,null,null,null,null,null,"Date",null,"Title",null,"Analyst Initials"]
[]
["CALSTARS CODE:",null,null,null,"-95918-9912-702-42-60 LGA"]
[null,null,null,"FY",null,null,null,null,null,null,null,"Rev. 12/8/14 DHCS/SNFD"]

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["Local Governmental Agency:",null,{"$f":"'Invoice - Summary Page'!D4","v":"ABC County"},null,null,null,null,"Program/Department:",null,{"$f":"'Invoice - Summary Page'!J4","v":"Public Health"}]
["Contract Number:",null,{"$f":"'Invoice - Summary Page'!D6","v":"14-85697"},null,null,null,null,"Claiming Unit:",null,{"$f":"'Invoice - Summary Page'!J6","v":"Outreach Program"}]
["Period of Service:",null,{"$f":"'Invoice - Summary Page'!D8","v":"07/01/2016 - 09/30/2016"},null,null,null,null,"Invoice Number:",null,{"$f":"'Invoice - Summary Page'!J8","v":"16/17-1"}]
[]
["Code","Description",null,null,null,null,null,"SPMP\n Total Hours","SPMP\nActivity %","Non-SPMP\nTotal Hours","Non-SPMP\nActivity %","Medi-Cal %","Method\nUsed"]
[1,"Other Programs/Activities",null,null,null,null,null,248.5,{"$f":"IF(H38=0,0,H6/H38)","v":0.23694874851013112},76.75,{"$f":"IF(J38=0,0,J6/J38)","v":4.0052185257664713E-2}]
[2,"Direct Patient Care",null,null,null,null,null,null,{"$f":"IF(H38=0,0,H7/H38)","v":0},null,{"$f":"IF(J38=0,0,J7/J38)","v":0}]
[3,"Outreach to Non Medi-Cal Programs",null,null,null,null,null,null,{"$f":"IF(H38=0,0,H8/H38)","v":0},null,{"$f":"IF(J38=0,0,J8/J38)","v":0}]
[4,"Medi-Cal Outreach ",null,null,null,null,null,86.5,{"$f":"IF(H38=0,0,H9/H38)","v":8.247914183551848E-2},null,{"$f":"IF(J38=0,0,J9/J38)","v":0},1]
[5,"Referral, Coordination, and Monitoring of Non Medi-Cal Services",null,null,null,null,null,null,{"$f":"IF(H38=0,0,H10/H38)","v":0},null,{"$f":"IF(J38=0,0,J10/J38)","v":0}]
[6,"Referral, Coordination, and Monitoring of Medi-Cal Services",null,null,null,null,null,185.5,{"$f":"IF(H38=0,0,H11/H38)","v":0.17687723480333731},35.75,{"$f":"IF(J38=0,0,J11/J38)","v":1.8656229615133725E-2},0.42749999999999999,"ACC"]
[7,"Facilitating Non Med-Cal Application",null,null,null,null,null,null,{"$f":"IF(H38=0,0,H12/H38)","v":0},null,{"$f":"IF(J38=0,0,J12/J38)","v":0}]
[8,"Facilitating Med-Cal Application",null,null,null,null,null,null,{"$f":"IF(H38=0,0,H13/H38)","v":0},null,{"$f":"IF(J38=0,0,J13/J38)","v":0},1]
[9,"Arranging and/or Providing Non-Emergency, Non-Medical Transportation to a Non Medi-Cal Covered Service",null,null,null,null,null,null,{"$f":"IF(H38=0,0,H14/H38)","v":0},null,{"$f":"IF(J38=0,0,J14/J38)","v":0}]
[10,"Arranging and/or Providing Non-Emergency, Non-Medical Transportation to a Medi-Cal Covered Service",null,null,null,null,null,null,{"$f":"IF(H38=0,0,H15/H38)","v":0},null,{"$f":"IF(J38=0,0,J15/J38)","v":0},null,"ACC"]
[11,"Contract Administration for Non Medi-Cal Covered Services",null,null,null,null,null,null,{"$f":"IF(H38=0,0,H16/H38)","v":0},25.5,{"$f":"IF(J38=0,0,J16/J38)","v":1.3307240704500978E-2}]
[12,"Contract Administration (A) for Medi-Cal Services specific for Medi-Cal populations",null,null,null,null,null,null,{"$f":"IF(H38=0,0,H17/H38)","v":0},null,{"$f":"IF(J38=0,0,J17/J38)","v":0},1]
[13,"Contract Administration (B) for Medi-Cal Services specific for Medi-Cal and Non Medi-Cal populations",null,null,null,null,null,null,{"$f":"IF(H38=0,0,H18/H38)","v":0},58.75,{"$f":"IF(J38=0,0,J18/J38)","v":3.0658838878016959E-2},0.42749999999999999,"ACC"]
[14,"Program Planning & Policy Development for Non Medi-Cal Services",null,null,null,null,null,null,{"$f":"IF(H38=0,0,H19/H38)","v":0},68.25,{"$f":"IF(J38=0,0,J19/J38)","v":3.5616438356164383E-2}]
[15,"Program Planning & Policy Development (A) (Non-enhanced) for Medi-Cal Services for Medi-Cal clients",null,null,null,null,null,null,{"$f":"IF(H38=0,0,H20/H38)","v":0},null,{"$f":"IF(J38=0,0,J20/J38)","v":0},1]
[16,"Program Planning & Policy Development Skilled Professional Medical Personnel (SPMP) (A) (Enhanced) for Medi-Cal Services for Medi-Cal clients",null,null,null,null,null,null,{"$f":"IF(H38=0,0,H21/H38)","v":0},null,null,1]
[17,"Program Planning & Policy Development (B) (Non-enhanced) for Medi-Cal Services for Medi-Cal and Non Medi-Cal clients",null,null,null,null,null,16.5,{"$f":"IF(H38=0,0,H22/H38)","v":1.5733015494636474E-2},60.5,{"$f":"IF(J38=0,0,J22/J38)","v":3.1572080887149377E-2},0.42749999999999999,"ACC"]
[18,"Program Planning & Policy Development (SPMP) (B) (Enhanced) for Medi-Cal Services for Medi-Cal and Non Medi-Cal clients",null,null,null,null,null,185.75,{"$f":"IF(H38=0,0,H23/H38)","v":0.17711561382598331},null,null,0.42749999999999999,"ACC"]
[19,"MAA/TCM Coordination and Claims Administration",null,null,null,null,null,null,{"$f":"IF(H38=0,0,H24/H38)","v":0},32.75,{"$f":"IF(J38=0,0,J24/J38)","v":1.7090671885192431E-2},1]
[20,"MAA/TCM Implementation Training",null,null,null,null,null,15.5,{"$f":"IF(H38=0,0,H25/H38)","v":1.4779499404052444E-2},9.25,{"$f":"IF(J38=0,0,J25/J38)","v":4.8271363339856491E-3},1]
[21,"General Administration",null,null,null,null,null,174.75,{"$f":"IF(H38=0,0,H26/H38)","v":0.16662693682955901},955,{"$f":"IF(J38=0,0,J26/J38)","v":0.49836921069797779}]
[22,"Paid Time Off (PTO)",null,null,null,null,null,135.75,{"$f":"IF(H38=0,0,H27/H38)","v":0.12943980929678189},593.75,{"$f":"IF(J38=0,0,J27/J38)","v":0.30984996738421394}]
[23,"Non-Targeted Case Management (TCM)",null,null,null,null,null,null,{"$f":"IF(H38=0,0,H28/H38)","v":0},null,{"$f":"IF(J38=0,0,J28/J38)","v":0}]
[24,"Providing TCM Service Components",null,null,null,null,null,null,{"$f":"IF(H38=0,0,H29/H38)","v":0},null,{"$f":"IF(J38=0,0,J29/J38)","v":0}]
[25,"TCM Encounter - Related Activities",null,null,null,null,null,null,{"$f":"IF(H38=0,0,H30/H38)","v":0},null,{"$f":"IF(J38=0,0,J30/J38)","v":0}]
[26,"Travel Related to Providing TCM",null,null,null,null,null,null,{"$f":"IF(H38=0,0,H31/H38)","v":0},null,{"$f":"IF(J38=0,0,J31/J38)","v":0}]
[27,"Supervision of Case Managers",null,null,null,null,null,null,{"$f":"IF(H38=0,0,H32/H38)","v":0},null,{"$f":"IF(J38=0,0,J32/J38)","v":0}]
[28,"Encounter Entry into TCM On-Line System",null,null,null,null,null,null,{"$f":"IF(H38=0,0,H33/H38)","v":0},null,{"$f":"IF(J38=0,0,J33/J38)","v":0}]
[29,"TCM Data Systems and Claiming Coordination",null,null,null,null,null,null,{"$f":"IF(H38=0,0,H34/H38)","v":0},null,{"$f":"IF(J38=0,0,J34/J38)","v":0}]
[30,"TCM Quality Assurance/Performance Monitoring",null,null,null,null,null,null,{"$f":"IF(H38=0,0,H35/H38)","v":0},null,{"$f":"IF(J38=0,0,J35/J38)","v":0}]
[31,"TCM Subcontract Administration",null,null,null,null,null,null,{"$f":"IF(H38=0,0,H36/H38)","v":0},null,{"$f":"IF(J38=0,0,J36/J38)","v":0}]
[32,"TCM Program Planning & Policy Development",null,null,null,null,null,null,{"$f":"IF(H38=0,0,H37/H38)","v":0},null,{"$f":"IF(J38=0,0,J37/J38)","v":0}]
["TOTALS",null,null,null,null,null,null,{"$f":"SUM(H6:H37)","v":1048.75},{"$f":"SUM(I6:I37)","v":1},{"$f":"SUM(J6:J37)","v":1916.25},{"$f":"SUM(K6:K37)","v":1}]
["Total Claimable Portion",null,null,null,null,null,null,{"$f":"SUM(H9,H11,H13,H15,H17:H18,H20:H27)","v":800.25},{"$f":"SUM(I9,I11,I13,I15,I17:I18,I20:I27)","v":0.76305125148986885},{"$f":"SUM(J9,J11,J13,J15,J17:J18,J20:J27)","v":1745.75},{"$f":"SUM(K9,K11,K13,K15,K17:K18,K20:K27)","v":0.91102413568166996}]
["Total Non-Claimable Portion",null,null,null,null,null,null,{"$f":"SUM(H6:H8,H10,H12,H14,H16,H19,H28:H37)","v":248.5},{"$f":"SUM(I6:I8,I10,I12,I14,I16,I19,I28:I37)","v":0.23694874851013112},{"$f":"SUM(J6:J8,J10,J12,J14,J16,J19,J28:J37)","v":170.5},{"$f":"SUM(K6:K8,K10,K12,K14,K16,K19,K28:K37)","v":8.8975864318330072E-2}]
[]
["Time Survey Frequency Used to Determine the Activity Percentages:"]
[]
["Claiming unit certification:\nI certify under penalty of perjury that the time survey participants within this claiming unit are not instructed to perform any additional MAA related activities (other than those related to the actual recording of time on the time survey form) during the time survey period and that the time recorded by the participants reflects only those activities that would be performed during the normal course of an average work day.  Based on my knowledge of the activities normally performed by the time survey participants within this claiming unit, I believe that the summary time survey results are a reasonable proxy, or in the case of the perpetual time survey – actual results, of the time spent during the entire period of service and result in allowable costs consistent with the requirements of OMB Circular A-87."]
