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Effective Date: 
4/2017

Documents

Instructions

Updated: 4/2017

Purpose

Form 6003 is used by the Children’s Autism Program contractors to request advance payment for amounts outstanding on claims made to third-party payers. The Texas Health and Human Services Commission (HHSC) may deny requests for advance payments within its discretion.

When and Where to Send the Completed Form

Contractors may submit a request for advance payment (the completed Form 6003) along with Form 6002, Children's Autism Program Invoice, by the 10th business day of the following month to:

Invoice-HHSC Accounting
Texas Health and Human Services Commission
4900 N. Lamar Blvd.
Austin, TX 78751
Phone: 512-424-6518
Fax: 512-424-6901
Email: HHSC_AP@hhsc.state.tx.us

Send a copy to the HHSC Children's Autism Program contract manager.

Requests for advance payment may be sent by mail or by electronic mail (attach a completed and signed copy of Form 6003 and Form 6002).

Detailed Instructions

Contractor Information

Contractor Name—name of contractor.

Contact Name—name of contractor contact person.

Phone Number—phone number of contractor contact person.

Contractor Remittance Address, City, State, ZIP Code—where advance payment is to be sent.

Texas Identification Number (TIN)—contractor Texas Identification Number.

HHSC Contract Number—ten-digit grant award number.

HHSC P.O. Number—HHSC purchase order number.

Current Fiscal Year Contract Balance—balance of contractor grant funds remaining for the current fiscal year.

Date of Request—a request for advance payment cannot be made after May 31 of each contract period.

Description

Treatment Hours—total number of treatment hours provided in the previous month where children have third-party payer coverage that was not reimbursed during the month.

HHSC Hourly Rate—HHSC blended hourly rate established for contractor.

Amount Requested—number of treatment hours provided in the previous month where children have third-party payer coverage that was not reimbursed during the month multiplied by the HHSC hourly rate.

Percent of Amount Requested—HHSC will pay 80% of the amount requested.

Amount of Advance Payment—80% of amount requested. The cumulative amount of outstanding advance payments shall not exceed 15% of the contractor’s current fiscal year contract balance.

Certification

Authorized Contractor Contact—name of authorized contact person.

Note about Retention

Internal HHSC users: In most cases, the original version of completed forms must be maintained in accordance with federal and state laws and HHSC policy. If you are unsure how long to maintain a given form, consult the HHSC Records Retention Schedule or HHSC Records Management Office.

Providers and contractors: The original version of completed forms must be maintained in accordance with federal and state laws, HHSC policy, and your contract with HHSC. If you have any questions, contact your contract manager.