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ICN Session Coding September 16, 2003
Medicaid Administrative Claiming for School-based Services (MACSS) in Iowa ICN Session Coding September 16, 2003
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Agenda Background - EPSDT
Agency Participation - Organizational Structure Staff Participation RMS Time Study Activity Codes Documentation of Medicaid Providers Audit File Use of Federal Reimbursements Getting Started On-line Resources State Level Contacts Process for Questions and Answers
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Background MACSS is a process by which Federal Financial Participation may be claimed for administrative case management activities carried out in a school setting that are necessary for the proper and efficient administration of Iowa’s Medicaid State Plan for children ages 0-21 (through age 20). MACSS supports Iowa’s EPSDT Care for Kids program
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Iowa’s EPSDT (Care for Kids) Program
Early = Children should receive quality health care beginning at birth and continuing through childhood including identification, diagnosis, and treatment of medical conditions as early as possible. Periodic = Children should receive screening and preventive care at regular intervals throughout childhood (age 0 through 20) according to standards set by responsible professional groups. Screening = Children should be screened for conditions, diseases, or abnormalities to initiate further diagnosis and receive early and continuing treatment of these conditions. Services shall include vision, hearing, medical, dental, and mental health screenings.
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Iowa’s EPSDT (Care for Kids) Program
Diagnosis = Children should receive further evaluation for conditions or signs identified in the periodic screens that indicate further treatment may be required. Treatment = Children should receive treatment that involves the correction of health problems identified in the screening and diagnosis components of EPSDT.
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Agency Participation Agreements will be established with school districts only. Time studies include only school district employees. No contracted staff may be included in time studies. Must have sufficient public unrestricted funds derived from state, county, or local generated revenues to match federal reimbursements May not be used as match for other programs.
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Agency Participation Organizational structure
Lead agency status will be limited to one school district per county Lead school district must participate in MACSS Other school districts may participate under the lead agency Annual agreements established Lead agency agreement with DHS Sub-agency agreement(s) with lead agency Fiscal year = July 1 through June 30
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MACSS Organizational Structure
Centers for Medicare and Medicaid Services (CMS) Iowa Dept. of Human Services Iowa Dept. of Public Health Interagency Agreement Technical Assistance Lead School District Sub-agreement Other School Districts
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Staff Participation Staff participating in time studies may include employees serving in schools who……... Facilitate Medicaid outreach / enrollment / eligibility determination. Provide administrative support for Medicaid related activities. Do not include staff who……… Provide ONLY direct care or educational services. Have positions that are 100% supported by grant funds. Bill service coordination under the Medicaid LEA program.
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Staff Participation Appropriate staff may include: Nurses Counselors
At-risk Coordinators Health Care Associates Interpreters / Translators for medical services Other paraprofessionals Psychologists Social Workers
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RMS Time Study Time studies will be conducted through a process known as Random Moment Sampling (RMS). Computer generated random worker - moments are selected for the quarter (3,000 statewide / quarter). For a given sample moment, the worker completes the RMS Observation Form. Who were you with?/ What were you doing?/ Why were you performing this activity? Signature and Date Certified time coder from Lead Agency codes the activity. Time code percentages included in an agency’s claim are based upon statewide coding percentages.
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RMS Time Study Certified Time Coder
Attends mandatory training and signs training certification Attends subsequent training(s) as needed Assigns activity codes for all coding staff in the lead agency and sub-agencies Assures adequate descriptions of activities on the Observation Form Serves as primary contact for coding questions from DHS Identifies a back-up certified time coder
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RMS Time Study Process for Implementation
One month before start of quarter, Lead Agency sends DHS a list of staff to be included in the time study for each participating agency (lead and subs). DHS generates the worker-moments for the upcoming quarter. Two weeks prior to start of quarter, DHS sends RMS Observation Forms and sample control lists to lead agency. Lead agency distributes RMS Observation Forms and instructions to their own staff and sub-agency. Completed RMS Observation Forms are returned to lead agency weekly. Certified coder at lead agency assigns activity codes. Completed forms are returned to DHS MACSS Auditor weekly.