["Kimberly Dahl",null,null,null,"Chief of Administration",null,null,null,null,null,"Date"]
["Printed Name of Claiming Unit Reviewer",null,null,null,"Classification/Title",null,"Signature",null,null,null,"Date"]
[]
["LGA certification:\nI hereby certify to the best of my knowledge and belief that the information contained herein accurately describes the MAA activities performed during the time survey period and the time survey results are reflective of MAA activities performed during the entire period of service.  I concur with the claiming unit’s assessment that the summary time survey results are a reasonable proxy, or in the case of the perpetual time survey – actual results, of the claiming unit’s activities for the entire period of service and result in allowable costs consistent with the requirements of OMB Circular A-87."]
["Dion Andres",null,null,null,"LGA MAA/TCM Coordinator",null,null,null,null,null,"Date"]
["Printed Name of LGA Reviewer",null,null,null,"Classification/Title",null,"Signature",null,null,null,"Date"]
[]
["DHCS certification:\nI hereby certify to the best of my knowledge and belief that the information contained herein accurately describes the MAA activities performed by the time survey participants of the named claiming unit.  I concur with the claiming unit’s assessment that the summary time survey results are a reasonable proxy, or in the case of the perpetual time survey – actual results, of the claiming unit’s activities for the entire period of service and result in allowable costs consistent with the requirements of OMB Circular A-87.  I have evaluated the actual activities performed, the positions of the staff performing the activities, and the amount of time spent in the performance of the activities and believe they are necessary for the proper and efficient administration of the Medi-Cal Program."]
[]
["Printed Name of DHCS Reviewer",null,null,null,"Classification/Title",null,"Signature",null,null,null,"Date"]
[null,null,null,null,null,null,null,null,null,{"$f":"'Invoice - Summary Page'!L28","v":"Rev. 12/8/14 DHCS/SNFD"}]

{"sheet":"Invoice - Revenue Worksheet","index":2,"n_rows":46,"n_cols":10,"rows_kept":46,"cut":false,"hidden":false,"merged":[[5,0,5,1],[6,0,6,1],[7,0,7,1],[8,0,8,1],[10,0,10,1],[9,0,9,1],[0,5,0,6],[1,5,1,6],[2,5,2,6],[0,7,0,9],[1,7,1,9],[2,7,2,9],[11,0,11,1],[12,0,12,1],[13,0,13,1],[14,0,14,1],[15,0,15,1],[16,0,16,1],[18,0,18,1],[17,0,17,1],[19,0,19,1],[20,0,20,1],[22,0,22,1],[34,0,34,1],[23,0,23,1],[24,0,24,1],[25,0,25,1],[26,0,26,1],[27,0,27,1],[28,0,28,1],[29,0,29,1],[30,0,30,1],[31,0,31,1],[32,0,32,1],[33,0,33,1],[42,6,43,9],[3,0,4,1],[3,2,4,2],[42,0,43,1],[44,0,44,1],[44,3,44,4],[42,3,43,4],[44,6,44,9],[41,0,41,9],[35,0,35,1],[36,0,36,1],[37,0,37,1],[38,0,38,1],[39,0,39,1],[40,0,40,1],[21,0,21,1]]}
["Local Governmental Agency:",{"$f":"'Invoice - Summary Page'!$D$4","v":"ABC County"},null,null,null,"Program:",null,{"$f":"'Invoice - Summary Page'!$J$4","v":"Public Health"}]
["Contract Number:",{"$f":"'Invoice - Summary Page'!$D$6","v":"14-85697"},null,null,null,"Claiming Unit:",null,{"$f":"'Invoice - Summary Page'!$J$6","v":"Outreach Program"}]
["Period of Service:",{"$f":"'Invoice - Summary Page'!$D$8","v":"07/01/2016 - 09/30/2016"},null,null,null,"Invoice #:",null,{"$f":"'Invoice - Summary Page'!$J$8","v":"16/17-1"}]
["SOURCE and DESCRIPTION",null,"Non Offset Funds","CP#1","CP#2","CP#3 (a & b)","CP#4","CP#5","CP#6","TOTAL"]
[null,null,null,"SPMP","Non-SPMP","Non-Claimable","Direct-Enhanced","Direct-Non-Enhanced","Allocated","(CPs 1 - 6)"]
["Medi-Cal Fees + Match"]
["MediCal reimbursement fees",null,null,null,null,50000,null,null,null,{"$f":"SUM(F7:I7)","v":50000}]
["Title XIX MAA Revenue",null,58350,null,null,null,null,null,null,{"$f":"SUM(F8:I8)","v":0}]
["Medi-Cal Reimbursement (% of Exp) Directly Observed Therapy",null,null,null,null,null,null,null,null,{"$f":"SUM(F9:I9)","v":0}]
["              Total Medi-Cal Fees + Match",null,{"$f":"SUM(C7:C9)","v":58350},null,null,{"$f":"SUM(F7:F9)","v":50000},{"$f":"SUM(G7:G9)","v":0},{"$f":"SUM(H7:H9)","v":0},{"$f":"SUM(I7:I9)","v":0},{"$f":"SUM(F10:I10)","v":50000}]
["Federal Grants + Match",null,null,null,null,null,null,null,null," "]
["Federal Outreach Grant",null,null,15000,null,null,null,null,null,{"$f":"SUM(D12:I12)","v":15000}]
["Local Required Match",null,null,7500,null,null,null,null,null,{"$f":"SUM(D13:I13)","v":7500}]
["Other Revenue",null,null,null,null,null,null,null,null,{"$f":"SUM(D14:I14)","v":0}]
["              Total Federal Grants + Match",null,{"$f":"SUM(C12:C14)","v":0},{"$f":"SUM(D12:D14)","v":22500},0,0,0,0,0,{"$f":"SUM(D15:I15)","v":22500}]
["State General Fund",null,null,null," ",null,null,null,null," "]
["State - Other (% of Exp) - Grant",null,null,null,null,null,null,null,null,{"$f":"SUM(D17:I17)","v":0}]
["SOURCE and DESCRIPTION",null,null,null,null,null,null,null,null,{"$f":"SUM(D18:I18)","v":0}]
[null,null,null,null,null,null,null,null,null,{"$f":"SUM(D19:I19)","v":0}]
["              Total State General Fund",null,{"$f":"SUM(C17:C19)","v":0},{"$f":"SUM(D17:D19)","v":0},0,0,0,0,0,{"$f":"SUM(D20:I20)","v":0}]
["Medicare",null,null," ",null,null,null," "," "]
["SOURCE and DESCRIPTION",null,null,null,null,null,null,null,null,{"$f":"SUM(F22:I22)","v":0}]
["SOURCE and DESCRIPTION",null,null,null,null,null,null,null,null,{"$f":"SUM(F23:I23)","v":0}]
["SOURCE and DESCRIPTION",null,null,null,null,null,null,null,null,{"$f":"SUM(F24:I24)","v":0}]
["              Total Medicare ",null,{"$f":"SUM(C22:C24)","v":0},null,null,{"$f":"SUM(F22:F24)","v":0},{"$f":"SUM(G22:G24)","v":0},{"$f":"SUM(H22:H24)","v":0},{"$f":"SUM(I22:I24)","v":0},{"$f":"SUM(F25:I25)","v":0}]
["Insurance"]
["SOURCE and DESCRIPTION",null,null,null,null,null,null,null,null,{"$f":"SUM(F27:I27)","v":0}]
["SOURCE and DESCRIPTION",null,null,null,null,null,null,null,null,{"$f":"SUM(F28:I28)","v":0}]
["SOURCE and DESCRIPTION",null,null,null,null,null,null,null,null,{"$f":"SUM(F29:I29)","v":0}]
["              Total Insurance ",null,{"$f":"SUM(C27:C29)","v":0},null,null,{"$f":"SUM(F27:F29)","v":0},{"$f":"SUM(G27:G29)","v":0},{"$f":"SUM(H27:H29)","v":0},{"$f":"SUM(I27:I29)","v":0},{"$f":"SUM(F30:I30)","v":0}]
["Fees"]
["Charges for Services (% of Exp)",null,null,null,null,null,null,null,null,{"$f":"SUM(F32:I32)","v":0}]
["SOURCE and DESCRIPTION",null,null,null,null,null,null,null,null,{"$f":"SUM(F33:I33)","v":0}]
["SOURCE and DESCRIPTION",null,null,null,null,null,null,null,null,{"$f":"SUM(F34:I34)","v":0}]
["              Total Fees ",null,{"$f":"SUM(C32:C34)","v":0},null,null,{"$f":"SUM(F32:F34)","v":0},{"$f":"SUM(G32:G34)","v":0},{"$f":"SUM(H32:H34)","v":0},{"$f":"SUM(I32:I34)","v":0},{"$f":"SUM(F35:I35)","v":0}]
["Other Revenue"]
["General Fund Contribution",null,98000,null,null,null,null,null,null,{"$f":"SUM(D37:I37)","v":0}]
[null,null,null,null,null,null,null,null,null,{"$f":"SUM(D38:I38)","v":0}]
[null,null,null,null,null,null,null,null,null,{"$f":"SUM(D39:I39)","v":0}]
["              Total Other Revenue",null,{"$f":"SUM(C37:C39)","v":98000},0,0,0,0,0,0,{"$f":"SUM(D40:I40)","v":0}]
["TOTALS:",null,{"$f":"ROUNDUP((C10+C15+C20+C25+C30+C35+C40),0)","v":156350},22500,0,50000,0,0,0,{"$f":"SUM(D41:I41)","v":72500}]
["I certify that the revenue sources identified above represent accurate identifiable costs for the program/claiming entity and that the revenue sources have been properly identified and allocated.  I declare under penalty of perjury that the foregoing is true and correct to the best of my knowledge, information, and belief, and that I have notice that this information is to be used for filing a claim with the Federal Government for federal funds, and the knowing misrepresentation constitutes violation of the Federal False Claims Act."]
