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. 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 explaining why the invoices are being submitted late. The attendance records for each child and service month listed below must be submitted with this form.
CHILD CARE PROVIDER/FACILITY
CONTACT NAME	DVN	TELEPHONE NUMBER
MAILING ADDRESS	CITY	STATE	ZIP CODE
The information provided below, along with complete attendance records, will be used to review payments for child care services provided. Your request will be reviewed and you will be notified of the outcome. Submission of this form does not guarantee payment.
CHILD'S NAME	DATE OF BIRTH	DCN	SERVICE MONTH/YEAR	REASON FOR REVIEW*
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 (attach additional pages if necessary)
Return this form, along with attendance records for the child(ren)/month(s) in question to the address, email, or fax below: DSS – CHILD CARE PAYMENT UNIT PO BOX 88 JEFFERSON CITY MO 65103 CD.AskCCOIS@dss.mo.gov FAX: 573-526-2926 For questions or additional information, please call 573-522-1385.
PROVIDER SIGNATURE	DATE

CHILD CARE PROVIDER PAYMENT RESOLUTION REQUEST

PURPOSE:

The Child Care Provider Payment Resolution Request is the form providers are required to submit when payments need to be reviewed for discrepancies. Submitting the Child Care Provider Payment Resolution Request will initiate the process for payments to be reviewed for discrepancies.

INSTRUCTIONS:

This form may be typed or legibly handwritten by the child care provider or a representative of the child care provider.

To be eligible for review, all Child Care Provider Payment Resolution Request forms must be submitted with complete attendance records for each child and service month in question.

CHILD CARE PROVIDER/FACILITY - Enter the child care facility name or the child care provider's name.

CONTACT NAME - Enter the name of the person that can be contacted for any questions pertaining to the resolution request.

DVN - Enter the Departmental Vendor Number (DVN) for the facility or the provider.

TELEPHONE NUMBER - Enter the telephone number of the contact name.

MAILING ADDRESS - Enter the mailing address of the facility or individual child care provider.

CITY - Enter the city for the mailing address of the facility or individual child care provider.

STATE - Enter the state for the mailing address of the facility or individual child care provider.

ZIP CODE - Enter the zip code for the mailing address of the facility or individual child care provider.

CHILD'S NAME - Enter the child's name for which payment review is being requested. Each form allows up to ten children to be listed for payment review.

DATE OF BIRTH - Enter the child's date of birth for which payment review is being requested.

DCN - Enter the child's DCN for which payment review is being requested. A DCN will need to be entered for each individual child listed.

SERVICE MONTH/YEAR - Enter the service month and year for which payment review is being requested.

REASON FOR REVIEW - Enter the letter (A – E) corresponding to the reason for the review request. (The different reasons are listed below the child's name listing 1 – 10.)

EXPLANATION - Enter any information that may support the request for review.

RETURN THE CHILD CARE PROVIDER PAYMENT REQUEST - Return the form along with attendance records to:

Child Care Payment Unit

PO Box 88, Jefferson City, MO, 65103

CD.AskCCOIS@dss.mo.gov

FAX: 573-526-2926

PROVIDER SIGNATURE - You must sign the request and keep a copy for your records.

DATE - Enter the date of the request.

SUBMIT - Once the Child Care Provider Payment Resolution Request has been completed in full, submit the request to the DSS – Child Care Payment Unit via mail, email, or fax along with the attendance record(s) for each child in question. Provider must keep a copy of the requests and attendance records for their records. Attendance records will not be returned to provider.