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RMS Time Study Corrections to RMS Observation Forms
If questions arise, sampled worker is contacted by Lead Agency (or DHS) to clarify his/her response. Only the sampled worker may make a substantive change to the form. Draw line through incorrect response Note correct response Initial at area of correction Return form to Lead Agency to forward to DHS
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RMS Time Study Advantages
Quality control occurs at both lead agency and DHS. Narrative documentation is supplied for all coded activities. Burden of coding entire days is eliminated. Burden of tallying codes is eliminated. Certified coder is required at lead agency level. Required certified back-up may be from lead agency or sub-agency. Completed RMS Observation Forms will be retained by DHS for 5 years to support statewide coding percentages.
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Activity Codes Code 1.a. Outreach and Facilitating Eligibility for Non-Medicaid Programs Use when informing individuals or families about non-Medicaid social, legal, vocational, general health, and educational programs Non-Medicaid programs include TANF, Food Stamps, food banks, WIC, Lion’s Club, child care, legal aid, wellness programs, clothing and housing resources, special education, parenting programs, tutoring services, IDEA child find, and free and reduced lunch programs
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Activity Codes Code 1.a. Outreach and Facilitating Eligibility for Non-Medicaid Programs Outreach campaigns that address life-style changes in the general populations (dental prevention, anti-smoking, alcohol reduction, general nutrition, general hygiene, CPR, and AED) Describing range of benefits, eligibility requirements, and how to access these programs Assisting with applications Includes related paperwork, clerical activities, or staff travel required to perform the activities
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Activity Codes Code 1.b. Outreach and Facilitating Eligibility for Medicaid & hawk-i Use when informing eligible or potentially eligible individuals about the Medicaid or hawk-i programs Describing the range of benefits covered under Medicaid or hawk-i, how to access the Medicaid or hawk-i programs, and assisting families to make application for Medicaid or hawk-i Providing information about the EPSDT program as well as Medicaid managed care programs
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Activity Codes Code 1.b. Outreach and Facilitating Eligibility for Medicaid & hawk-i Compiling and distributing literature about the Medicaid or hawk-i programs Contacting pregnant and parenting teens about prenatal and well baby services available under Medicaid Explaining eligibility rules and the eligibility process to prospective applicants for Medicaid or hawk-i programs Assisting families to complete a Medicaid or hawk-i application
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Activity Codes Code 1.b. Outreach and Facilitating Eligibility for Medicaid & hawk-i Assisting families in collecting required information and documents for a Medicaid or hawk-i application Referring an individual to make application for the Medicaid or hawk-i programs Ordering and distributing state prepared hawk-i outreach marketing materials Informing parenting teenagers about the availability of hawk-i well baby care services
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Activity Codes Code 1.b. Outreach and Facilitating Eligibility for Medicaid & hawk-i Verifying an individual’s Medicaid eligibility status for the purpose of the eligibility process. Coordinating activities with local hawk-i outreach coordinators Includes related paperwork, clerical activities, or staff travel required to perform the activities
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Activity Codes Code 2. School Related Educational Activities
Use for school related activities such as educational services, teaching services, and employment and job training activities Providing classroom instruction, testing, correcting papers, playground and lunchroom duty, monitoring academic achievement, carrying out discipline, and all activities related to school attendance Development of the IEP, annual reviews, and attendance at IEP meetings Development of 504 plans
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Activity Codes Code 2. School Related Educational Activities
Activities related to meeting immunization requirements for school attendance including audit of immunization records Conferring with parents on discipline, academic matters, or other school related issues Evaluating curriculum and participating in training related to curriculum or academic instruction Includes related paperwork, clerical activities, or staff travel required to perform the activities
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Activity Codes Code 3. Direct Medical Services
Use when providing direct health care, screenings / evaluations / assessments, treatment, and/or counseling services to a student Activities that are an integral part of or extension of the medical service such as patient assessment, patient follow-up, patient counseling, patient education, parent consultations, preparing medical reports, and billing activities Providing health and/or mental health services in an IEP Providing immunizations
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Activity Codes Code 3. Direct Medical Services