[null,null,null,null,null,null,"Jim Morrison"]
[]
["Signature",null,null,"Date",null,null,"Printed Name of Signer"]
[null,null,null,null,null,null,null,null,null,{"$f":"'Invoice - Summary Page'!L28","v":"Rev. 12/8/14 DHCS/SNFD"}]

{"sheet":"Invoice - Cost Worksheet","index":3,"n_rows":42,"n_cols":8,"rows_kept":42,"cut":false,"hidden":false,"merged":[[22,0,22,1],[23,0,23,1],[25,0,25,1],[37,0,37,1],[26,0,26,1],[27,0,27,1],[28,0,28,1],[29,0,29,1],[36,0,36,1],[30,0,30,1],[12,0,12,1],[38,0,38,7],[40,0,40,1],[39,0,39,1],[39,6,39,7],[40,6,40,7],[24,0,24,1],[13,0,13,1],[14,0,14,1],[15,0,15,1],[16,0,16,1],[17,0,17,1],[18,0,18,1],[19,0,19,1],[20,0,20,1],[21,0,21,1],[0,6,0,7],[1,6,1,7],[2,6,2,7],[3,0,5,1],[11,0,11,6],[6,0,6,6],[7,0,7,1],[8,0,8,1],[9,0,9,1],[10,0,10,1]]}
["Local Governmental Agency:",{"$f":"'Invoice - Summary Page'!D4","v":"ABC County"},null,null,null,"Program:",{"$f":"'Invoice - Summary Page'!J4","v":"Public Health"}]
["Contract Number:",{"$f":"'Invoice - Summary Page'!D6","v":"14-85697"},null,null,null,"Claiming Unit:",{"$f":"'Invoice - Summary Page'!J6","v":"Outreach Program"}]
["Period of Service:",{"$f":"'Invoice - Summary Page'!D8","v":"07/01/2016 - 09/30/2016"},null,null,null,"Invoice #:",{"$f":"'Invoice - Summary Page'!J8","v":"16/17-1"}]
["SELECTED ITEMS OF COST",null,"Cost Pool #1","Cost Pool #2","Cost Pool #3a","Cost Pool #5","Cost Pool #6"]
[null,null,"SPMP","Non-SPMP","Non-Claimable","Non-SPMP Dir. Charge","Allocated/Support"]
[null,null,"Costs","Costs","Costs","Other Costs","Costs"]
["SALARY COSTS",null,null,null,null,null,null,"TOTALS"]
["Wages/Salary:",null,46586.407000000007,35450.51999999999,31033.274999999998,null,51933,{"$f":"SUM(C8:G8)","v":165003.20199999999}]
["Benefits:",null,19965.603000000003,15193.079999999996,13299.975,null,22257,{"$f":"SUM(C9:G9)","v":70715.657999999996}]
["Personal Services Contracts:",null,null,null,null,null,null,{"$f":"SUM(C10:G10)","v":0}]
["TOTAL Compensation for Personal Services:",null,{"$f":"SUM(C8:C10)","v":66552.010000000009},{"$f":"SUM(D8:D10)","v":50643.599999999984},{"$f":"SUM(E8:E10)","v":44333.25},null,{"$f":"SUM(G8:G10)","v":74190},{"$f":"SUM(H8:H10)","v":235718.86}]
["NON-SALARY COSTS",null,null,null,null,null,null,"TOTALS"]
["See attached Other Costs worksheet",null,5294.74,1700,1400,null,48923.643593094988,{"$f":"SUM(C13:G13)","v":57318.383593094986}]
[null,null,null,null,null,null,null,{"$f":"SUM(C14:G14)","v":0}]
[null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,0]
["Direct Charge Other Cost:"]
["Direct Charge Other Cost:"]
["Direct Charge Other Cost:"]
["Direct Charge Other Cost:"]
["Direct Charge Other Cost:"]
["Indirect Costs",null,null,null,null,null,null,{"$f":"SUM(C37:G37)","v":0}]
["TOTAL Non-Salary Costs:",null,{"$f":"SUM(C13:C37)","v":5294.74},{"$f":"SUM(D13:D37)","v":1700},{"$f":"SUM(E13:E37)","v":1400},{"$f":"SUM(F13:F37)","v":0},{"$f":"SUM(G13:G37)","v":48923.643593094988},{"$f":"SUM(C38:G38)","v":57318.383593094986}]
["I certify that the costs identified above represent accurate identifiable costs for the program/claiming entity and that the costs have been properly identified and allocated.  I declare under penalty of perjury that the foregoing is true and correct to the best of my knowledge, information, and belief, and that I have notice that this information is to be used for filing a claim with the Federal Government for federal funds, and the knowing misrepresentation constitutes violation of the Federal False Claims Act."]
