Form Mo 886 4246N – Fill Out and Use This PDF

STATE OF MISSOURI

DEPARTMENT OF SOCIAL SERVICES

CHILD CARE PROVIDER PAYMENT RESOLUTION REQUEST

The payment resolution process is a formal process for child care providers to have their child care payments reviewed when discrepancies occur. To initiate the review, this form must be completed by the child care provider and must be submitted within 60 days of the end of the service month in question. The attendance sheets for each child and service month listed below must be submitted with this form.

This form must also be used when a child care provider is submitting any regular invoices 60 days past the service month or 60 days past the “Return by” date found on the paper invoice, whichever is later. A statement must be included in the “Explanation” section below explain- ing why the invoices are being submitted late.

Mail all information to: Early Childhood and Prevention Services Section, Children’s Division, Attn: PRRP Unit, PO Box 88, Jefferson City, MO 65103-0088. Incomplete forms or forms submitted without attendance sheets cannot be processed and will be returned to the provider. Note: Submission of this form does not guarantee payment. ECPSS will review the request and verify the child’s and provider’s eligibility. Once the review is complete, ECPSS will notify the provider of the outcome.

CHILD CARE PROVIDER/FACILITY

The information provided below along with the attendance sheets will be used to review payment. Attach additional sheets if more space is needed.

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

*In the Reason for Review column, enter the letter that best describes the situation:

•A - This child was not on my invoice.

•B - The rates on my invoice were incorrect.

•C - I provided more units of care than the child was authorized.

•D - I was not paid for the units I submitted on my invoice.

•E - Other; explain in space below.

EXPLANATION

MO 886-4246N (2-06)