Coordinating, monitoring, and evaluating a treatment plan if provided as a medical service (i.e. service coordination under the Medicaid LEA program) Performing routine health screens (vision, hearing, ht, wt, dental, scoliosis, and EPSDT screens) Providing personal aide services and medical transportation All health related services for adults (age 21 and older) Includes related paperwork, clerical activities, or staff travel required to perform the activities
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Activity Codes Code 4. a. Coordination of Transportation for Non-Medicaid Services Use when assisting an individual to obtain transportation for services not covered by Medicaid Scheduling or arranging transportation to social, vocational, and/or educational programs and activities Includes related paperwork and clerical activities required to perform the activities
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Activity Codes Code 4. b. Coordination of Transportation for Medicaid Services Use when assisting an individual to obtain transportation for services covered by Medicaid. This does not include PROVIDING transportation (Code 3) Scheduling or arranging transportation to Medicaid covered services Includes related paperwork and clerical activities required to perform the activities
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Activity Codes Code 5. a. Non-Medicaid Translation
Use this for translating non-Medicaid activities such as arranging for or providing translation services (including signing services for the hearing impaired) that assist the individual to access and understand social, educational, and vocational services Arranging for or providing translation services that assist the individual to access and understand routine health screenings (e.g. vision, hearing, ht, wt, dental, scoliosis) and general health education outreach campaigns
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Activity Codes Code 5. a. Non-Medicaid Translation
Translation of academic tests, assignments, and other academic subject matter Includes related paperwork, clerical activities, or staff travel required to perform the activities
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Activity Codes Code 5. b. Medicaid Translation
Use when provided by employees designated to perform translation functions for the school. Employee position description must include responsibility for medical translation Arranging for or providing translation services (including signing services for the hearing impaired) that assist the individual to access and understand care or treatment covered by Medicaid Includes related paperwork, clerical activities, or staff travel required to perform the activities
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Activity Codes Code 6. a. Program Planning, Policy Development, and Interagency Coordination Related to Non-Medical Services Use when developing strategies to improve coordination and delivery of non-medical services for students (e.g. social services, educational services, vocational services, and routine health screenings) Employees whose position descriptions include program planning, policy development, and interagency coordination may use this code Coordinating with interagency committees to identify, promote, and develop non-medical services in schools
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Activity Codes Code 6. a. Program Planning, Policy Development, and Interagency Coordination Related to Non-Medical Services Identifying gaps or duplication of non-medical services and developing strategies to improve service delivery and coordination Developing strategies to assess or increase capacity of non-medical programs Monitoring non-medical service delivery in schools Developing procedures for tracking families requests for assistance with non-medical programs and providers of these services
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Activity Codes Code 6. a. Program Planning, Policy Development, and Interagency Coordination Related to Non-Medical Services Evaluating need for non-medical services for populations or geographic service areas (e.g. evaluating data) Working with other agencies to improve non-medical service delivery Developing advisory groups to provide consultation on delivery of non-medical services or routing screenings Developing non-medical referral sources Includes related paperwork, clerical activities, or staff travel required to perform the activities
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Activity Codes Code 6. b. Program Planning, Policy Development, and Interagency Coordination Related to Medical Services Use when developing strategies to improve coordination and delivery of Medicaid covered medical, dental, and mental health services for school age children Employees whose position descriptions include program planning, policy development and interagency coordination may use this code Coordinating with interagency committees to identify, promote, and develop Medicaid services in school systems
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Activity Codes Code 6. b. Program Planning, Policy Development, and Interagency Coordination Related to Medical Services Identifying gaps or duplication of medical, dental, mental health services and developing strategies to improve service delivery and coordination Developing strategies to assess or increase capacity of school medical, dental, mental health programs Monitoring medical, dental, mental health delivery systems in schools Developing procedures for tracking families requests for assistance with medical, dental, mental health services and providers (Actual tracking is Code 8 b.)