[null,null,null,null,null,null,"Jim Morrison"]
["Signature",null,null,"Date",null,null,"Type or Print Name of Signer"]
[null,null,null,null,null,null,null,{"$f":"'Invoice - Summary Page'!L28","v":"Rev. 12/8/14 DHCS/SNFD"}]

{"sheet":"Invoice - Direct Charge Costs","index":4,"n_rows":53,"n_cols":15,"rows_kept":53,"cut":false,"hidden":false,"merged":[[43,0,43,3],[1,8,1,12],[1,1,1,2],[1,6,1,7],[2,1,2,2],[11,0,11,14],[10,0,10,5],[3,0,3,14],[23,0,23,5],[38,0,38,8],[43,9,43,14],[43,5,43,7],[0,1,0,2],[41,0,41,14],[0,6,0,7],[42,9,42,14],[32,0,32,8],[2,8,2,12],[42,5,42,7],[24,0,24,8],[0,8,0,12],[42,0,42,3],[37,0,37,5],[31,0,31,5],[2,6,2,7]]}
[null,"Local Governmental Agency:",null,{"$f":"'Invoice - Summary Page'!$D$4","v":"ABC County"},null,null,"Program:",null,{"$f":"'Invoice - Summary Page'!$J$4","v":"Public Health"}]
[null,"Contract Number:",null,{"$f":"'Invoice - Summary Page'!$D$6","v":"14-85697"},null,null,"Claiming Unit:",null,{"$f":"'Invoice - Summary Page'!$J$6","v":"Outreach Program"}]
[null,"Period of Service:",null,{"$f":"'Invoice - Summary Page'!$D$8","v":"07/01/2016 - 09/30/2016"},null,null,"Invoice #:",null,{"$f":"'Invoice - Summary Page'!$J$8","v":"16/17-1"}]
["ENHANCED (SPMP) MAA STAFF COSTS"]
["Staff Member","Classification","Code","Description","Medi-Cal %","Activity %\nResults","Salary Costs","MAA\nClaimable\nPortion","Non\nClaimable\nPortion","Benefits\nCosts","MAA\nClaimable\nPortion","Non\nClaimable\nPortion","Non-Salary Costs","MAA\nClaimable\nPortion","Non\nClaimable\nPortion"]
[null,null,null,{"$f":"LOOKUP(C6,ECodes,'Enhanced MAA Codes'!B2:B3)","v":{"$error":"#N/A"}},{"$f":"LOOKUP('Invoice - Direct Charge Costs'!C6,NECodes,'Non-Enhanced MAA Codes'!D2:D11)","v":{"$error":"#N/A"}},null,null,{"$f":"IF(C6=0,0,(G6*F6)*E6)","v":0},{"$f":"G6-H6","v":0},null,{"$f":"IF(C6=0,0,(J6*F6)*E6)","v":0},{"$f":"J6-K6","v":0},0,{"$f":"IF(C6=0,0,(M6*F6)*E6)","v":0},{"$f":"M6-N6","v":0}]
[null,null,null,{"$f":"LOOKUP(C7,ECodes,'Enhanced MAA Codes'!B2:B3)","v":{"$error":"#N/A"}},{"$f":"LOOKUP('Invoice - Direct Charge Costs'!C7,NECodes,'Non-Enhanced MAA Codes'!D2:D11)","v":{"$error":"#N/A"}},null,null,{"$f":"IF(C7=0,0,(G7*F7)*E7)","v":0},{"$f":"G7-H7","v":0},null,{"$f":"IF(C7=0,0,(J7*F7)*E7)","v":0},{"$f":"J7-K7","v":0},0,{"$f":"IF(C7=0,0,(M7*F7)*E7)","v":0},{"$f":"M7-N7","v":0}]
[null,null,null,{"$f":"LOOKUP(C8,ECodes,'Enhanced MAA Codes'!B2:B3)","v":{"$error":"#N/A"}},{"$f":"LOOKUP('Invoice - Direct Charge Costs'!C8,NECodes,'Non-Enhanced MAA Codes'!D2:D11)","v":{"$error":"#N/A"}},null,0,{"$f":"IF(C8=0,0,(G8*F8)*E8)","v":0},{"$f":"G8-H8","v":0},0,{"$f":"IF(C8=0,0,(J8*F8)*E8)","v":0},{"$f":"J8-K8","v":0},0,{"$f":"IF(C8=0,0,(M8*F8)*E8)","v":0},{"$f":"M8-N8","v":0}]
[null,null,null,{"$f":"LOOKUP(C9,ECodes,'Enhanced MAA Codes'!B2:B3)","v":{"$error":"#N/A"}},{"$f":"LOOKUP('Invoice - Direct Charge Costs'!C9,NECodes,'Non-Enhanced MAA Codes'!D2:D11)","v":{"$error":"#N/A"}},null,0,{"$f":"IF(C9=0,0,(G9*F9)*E9)","v":0},{"$f":"G9-H9","v":0},0,{"$f":"IF(C9=0,0,(J9*F9)*E9)","v":0},{"$f":"J9-K9","v":0},0,{"$f":"IF(C9=0,0,(M9*F9)*E9)","v":0},{"$f":"M9-N9","v":0}]
[null,null,null,{"$f":"LOOKUP(C10,ECodes,'Enhanced MAA Codes'!B2:B3)","v":{"$error":"#N/A"}},{"$f":"LOOKUP('Invoice - Direct Charge Costs'!C10,NECodes,'Non-Enhanced MAA Codes'!D2:D11)","v":{"$error":"#N/A"}},null,0,{"$f":"IF(C10=0,0,(G10*F10)*E10)","v":0},{"$f":"G10-H10","v":0},0,{"$f":"IF(C10=0,0,(J10*F10)*E10)","v":0},{"$f":"J10-K10","v":0},0,{"$f":"IF(C10=0,0,(M10*F10)*E10)","v":0},{"$f":"M10-N10","v":0}]
["TOTALS",null,null,null,null,null,{"$f":"SUM(G6:G10)","v":0},0,0,0,0,0,0,{"$f":"SUM(N6:N10)","v":0},0]
["NON-ENHANCED MAA STAFF COSTS"]
["Staff Member","Classification","Code","Description","Medi-Cal %","Activity %\nResults","Salary Costs","MAA\nClaimable\nPortion","Non\nClaimable\nPortion","Benefits\nCosts","MAA\nClaimable\nPortion","Non\nClaimable\nPortion","Non-Salary Costs","MAA\nClaimable\nPortion","Non\nClaimable\nPortion"]
["Jim Morrison","MAA/TCM Coordinator",19,{"$f":"LOOKUP('Invoice - Direct Charge Costs'!C14,NECodes,'Non-Enhanced MAA Codes'!B2:B11)","v":"MAA/TCM Coordination and Claims Administration"},{"$f":"LOOKUP('Invoice - Direct Charge Costs'!C14,NECodes,'Non-Enhanced MAA Codes'!D2:D11)","v":1},1,7691.3549999999996,{"$f":"IF(C14=0,0,(G14*F14)*E14)","v":7691.3549999999996},{"$f":"G14-H14","v":0},3296.2949999999996,{"$f":"IF(C14=0,0,(J14*F14)*E14)","v":3296.2949999999996},{"$f":"J14-K14","v":0},{"$f":"4431.30390470088-1000","v":3431.3039047008797},{"$f":"IF(C14=0,0,(M14*F14)*E14)","v":3431.3039047008797},{"$f":"M14-N14","v":0}]
["Stevie Nicks","Accountant",19,{"$f":"LOOKUP('Invoice - Direct Charge Costs'!C15,NECodes,'Non-Enhanced MAA Codes'!B2:B11)","v":"MAA/TCM Coordination and Claims Administration"},{"$f":"LOOKUP('Invoice - Direct Charge Costs'!C15,NECodes,'Non-Enhanced MAA Codes'!D2:D11)","v":1},1,3024.7629999999999,3024.7629999999999,{"$f":"G15-H15","v":0},1296.327,{"$f":"IF(C15=0,0,(J15*F15)*E15)","v":1296.327},{"$f":"J15-K15","v":0},null,{"$f":"IF(C15=0,0,(M15*F15)*E15)","v":0},{"$f":"M15-N15","v":0}]
[null,null,null,{"$f":"LOOKUP('Invoice - Direct Charge Costs'!C16,NECodes,'Non-Enhanced MAA Codes'!B2:B11)","v":{"$error":"#N/A"}},{"$f":"LOOKUP('Invoice - Direct Charge Costs'!C16,NECodes,'Non-Enhanced MAA Codes'!D2:D11)","v":{"$error":"#N/A"}},null,null,0,0,null,0,0,null,{"$f":"IF(C16=0,0,(M16*F16)*E16)","v":0},0]
[null,null,null,{"$f":"LOOKUP('Invoice - Direct Charge Costs'!C17,NECodes,'Non-Enhanced MAA Codes'!B2:B11)","v":{"$error":"#N/A"}},{"$f":"LOOKUP('Invoice - Direct Charge Costs'!C17,NECodes,'Non-Enhanced MAA Codes'!D2:D11)","v":{"$error":"#N/A"}},null,null,0,0,null,0,0,null,0,0]
[null,null,null,{"$f":"LOOKUP('Invoice - Direct Charge Costs'!C18,NECodes,'Non-Enhanced MAA Codes'!B2:B11)","v":{"$error":"#N/A"}},{"$f":"LOOKUP('Invoice - Direct Charge Costs'!C18,NECodes,'Non-Enhanced MAA Codes'!D2:D11)","v":{"$error":"#N/A"}},null,null,0,0,null,0,0,null,0,0]
[null,null,null,{"$f":"LOOKUP('Invoice - Direct Charge Costs'!C19,NECodes,'Non-Enhanced MAA Codes'!B2:B11)","v":{"$error":"#N/A"}},{"$f":"LOOKUP('Invoice - Direct Charge Costs'!C19,NECodes,'Non-Enhanced MAA Codes'!D2:D11)","v":{"$error":"#N/A"}},null,null,0,0,null,0,0,null,0,0]
[null,null,null,{"$f":"LOOKUP('Invoice - Direct Charge Costs'!C20,NECodes,'Non-Enhanced MAA Codes'!B2:B11)","v":{"$error":"#N/A"}},{"$f":"LOOKUP('Invoice - Direct Charge Costs'!C20,NECodes,'Non-Enhanced MAA Codes'!D2:D11)","v":{"$error":"#N/A"}},null,null,0,0,null,0,0,null,0,0]
[null,null,null,{"$f":"LOOKUP('Invoice - Direct Charge Costs'!C21,NECodes,'Non-Enhanced MAA Codes'!B2:B11)","v":{"$error":"#N/A"}},{"$f":"LOOKUP('Invoice - Direct Charge Costs'!C21,NECodes,'Non-Enhanced MAA Codes'!D2:D11)","v":{"$error":"#N/A"}},null,null,0,0,null,0,0,null,0,0]
[null,null,null,{"$f":"LOOKUP('Invoice - Direct Charge Costs'!C22,NECodes,'Non-Enhanced MAA Codes'!B2:B11)","v":{"$error":"#N/A"}},{"$f":"LOOKUP('Invoice - Direct Charge Costs'!C22,NECodes,'Non-Enhanced MAA Codes'!D2:D11)","v":{"$error":"#N/A"}},null,null,0,0,null,0,0,null,0,0]
[null,null,null,{"$f":"LOOKUP('Invoice - Direct Charge Costs'!C23,NECodes,'Non-Enhanced MAA Codes'!B2:B11)","v":{"$error":"#N/A"}},{"$f":"LOOKUP('Invoice - Direct Charge Costs'!C23,NECodes,'Non-Enhanced MAA Codes'!D2:D11)","v":{"$error":"#N/A"}},null,null,0,0,null,0,0,null,0,0]
["TOTALS",null,null,null,null,null,{"$f":"SUM(G14:G23)","v":10716.117999999999},10716.117999999999,0,4592.6219999999994,4592.6219999999994,0,3431.3039047008797,3431.3039047008797,0]
["NON-ENHANCED MAA PERSONAL SERVICES CBO/CONTRACTOR COSTS"]
["CBO/Contractor ","Expense Detail","Code","Description","Medi-Cal %",null,"Pers. Svcs.\nContract\nCosts","MAA\nClaimable\nPortion","Non\nClaimable\nPortion"]
["MAA consultant","MAA Coordination",19,{"$f":"LOOKUP('Invoice - Direct Charge Costs'!C27,NECodes,'Non-Enhanced MAA Codes'!B2:B11)","v":"MAA/TCM Coordination and Claims Administration"},{"$f":"LOOKUP('Invoice - Direct Charge Costs'!C27,NECodes,'Non-Enhanced MAA Codes'!D2:D11)","v":1},null,600,{"$f":"IF(C27=0,0,(G27*E27))","v":600},{"$f":"G27-H27","v":0}]
["TractivityPro","Time Survey database",19,{"$f":"LOOKUP('Invoice - Direct Charge Costs'!C28,NECodes,'Non-Enhanced MAA Codes'!B2:B11)","v":"MAA/TCM Coordination and Claims Administration"},{"$f":"LOOKUP('Invoice - Direct Charge Costs'!C28,NECodes,'Non-Enhanced MAA Codes'!D2:D11)","v":1},null,400,{"$f":"IF(C28=0,0,(G28*E28))","v":400},{"$f":"G28-H28","v":0}]
[null,null,null,{"$f":"LOOKUP('Invoice - Direct Charge Costs'!C29,NECodes,'Non-Enhanced MAA Codes'!B2:B11)","v":{"$error":"#N/A"}},{"$f":"LOOKUP('Invoice - Direct Charge Costs'!C29,NECodes,'Non-Enhanced MAA Codes'!D2:D11)","v":{"$error":"#N/A"}},null,null,{"$f":"IF(C29=0,0,(G29*E29))","v":0},{"$f":"G29-H29","v":0}]
[null,null,null,{"$f":"LOOKUP('Invoice - Direct Charge Costs'!C30,NECodes,'Non-Enhanced MAA Codes'!B2:B11)","v":{"$error":"#N/A"}},{"$f":"LOOKUP('Invoice - Direct Charge Costs'!C30,NECodes,'Non-Enhanced MAA Codes'!D2:D11)","v":{"$error":"#N/A"}},null,null,{"$f":"IF(C30=0,0,(G30*E30))","v":0},{"$f":"G30-H30","v":0}]
[null,null,null,{"$f":"LOOKUP('Invoice - Direct Charge Costs'!C31,NECodes,'Non-Enhanced MAA Codes'!B2:B11)","v":{"$error":"#N/A"}},{"$f":"LOOKUP('Invoice - Direct Charge Costs'!C31,NECodes,'Non-Enhanced MAA Codes'!D2:D11)","v":{"$error":"#N/A"}},null,null,{"$f":"IF(C31=0,0,(G31*E31))","v":0},{"$f":"G31-H31","v":0}]
["TOTALS",null,null,null,null,null,{"$f":"SUM(G27:G31)","v":1000},{"$f":"SUM(H27:H31)","v":1000},{"$f":"SUM(I27:I31)","v":0}]
["NON-ENHANCED MAA TRANSPORTATION COSTS"]
["Contractor ","Expense Detail","Code","Description","Medi-Cal %",null,"MAA Transportation\nCosts","MAA\nClaimable\nPortion","Non\nClaimable\nPortion"]
[null,null,null,{"$f":"LOOKUP('Invoice - Direct Charge Costs'!C35,NECodes,'Non-Enhanced MAA Codes'!B2:B11)","v":{"$error":"#N/A"}},{"$f":"LOOKUP('Invoice - Direct Charge Costs'!C35,NECodes,'Non-Enhanced MAA Codes'!D2:D11)","v":{"$error":"#N/A"}},null,null,{"$f":"IF(C35=0,0,(G35*E35))","v":0},{"$f":"G35-H35","v":0}]
[null,null,null,{"$f":"LOOKUP('Invoice - Direct Charge Costs'!C36,NECodes,'Non-Enhanced MAA Codes'!B2:B11)","v":{"$error":"#N/A"}},{"$f":"LOOKUP('Invoice - Direct Charge Costs'!C36,NECodes,'Non-Enhanced MAA Codes'!D2:D11)","v":{"$error":"#N/A"}},null,null,{"$f":"IF(C36=0,0,(G36*E36))","v":0},{"$f":"G36-H36","v":0}]
[null,null,null,{"$f":"LOOKUP('Invoice - Direct Charge Costs'!C37,NECodes,'Non-Enhanced MAA Codes'!B2:B11)","v":{"$error":"#N/A"}},{"$f":"LOOKUP('Invoice - Direct Charge Costs'!C37,NECodes,'Non-Enhanced MAA Codes'!D2:D11)","v":{"$error":"#N/A"}},null,null,{"$f":"IF(C37=0,0,(G37*E37))","v":0},{"$f":"G37-H37","v":0}]
["TOTALS",null,null,null,null,null,{"$f":"SUM(G35:G37)","v":0},{"$f":"SUM(H35:H37)","v":0},{"$f":"SUM(I35:I37)","v":0}]
["NON-ENHANCED MAA DIRECT CHARGE OTHER COSTS"]
[null,null,null,"Description","Medi-Cal %",null,"MAA Other Costs","MAA\nClaimable\nPortion"]
[null,null,null,"Cost Pool#5 Direct Charge Other Costs Total ",1,null,{"$f":"'Invoice - Cost Worksheet'!F38","v":0},{"$f":"G41","v":0}]
["I certify that the direct charges identified above represent accurate identifiable costs for the program/claiming entity and that the direct charges have been properly identified and allocated.  I declare under penalty of perjury that the foregoing is true and correct to the best of my knowledge, information, and belief, and that I have notice that this information is to be used for filing a claim with the Federal Government for federal funds, and the knowing misrepresentation constitutes violation of the Federal False Claims Act."]
[null,null,null,null,null,null,null,null,null,"Jim Morrison"]
["Signature",null,null,null,null,"Date",null,null,null,"Type or Print Name of Signer"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"'Invoice - Summary Page'!L28","v":"Rev. 12/8/14 DHCS/SNFD"}]
[]
[]
[]
[null,null," "]
[null,null," "," "]
[]
[]
[null,null," "]

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["Local Governmental Agency:",{"$f":"'Invoice - Summary Page'!$D$4","v":"ABC County"},null,null,"Program:",{"$f":"'Invoice - Summary Page'!$J$4","v":"Public Health"}]
["Contract Number:",{"$f":"'Invoice - Summary Page'!$D$6","v":"14-85697"},null,null,"Claiming Unit:",{"$f":"'Invoice - Summary Page'!$J$6","v":"Outreach Program"}]
["Period of Service:",{"$f":"'Invoice - Summary Page'!$D$8","v":"07/01/2016 - 09/30/2016"},null,null,"Invoice #:",{"$f":"'Invoice - Summary Page'!$J$8","v":"16/17-1"}]
[]
["COSTS:","Cost Pool #1","Cost Pool #2","Cost Pool #3a","Cost Pool #3b","Cost Pool #4","Cost Pool #5","Cost Pool #6"]
[null,"SPMP","Non-SPMP","Non-Claimable","Non-Claimable","SPMP","Non-SPMP","Allocated/Support"]
[null,"Costs","Costs","Costs","Dir. Charge Costs","Dir. Charge Costs","Dir. Charge Costs","Costs"]
["Salary:",{"$f":"'Invoice - Cost Worksheet'!C8","v":46586.407000000007},{"$f":"'Invoice - Cost Worksheet'!D8","v":35450.51999999999},{"$f":"'Invoice - Cost Worksheet'!E8","v":31033.274999999998},{"$f":"'Invoice - Direct Charge Costs'!I11+'Invoice - Direct Charge Costs'!I24","v":0},{"$f":"'Invoice - Direct Charge Costs'!H11","v":0},{"$f":"'Invoice - Direct Charge Costs'!H24","v":10716.117999999999},{"$f":"'Invoice - Cost Worksheet'!G8","v":51933}]