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Activity Codes Code 6. b. Program Planning, Policy Development, and Interagency Coordination Related to Medical Services Evaluating need for medical, dental, mental health services for populations or geographic service areas (e.g. evaluating data) Working with other agencies to improve medical service delivery. (e.g. Title V Child Health or Child Health Specialty Clinics) Developing strategies to address the cost effectiveness of school medical, dental, mental health programs Working with Medicaid to locate and develop referral relationships
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Activity Codes Code 6. b. Program Planning, Policy Development, and Interagency Coordination Related to Medical Services Developing advisory groups to provide consultation on delivery of health care services to school populations Working with Medicaid to identify and promote the enrollment of potential Medicaid providers Developing medical referral resources such as directories of Medicaid providers Includes related paperwork, clerical activities, or staff travel required to perform the activities
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Activity Codes Code 7. a. Non-Medicaid Related Training
Use when coordinating, conducting, or participating in training for programs other than the Medicaid program (e.g. educational, vocational, or social programs) How to assist families to access non-Medicaid programs How to more effectively refer students for non-Medicaid programs How to improve delivery of services other than Medicaid (i.e. IDEA child find)
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Activity Codes Code 7. a. Non-Medicaid Related Training
Coordinating, conducting, or participating in training for general health education programs that address life-style changes in the general population (i.e. dental prevention, anti-smoking, alcohol reduction, general nutrition, general hygiene, CPR, AED) Include related paperwork, clerical activities, or staff travel required to perform the activities
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Activity Codes Code 7. b. Medicaid Related Training
Use when coordinating, conducting, or participating in training regarding the benefits of Medicaid related services, how to assist families to access Medicaid services, and how to more effectively refer students Includes related paperwork, clerical activities, or staff travel required to perform the activities
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Activity Codes Code 7. b. Medicaid Related Training Training that
Improves delivery of Medicaid related services Enhances early identification, intervention, screening, and referral of students with health needs to Medicaid related services (i.e. EPSDT services) Emphasizes importance of maintaining the scheduled health screenings under EPSDT Improves the quality of identification, referral, and coordination of care for children with special health or mental health needs Addresses administrative requirements related to Medicaid services
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Activity Codes Code 8. a. Referral, Coordination, and Monitoring of Non-Medicaid Services Use when making referrals for, coordinating, and/or monitoring access to and delivery of non-medical services including educational, vocational, and social services Activities related to child abuse reporting to DHS Making referrals for, coordinating, and/or monitoring the delivery of routine health screens (e.g. vision, hearing, ht, wt, dental, scoliosis) Gathering information required in advance for non-Medicaid related referrals
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Activity Codes Code 8. a. Referral, Coordination, and Monitoring of Non-Medicaid Services Participating in a meeting to coordinate or review a student’s need for educational, vocational, social, and other non-Medicaid services Coordinating, monitoring, and evaluating the components of an established 504 plan Coordinating, monitoring, and evaluating the non-medical components of an established IEP Any referral, coordination, or monitoring of health services for adults – excluding pregnant women Include related paperwork, clerical activities, or staff travel required to perform the activities
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Activity Codes Code 8. b. Referral, Coordination, and Monitoring of Medicaid Services Use when making referrals for, coordinating, and/or monitoring access to and delivery of Medicaid covered services including those under managed care plans Referral, coordination, and monitoring activities related to Medicaid services in an established IEP (If billing service coordination under Medicaid LEA program, then use Code 3.) Identifying and referring adolescents who may be in need of Medicaid family planning services Making referrals for and/or coordinating medical or physical examinations and necessary medical, dental, or mental health evaluations (including those for substance abuse)
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Activity Codes Code 8. b. Referral, Coordination, and Monitoring of Medicaid Services Making referrals for and/or coordinating medical or physical examinations and necessary medical health evaluations for pregnant women Making referrals for and/or scheduling EPSDT screens and interperiodic screens Arranging for Medicaid covered medical, dental, mental health diagnostic or treatment services Tracking requests from families for assistance with medical, dental, mental health services and/or providers Gathering information needed in advance of medical, dental, mental health referrals