["Benefits:",{"$f":"'Invoice - Cost Worksheet'!C9","v":19965.603000000003},{"$f":"'Invoice - Cost Worksheet'!D9","v":15193.079999999996},{"$f":"'Invoice - Cost Worksheet'!E9","v":13299.975},{"$f":"'Invoice - Direct Charge Costs'!L11+'Invoice - Direct Charge Costs'!L24","v":0},{"$f":"'Invoice - Direct Charge Costs'!K11","v":0},{"$f":"'Invoice - Direct Charge Costs'!K24","v":4592.6219999999994},{"$f":"'Invoice - Cost Worksheet'!G9","v":22257}]
["Salary + Benefits SUBTOTAL:",{"$f":"B8+B9","v":66552.010000000009},50643.599999999984,44333.25,{"$f":"E8+E9","v":0},0,{"$f":"G8+G9","v":15308.739999999998},74190]
["Personal Service Contracts ",null,{"$f":"'Invoice - Cost Worksheet'!D10","v":0},{"$f":"'Invoice - Cost Worksheet'!E10","v":0},{"$f":"'Invoice - Direct Charge Costs'!I32","v":0},null,{"$f":"'Invoice - Direct Charge Costs'!H32","v":1000}]
["All Personnel Costs SUBTOTAL:",{"$f":"B10","v":66552.010000000009},{"$f":"SUM(C10:C11)","v":50643.599999999984},{"$f":"SUM(D10:D11)","v":44333.25},{"$f":"SUM(E10:E11)","v":0},{"$f":"F10","v":0},{"$f":"SUM(G10:G11)","v":16308.739999999998}]
["Personnel Costs Distribution Percentage:",{"$f":"IF(B12=0,0,(B12/(SUM(B12:G12))))","v":0.37422912814837817},{"$f":"IF(C12=0,0,(C12/(SUM(B12:G12))))","v":0.28477442340652365},{"$f":"IF(D12=0,0,(D12/(SUM(B12:G12))))","v":0.24929064494797504},{"$f":"IF(E12=0,0,(E12/(SUM(B12:G12))))","v":0},{"$f":"IF(F12=0,0,(F12/(SUM(B12:G12))))","v":0},{"$f":"IF(G12=0,0,(G12/(SUM(B12:G12))))","v":9.170580349712322E-2}]
["MAA Transportation Costs:",null,null,null,{"$f":"'Invoice - Direct Charge Costs'!I38","v":0},null,{"$f":"'Invoice - Direct Charge Costs'!H38","v":0}]
["Non-Salary Costs:",{"$f":"'Invoice - Cost Worksheet'!C38","v":5294.74},{"$f":"'Invoice - Cost Worksheet'!D38","v":1700},{"$f":"'Invoice - Cost Worksheet'!E38","v":1400},{"$f":"'Invoice - Direct Charge Costs'!O11+'Invoice - Direct Charge Costs'!O24","v":0},{"$f":"'Invoice - Direct Charge Costs'!N11","v":0},{"$f":"'Invoice - Direct Charge Costs'!N24","v":3431.3039047008797},{"$f":"'Invoice - Cost Worksheet'!G38","v":48923.643593094988}]
["Other Costs:",null,null,null,null,null,{"$f":"'Invoice - Direct Charge Costs'!H41","v":0}]
["CP #6 Allocated/Support Costs to be Distributed TOTAL:",null,null,null,null,null,null,{"$f":"H10+H15","v":123113.64359309498}]
["Distribution of CP #6 Allocated/Support Costs:",{"$f":"ROUND((SUM(H17*B13)),0)","v":46073},{"$f":"ROUND((SUM(H17*C13)),0)","v":35060},{"$f":"ROUND((SUM(H17*D13)),0)","v":30691},{"$f":"ROUND((SUM(H17*E13)),0)","v":0},{"$f":"ROUND((SUM(H17*F13)),0)","v":0},{"$f":"ROUND((SUM(H17*G13)),0)","v":11290}]
["Non-Salary Costs SUBTOTAL:",{"$f":"B15+B18","v":51367.74},{"$f":"C15+C18","v":36760},{"$f":"D15+D18","v":32091},{"$f":"(E14+E15+E18)","v":0},{"$f":"F15+F18","v":0},{"$f":"(G14+G15+G16+G18)","v":14721.303904700879}]
["CP #3b All Personnel + Non-Salary Costs TOTAL:",null,null,{"$f":"E12+E19","v":0}]
["TOTAL COST:",{"$f":"ROUND((B12+B19),0)","v":117920},{"$f":"ROUND((C12+C19),0)","v":87404},{"$f":"ROUND((D12+D19+D20),0)","v":76424},null,{"$f":"ROUND(F12+F19,0)","v":0},{"$f":"ROUND(G12+G19,0)","v":31030}]
["PERCENTAGE OF TOTAL COST:",{"$f":"IF(B21=0,0,(B21/(SUM(B21:G21))))","v":0.37700861313775264},{"$f":"IF(C21=0,0,(C21/(SUM(B21:G21))))","v":0.27944420643395634},{"$f":"IF(D21=0,0,(D21/(SUM(B21:G21))))","v":0.24433943563805638},null,{"$f":"IF(F21=0,0,(F21/(SUM(B21:G21))))","v":0},{"$f":"IF(G21=0,0,(G21/(SUM(B21:G21))))","v":9.92077447902346E-2}]
[]
["FUNDING/REVENUE:","Cost Pool #1","Cost Pool #2","Cost Pool #3","Cost Pool #4","Cost Pool #5","Cost Pool #6"]
[null,"SPMP","Non-SPMP","Non-Claimable","SPMP Dir. Chg.","Non-SPMP Dir. Chg.","Allocated/Support"]
[null,"Funding/Revenue","Funding/Revenue","Funding/Revenue","Funding/Revenue","Funding/Revenue","Funding/Revenue"]
["Funding/Revenue:",{"$f":"'Invoice - Revenue Worksheet'!D41","v":22500},{"$f":"'Invoice - Revenue Worksheet'!E41","v":0},{"$f":"'Invoice - Revenue Worksheet'!F41","v":50000},{"$f":"'Invoice - Revenue Worksheet'!G41","v":0},{"$f":"'Invoice - Revenue Worksheet'!H41","v":0},{"$f":"'Invoice - Revenue Worksheet'!I41","v":0}]
["Distribution of CP #6 Funding/Revenue:",{"$f":"(G27*B22)","v":0},{"$f":"(G27*C22)","v":0},{"$f":"(G27*D22)","v":0},{"$f":"(G27*F22)","v":0},{"$f":"(G27*G22)","v":0}]
["Funding/Revenue TOTAL:",{"$f":"SUM(B27:B28)","v":22500},{"$f":"SUM(C27:C28)","v":0},{"$f":"SUM(D27:D28)","v":50000},{"$f":"SUM(E27:E28)","v":0},{"$f":"SUM(F27:F28)","v":0}]
["Non-Claimable Activity Percentage:",{"$f":"IF(E64=0,0,E64)","v":0.33660684050118522},{"$f":"IF(G64=0,0,G64)","v":0.46394557823129257}]
["Non-Claimable Activity Cost:",{"$f":"IF(B21=0,0,IF(C67=0,0,((B21*B30))))","v":39692.678631899762},{"$f":"IF(C21=0,0,IF(D67=0,0,((C21*C30))))","v":40550.699319727893},{"$f":"D21","v":76424}]
["CP #3 Remaining Non-Claimable Funding/Revenue:",null,null,{"$f":"IF(D29-D31>0,D29-D31,0)","v":0}]
["Non-Claimable Activity Distribution Percentage:",{"$f":"IF(B31+C31=0,0,(B31/(B31+C31)))","v":0.49465363554145636},{"$f":"IF(B31+C31=0,0,(C31/(B31+C31)))","v":0.50534636445854364}]
["Distribution of CP #3 Reman. Non-Claim. Funding/Revenue:",{"$f":"(D32*B33)","v":0},{"$f":"(D32*C33)","v":0}]
["Adjusted Remaining Funding/Revenue:",{"$f":"IF(B22=0,B29,IF(B34<B31,B29,IF(B34>B31,B29+B34-B31,IF(B34=B31,B29,0))))","v":22500},{"$f":"IF(C22=0,C29,IF(C34<C31,C29,IF(C34>C31,C29+C34-C31,IF(C34=C31,C29,0))))","v":0}]
["Remaining Funding/Revenue Distributed to Personnel Svcs:",{"$f":"IF(B21=0,0,(B35*(B12/B21)))","v":12698.611134667573},{"$f":"IF(C21=0,0,(C35*C12/C21))","v":0}]
["Remaining Fund/Rev Distributed to Non-Salary Costs:",{"$f":"IF(B21=0,0,(B35*(B19/B21)))","v":9801.3411635006778},{"$f":"IF(C21=0,0,(C35*C19/C21))","v":0}]
["Adjusted Remaining Personnel Services Costs",{"$f":"IF(B12-B36=0,0,(B12-B36))","v":53853.398865332434},{"$f":"IF(C12-C36=0,0,(C12-C36))","v":50643.599999999984}]
["Adjusted Remaining Non-Salary Costs",{"$f":"IF(B19-B37=0,0,(B19-B37))","v":41566.39883649932},{"$f":"IF(C19-C37=0,0,(C19-C37))","v":36760}]
["TOTAL ADJUSTED COST",{"$f":"B38+B39","v":95419.797701831762},{"$f":"C38+C39","v":87403.599999999977},null,{"$f":"IF(F21-E29=0,0,(F21-E29))","v":0},{"$f":"IF(G21-F29=0,0,(G21-F29))","v":31030}]
[]
["I certify that the information above represents accurate and identifiable data for the program/claiming entity.  I declare under penalty of perjury that the foregoing is true and correct to the best of my knowledge, information, and belief, and that I have notice that this information is to be used for filing a claim with the Federal Government for federal funds, and the knowing misrepresentation constitutes violation of the Federal False Claims Act."]
[null,null,null,null,"Jim Morrison"]
["Signature",null,"Date",null,"Type or Print Name of Signer"]
[null,null,null,null,null,null,null,{"$f":"'Invoice - Summary Page'!L28","v":"Rev. 12/8/14 DHCS/SNFD"}]
["Local Governmental Agency:",{"$f":"'Invoice - Summary Page'!$D$4","v":"ABC County"},null,null,"Program:",{"$f":"'Invoice - Summary Page'!$J$4","v":"Public Health"}]
["Contract Number:",{"$f":"'Invoice - Summary Page'!$D$6","v":"14-85697"},null,null,"Claiming Unit:",{"$f":"'Invoice - Summary Page'!$J$6","v":"Outreach Program"}]
["Period of Service:",{"$f":"'Invoice - Summary Page'!$D$8","v":"07/01/2016 - 09/30/2016"},null,null,"Invoice #:",{"$f":"'Invoice - Summary Page'!$J$8","v":"16/17-1"}]
[]
["ACTIVITIES:","MEDI-CAL %","ACTIVITY RESULTS PERCENTAGES",null,"REALLOCATED\nSPMP %","SPMP\nMedi-Cal %","REALLOCATED\nNon-SPMP %","Non-SPMP\nMedi-Cal %"]
[null,null,"SPMP","NON-SPMP"]
["CODE 4: Medi-Cal Outreach ",1,{"$f":"'Invoice - T.S. Results Summary'!I9","v":8.247914183551848E-2},{"$f":"'Invoice - T.S. Results Summary'!K9","v":0},{"$f":"IF(C52=0,0,C52/SUM(C52:C64))","v":0.11716898069759567},{"$f":"E52*B52","v":0.11716898069759567},{"$f":"IF(D52=0,0,D52/SUM(D52:D64))","v":0},{"$f":"G52*B52","v":0}]
["CODE 6: Referral, Coordination, and Monitoring of Medi-Cal Services",{"$f":"'Invoice - T.S. Results Summary'!L11","v":0.42749999999999999},{"$f":"'Invoice - T.S. Results Summary'!I11","v":0.17687723480333731},{"$f":"'Invoice - T.S. Results Summary'!K11","v":1.8656229615133725E-2},{"$f":"IF(C53=0,0,C53/SUM(C52:C64))","v":0.25126989502201152},{"$f":"E53*B53","v":0.10741788012190992},{"$f":"IF(D53=0,0,D53/SUM(D52:D64))","v":9.7278911564625856E-2},{"$f":"G53*B53","v":4.1586734693877553E-2}]
["CODE 8: Facilitating Med-Cal Application",1,{"$f":"'Invoice - T.S. Results Summary'!I13","v":0},{"$f":"'Invoice - T.S. Results Summary'!K13","v":0},{"$f":"IF(C54=0,0,C54/SUM(C52:C64))","v":0},0,{"$f":"IF(D54=0,0,D54/SUM(D52:D64))","v":0},0]
["CODE 10: Arranging and/or Providing Non-Emergency, Non-Medical Transportation to a Medi-Cal Covered Service",{"$f":"'Invoice - T.S. Results Summary'!L15","v":0},{"$f":"'Invoice - T.S. Results Summary'!I15","v":0},{"$f":"'Invoice - T.S. Results Summary'!K15","v":0},{"$f":"IF(C55=0,0,C55/SUM(C52:C64))","v":0},0,{"$f":"IF(D55=0,0,D55/SUM(D52:D64))","v":0},0]
["CODE 12: Contract Administration (A) for Medi-Cal Services specific for Medi-Cal populations",1,{"$f":"'Invoice - T.S. Results Summary'!I17","v":0},{"$f":"'Invoice - T.S. Results Summary'!K17","v":0},{"$f":"IF(C56=0,0,C56/SUM(C52:C64))","v":0},0,{"$f":"IF(D56=0,0,D56/SUM(D52:D64))","v":0},0]
["CODE 13: Contract Administration (B) for Medi-Cal Services specific for Medi-Cal and Non Medi-Cal populations",{"$f":"'Invoice - T.S. Results Summary'!L18","v":0.42749999999999999},{"$f":"'Invoice - T.S. Results Summary'!I18","v":0},{"$f":"'Invoice - T.S. Results Summary'!K18","v":3.0658838878016959E-2},{"$f":"IF(C57=0,0,C57/SUM(C52:C64))","v":0},0,{"$f":"IF(D57=0,0,D57/SUM(D52:D64))","v":0.1598639455782313},6.8341836734693878E-2]
["CODE 15: PP & PD (A) (Non-enhanced) for Medi-Cal Services for                        Medi-Cal clients",1,{"$f":"'Invoice - T.S. Results Summary'!I20","v":0},{"$f":"'Invoice - T.S. Results Summary'!K20","v":0},{"$f":"IF(C58=0,0,C58/SUM(C52:C64))","v":0},0,{"$f":"IF(D58=0,0,D58/SUM(D52:D64))","v":0},0]
["CODE 16: PP & PD (SPMP) (A) (Enhanced) for Medi-Cal Services for Medi-Cal clients",1,{"$f":"'Invoice - T.S. Results Summary'!I21","v":0},null,{"$f":"IF(C59=0,0,C59/SUM(C52:C64))","v":0},{"$f":"E59*B59","v":0}]
["CODE 17: PP & PD (B) (Non-enhanced) for Medi-Cal Services for                             Medi-Cal and Non Medi-Cal clients",{"$f":"'Invoice - T.S. Results Summary'!L22","v":0.42749999999999999},{"$f":"'Invoice - T.S. Results Summary'!I22","v":1.5733015494636474E-2},{"$f":"'Invoice - T.S. Results Summary'!K22","v":3.1572080887149377E-2},{"$f":"IF(C60=0,0,C60/SUM(C52:C64))","v":2.2350152387402643E-2},{"$f":"E60*B60","v":9.5546901456146291E-3},{"$f":"IF(D60=0,0,D60/SUM(D52:D64))","v":0.16462585034013605},{"$f":"G60*B60","v":7.0377551020408158E-2}]
["CODE 18: PP & PD (SPMP) (B) (Enhanced) for Medi-Cal Services for Medi-Cal and Non Medi-Cal clients",{"$f":"'Invoice - T.S. Results Summary'!L23","v":0.42749999999999999},{"$f":"'Invoice - T.S. Results Summary'!I23","v":0.17711561382598331},null,{"$f":"IF(C61=0,0,C61/SUM(C52:C64))","v":0.25160853369454794},{"$f":"E61*B61","v":0.10756264815441924}]
["CODE 19: MAA/TCM Coordination and Claims Administration",1,{"$f":"'Invoice - T.S. Results Summary'!I24","v":0},{"$f":"'Invoice - T.S. Results Summary'!K24","v":1.7090671885192431E-2},{"$f":"IF(C62=0,0,C62/SUM(C52:C64))","v":0},{"$f":"E62*B62","v":0},{"$f":"IF(D62=0,0,D62/SUM(D52:D64))","v":8.9115646258503392E-2},{"$f":"G62*B62","v":8.9115646258503392E-2}]
["CODE 20: MAA/TCM Implementation Training",1,{"$f":"'Invoice - T.S. Results Summary'!I25","v":1.4779499404052444E-2},{"$f":"'Invoice - T.S. Results Summary'!K25","v":4.8271363339856491E-3},{"$f":"IF(C63=0,0,C63/SUM(C52:C64))","v":2.0995597697257028E-2},{"$f":"E63*B63","v":2.0995597697257028E-2},{"$f":"IF(D63=0,0,D63/SUM(D52:D64))","v":2.5170068027210887E-2},{"$f":"G63*B63","v":2.5170068027210887E-2}]
["CODES 1, 2, 3, 5, 7, 9, 11, 14, 23-32: All NON-CLAIMABLE Activities",null,{"$f":"'Invoice - T.S. Results Summary'!I40","v":0.23694874851013112},{"$f":"'Invoice - T.S. Results Summary'!K40","v":8.8975864318330072E-2},{"$f":"IF(C64=0,0,C64/SUM(C52:C64))","v":0.33660684050118522},null,{"$f":"IF(D64=0,0,D64/SUM(D52:D64))","v":0.46394557823129257}]
["CODE 21: General Administration",null,{"$f":"'Invoice - T.S. Results Summary'!I26","v":0.16662693682955901},{"$f":"'Invoice - T.S. Results Summary'!K26","v":0.49836921069797779}]
["CODE 22: Paid Time Off (PTO)",null,{"$f":"'Invoice - T.S. Results Summary'!I27","v":0.12943980929678189},{"$f":"'Invoice - T.S. Results Summary'!K27","v":0.30984996738421394}]
["TOTAL",null,{"$f":"SUM(C52:C66)","v":1},1,1,{"$f":"SUM(F52:F66)","v":0.36269979681679643},{"$f":"SUM(G52:G66)","v":1},0.29459183673469386]
[]
["CLAIM CALCULATION:","CP1","CP2","CP4","CP5","FFP @ 50%","FFP @ 75%"]
["Non-Enhanced Federal Share",{"$f":"B40*(F67-(F59+F61))","v":24345.135111586209},{"$f":"C40*H67","v":25748.387061224483},null,{"$f":"F40","v":31030},{"$f":"SUM(B70:E70)*0.5","v":40561.761086405342}]
["Enhanced Federal Share",{"$f":"B40*(F59+F61)","v":10263.606127167992},null,{"$f":"E40","v":0},null,null,{"$f":"SUM(B71:E71)*0.75","v":7697.7045953759934}]
[null,null,null,null," "]
["TOTAL FEDERAL SHARE:",{"$f":"F70+G71","v":48259.465681781337},null,"Total Inv. Amt.","50% Inv. Portion","75% Inv. Portion"]
["CPE Eligibility:",{"$f":"IF(B73<(0.5*'Invoice - Revenue Worksheet'!C41+0.5),\"COMPLIANT\",\"NON-COMPLIANT\")","v":"COMPLIANT"},null,{"$f":"B75","v":48259.465681781337},{"$f":"D74*(F70/B73)","v":40561.761086405342},{"$f":"D74*(G71/B73)","v":7697.7045953759944}]
["CPE Compliant Federal Share:",{"$f":"IF(B74=\"NON-COMPLIANT\",0.5*'Invoice - Revenue Worksheet'!C41,B73)","v":48259.465681781337}]
[null,null,null,null," "]
["I certify that the information above represents accurate and identifiable data for the program/claiming entity.  I declare under penalty of perjury that the foregoing is true and correct to the best of my knowledge, information, and belief, and that I have notice that this information is to be used for filing a claim with the Federal Government for federal funds, and the knowing misrepresentation constitutes violation of the Federal False Claims Act."]