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Activity Codes Code 8. b. Referral, Coordination, and Monitoring of Medicaid Services Participating in a meeting to coordinate or review a student’s need for Medicaid related services (not related to IEP or 504) Providing follow-up contact to ensure that a child has received the prescribed medical, dental, and/or mental health services Coordinating, monitoring and evaluating a plan of care and the delivery of services for a child with special or severe health needs (i.e. diabetic or asthmatic child) Coordinating completion or termination of prescribed services and referral to other Medicaid service providers to allow continuity of care Providing information to other staff on child’s medical, dental, and mental health services and care plans
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Activity Codes Code 9. General Administration
Use when performing activities that are not directly assignable to previously described codes Paid time off (i.e. paid lunch, breaks, vacations, personal days, sick days, etc.) Comp time for paid hours previously worked Work time prior to late start or following early dismissal Establishing goals and objectives for health related programs as part of the school’s planning process Reviewing school or district procedures or rules
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Activity Codes Code 9. General Administration
Attending or facilitating staff meetings, training, or board meetings Performing administrative or clerical activities related to district functions or operations Supervising staff such as student teachers or volunteers Evaluation of employee performance Reviewing technical literature and research articles
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Activity Codes Code 9. General Administration
Training health assistants on medication administration and medical procedures Training of school staff on health topics such as bloodborne pathogens and medical conditions / diagnoses pertinent to the student population Includes related paperwork, clerical activities, or staff travel required to perform the activities
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Activity Codes Code 10 Not Scheduled to Work
Use when NOT scheduled to be at work at the time of the coding sample Unpaid time off which may include unpaid lunches, breaks, vacations, personal days, sick leave, and other unpaid time Time when part-time staff are not scheduled to work
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Documentation of Medicaid Providers
CMS requires tracking of providers. Each agency must identify providers to whom students are referred or with whom services are coordinated or monitored. These providers may include physicians, dentists, psychologists, psychiatrists, opticians, therapists, AEAs and other providers such as pharmacies. For determining the Medicaid provider percentage, maintain a tracking document for all providers as to whether or not they participate in the Medicaid.
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Documentation of Medicaid Providers
Suggested format for tracking is provided. Any modifications must be approved by DHS MACSS Auditor Website link to Medicaid provider list will be provided by Department of Education. Submit tracking document with initial claim. Maintain documentation of the Medicaid provider percentage for the audit file.
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Audit File Audit file must be retained for 5 years
Include these components related to coding: Coding policies Job descriptions reflecting activities claimed Table of organization Tracking document(s) supporting the determination of the Medicaid provider percentage Documentation of technical assistance & training Certifications for coders
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Use of Federal Reimbursements
Per contract must be used to expand or enhance health related services for children Narrative submission required in annual report to DHS Due September 30 of each year
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Getting Started Determine whether participating as lead agency or sub-agency Establish MACSS agreement (lead or sub) each year New contracts to begin October 1, 2003 – June 30, 2004. New coding structure and RMS time study anticipated to begin January 1, 2004. School districts that have no previous experience with the program may begin when RMS time study is implemented.
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Getting Started Identify key contact personnel for MACSS
Certified coder from lead agency and certified back-up coder Contact persons for RMS Time Study and Fiscal components Determine appropriate staff for inclusion in the RMS time study Provide list of participating staff by name and position to Lead Agency and then DHS. Update job descriptions and Table of Organization Establish process for tracking providers
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On-line Resources CMS Medicaid School-Based Administrative Claiming Guide, May 2003 DHS Administrative Rules – Chapter 78 Go to Rules; Medicaid and State Supplementary Assistance; Chapter 78 (Amount, Duration, and Scope of Medical and Remedial Services) Iowa’s Medicaid State Plan Go to “select a state” and click on Iowa
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State Level Contacts Sally Nadolsky Anieta O’Hair Janet Beaman
Lead Agreements & Annual Report: Sally Nadolsky IA Dept. Human Services Hoover State Office Building 1305 East Walnut Des Moines, IA Phone: FAX: MACSS Auditor & Invoice Processing: Anieta O’Hair Phone: FAX: Training & Technical Assistance: Janet Beaman IA Dept. Public Health Lucas State Office Building 321 East 12th Street Phone: FAX:
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Process for Questions and Answers
Questions may be submitted at anytime. Written responses will be developed for those questions submitted by Wednesday, October 15th. Submit to Janet Beaman at Written responses will be sent to all participants.
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