[null,null,null,null,"Jim Morrison"]
["Signature",null,"Date",null,"Type or Print Name of Signer"]
[null,null,null,null,null,null,null,{"$f":"'Invoice - Summary Page'!L28","v":"Rev. 12/8/14 DHCS/SNFD"}]

{"sheet":"Invoice - 20% Variance","index":6,"n_rows":51,"n_cols":13,"rows_kept":51,"cut":false,"hidden":false,"merged":[[27,4,27,12],[38,1,38,12],[32,3,32,12],[33,3,33,12],[19,0,19,13],[20,0,20,13],[21,1,21,12],[22,3,22,12],[23,3,23,12],[41,1,41,12],[43,1,43,6],[43,8,43,9],[43,11,43,12],[39,1,39,12],[40,0,40,13],[42,1,42,6],[42,8,42,9],[42,11,42,12],[14,9,14,13],[45,1,45,6],[46,1,46,3],[46,4,46,8],[46,11,46,12],[36,3,36,12],[37,4,37,12],[34,3,34,12],[35,3,35,12],[44,1,44,6],[25,3,25,12],[26,3,26,12],[29,1,29,12],[28,1,28,12],[30,0,30,13],[31,1,31,12],[12,1,12,12],[24,3,24,12],[50,12,50,13],[1,4,1,12],[3,4,3,12],[4,4,4,12],[6,4,6,12],[7,4,7,12],[9,4,9,10],[9,11,9,12],[18,9,18,11],[18,12,18,13],[10,1,10,12],[11,1,11,12],[13,0,13,13],[14,0,14,7],[50,0,50,10],[49,0,49,13],[47,11,47,12],[48,11,48,12],[15,0,15,5],[48,4,48,8],[16,0,16,5],[17,0,17,5],[15,12,15,13],[16,12,16,13],[17,12,17,13],[17,6,17,7],[16,9,16,11],[17,9,17,11],[15,9,15,11],[18,6,18,7],[0,0,0,13],[18,0,18,5],[47,1,47,3],[48,1,48,3],[47,4,47,8],[1,1,1,3],[3,1,3,3],[6,1,6,3],[9,1,9,3],[2,0,2,13],[5,0,5,13],[8,0,8,13],[4,0,4,3],[7,0,7,3],[15,6,15,7],[16,6,16,7]]}
["(delete this text) *PRINT ON LGA LETTER HEAD* (delete this text)"]
[null,"Date:",null,null,"Date"]
[]
[null,"To:",null,null,"The Department of Health Care Services"]
[null,null,null,null,"County Based Medi-Cal Administrative Activities Unit"]
[]
[null,"From:",null,null,{"$f":"'Invoice - Summary Page'!D4","v":"ABC County"}]
[null,null,null,null,{"$f":"'Invoice - Summary Page'!J6","v":"Outreach Program"}]
[]
[null,"Subject:",null,null,"CMAA Program Invoice Percentage Variance Documentation for",null,null,null,null,null,null,{"$f":"'Invoice - Summary Page'!D8","v":"07/01/2016 - 09/30/2016"}]
[]
[]
[null,"The following information represents the CMAA Program invoice variance data for the LGA/Claiming Unit and Period of Service notated above."]
[]
["Prior Year Corresponding Quarter Variance Data",null,null,null,null,null,null,null,null,"Prior Quarter Variance Data"]
["PY Corresponding Quarter Invoice Amount:",null,null,null,null,null,57527,null,null,"Prior Quarter Invoice Amount:",null,null,79850]
["Current Quarter Invoice Amount:",null,null,null,null,null,{"$f":"'Invoice - Claim Calculation'!D74","v":48259.465681781337},null,null,"Current Quarter Invoice Amount:",null,null,{"$f":"'Invoice - Claim Calculation'!D74","v":48259.465681781337}]
["Variance Percentage:",null,null,null,null,null,{"$f":"((G17-G16)/G16)*1","v":-0.16109886345922197},null,null,"Variance Percentage:",null,null,{"$f":"(M17-M16)/M16","v":-0.39562347298958878}]
["A variance percentage explanation is:",null,null,null,null,null,{"$f":"IF(G18>=20%,\"REQUIRED\",IF(G18<=-20%,\"REQUIRED\",\"NOT REQUIRED\"))","v":"NOT REQUIRED"},null,null,"A variance percentage explanation is:",null,null,{"$f":"IF(M18>=20%,\"REQUIRED\",IF(M18<=-20%,\"REQUIRED\",\"NOT REQUIRED\"))","v":"REQUIRED"}]
["*If an explanation of the variance percentage is \"REQUIRED\", please fill out the appropriate variance narrative information below"]
[]
[null,"Prior Year Corresponding Quarter Variance Narrative (check all that apply):"]
[null,null,null,"Change in the number of Time Survey Participants"]
[null,null,null,"Time Survey results were materially different"]
[null,null,null,"Increase/Decrease to other costs"]
[null,null,null,"Change in Medi-Cal Percentage"]
[null,null,null,"Difference in the number of Pay Periods"]
[null,null,null,"Other:"]
[null,"Detailed Explanation:"]
[]
[]
[null,"Prior Quarter Variance Narrative (check all that apply):"]
[null,null,null,"Change in the number of Time Survey Participants"]
[null,"X",null,"Time Survey results were materially different"]
[null,null,null,"Increase/Decrease to other costs"]
[null,null,null,"Change in Medi-Cal Percentage"]
[null,null,null,"Difference in the number of Pay Periods"]
[null,null,null,"Other:"]
[null,"Detailed Explanation:"]
[null,"There was a significant decrease in MAA activities and an increase in non-claimable activities"]
[]
[null,"If you have any questions or require further information, please feel free to contact me."]
[null,null,null,null,null,null,null,null,"Date",null,null,"805-216-6585"]
[null,"Signature",null,null,null,null,null,null,"Date",null,null,"Phone number"]
[null,"Jim Morrison"]
[null,"MAA/TCM Coordinator"]
[null,"LGA:",null,null,{"$f":"'Invoice - Summary Page'!D4","v":"ABC County"},null,null,null,null,null,"Program:",{"$f":"'Invoice - Summary Page'!J4","v":"Public Health"}]
[null,"Contract #:",null,null,{"$f":"'Invoice - Summary Page'!D6","v":"14-85697"},null,null,null,null,null,"Claiming Unit:",{"$f":"'Invoice - Summary Page'!J6","v":"Outreach Program"}]
[null,"Period of Service:",null,null,{"$f":"'Invoice - Summary Page'!D8","v":"07/01/2016 - 09/30/2016"},null,null,null,null,null,"Invoice Number:",{"$f":"'Invoice - Summary Page'!J8","v":"16/17-1"}]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"'Invoice - Summary Page'!L28","v":"Rev. 12/8/14 DHCS/SNFD"}]

{"sheet":"DHCS Info","index":7,"n_rows":20,"n_cols":3,"rows_kept":20,"cut":false,"hidden":true,"merged":[]}
["ps","th@tnew$"]
[12,2,"Medi-Cal"]
[16,2,"Grants"]
[20,2,"General"]
[24,2,"Medicare"]
[28,2,"Insurance"]
[32,2,"Fees"]
[36,2,"Revenue"]
[]
[]
[]
[]
["original"]
[12,4,"Medi-Cal"]
[18,4,"Grants"]
[24,4,"General"]
[30,4,"Medicare"]
[36,4,"Insurance"]
[42,4,"Fees"]
[48,4,"Revenue"]

{"sheet":"Non-Enhanced MAA Codes","index":8,"n_rows":11,"n_cols":4,"rows_kept":11,"cut":false,"hidden":true,"merged":[]}
["Code","Description","FFP\nRate","Medi-Cal %"]
[4,"Medi-Cal Outreach ","TM",{"$f":"'Invoice - T.S. Results Summary'!L9","v":1}]
[6,"Referral, Coordination, and Monitoring of Medi-Cal Services","PM",{"$f":"'Invoice - T.S. Results Summary'!L11","v":0.42749999999999999}]
[8,"Facilitating Med-Cal Application","TM",{"$f":"'Invoice - T.S. Results Summary'!L13","v":1}]
[10,"Arranging and/or Providing Non-Emergency, Non-Medical Transporation to a Medi-Cal Covered Service","PM",{"$f":"'Invoice - T.S. Results Summary'!L15","v":0}]
[12,"Contract Administration (A) for Medi-Cal Services specific for Medi-Cal populations","TM",{"$f":"'Invoice - T.S. Results Summary'!L17","v":1}]
[13,"Contract Administration (B) for Medi-Cal Services specific for Medi-Cal and Non Medi-Cal populations","PM",{"$f":"'Invoice - T.S. Results Summary'!L18","v":0.42749999999999999}]
[15,"Program Planning & Policy Development (A) (Non-enhanced) for Medi-Cal Services for Medi-Cal clients","TM",{"$f":"'Invoice - T.S. Results Summary'!L20","v":1}]
[17,"Program Planning & Policy Development (B) (Non-enhanced) for Medi-Cal Services for Medi-Cal and Non Medi-Cal clients","PM",{"$f":"'Invoice - T.S. Results Summary'!L22","v":0.42749999999999999}]
[19,"MAA/TCM Coordination and Claims Administration","TM",{"$f":"'Invoice - T.S. Results Summary'!L24","v":1}]
[20,"MAA/TCM Implementation Training","TM",{"$f":"'Invoice - T.S. Results Summary'!L25","v":1}]

{"sheet":"Enhanced MAA Codes","index":9,"n_rows":3,"n_cols":4,"rows_kept":3,"cut":false,"hidden":true,"merged":[]}
["Code","Description","FFP\nRate","Medi-Cal %"]
[16,"Program Planning & Policy Development Skilled Professional Medical Personnel (SPMP) (A) (Enhanced) for Medi-Cal Services for Medi-Cal clients","TM\n(Enhanced)",{"$f":"'Invoice - T.S. Results Summary'!L21","v":1}]
[18,"Program Planning & Policy Development (SPMP) (B) (Enhanced) for Medi-Cal Services for Medi-Cal and Non Medi-Cal clients","PM\n(Enhanced)",{"$f":"'Invoice - T.S. Results Summary'!L23","v":0.42749999999999999}]