Provider Information: Due Date: 1/15/2024
Payment Details:
Year: 2024 Collection #: 1
1356960413
Program/Payee Information: Banking Information:
PP-GEMT Program Email: Payment Methods Accepted:
[email protected] ACH or Wire Transfer
Payment Instructions:
IGT Non-Federal Share (NFS) Breakdown By DHCS Delivery System Managed Care (MC)
MC NFS #1 $574,241.81
MC Admin Fee #1 $0.00
Fee For Service (FFS)
FFS NFS #1 $64,112.81
FFS Admin Fee #1 $0.00
$638,354.62
Please await Wire Request Memo for payment instructions Attention: Please review, sign, and submit the Intergovernmental Transfer (IGT) Certification by January 1, 2024, to [email protected].
IGT Certification forms are required to be submitted prior to each collection due date. Once the IGT Certification form is received, DHCS will send a Wire Request Memo providing payment details and instructions.
Please do not send your IGT payment until you have received the Wire Request Memo as payment details are subject to change.
Total* IGT Transfer Amount:
*Any differences are due to rounding.
Total Amount Due: $638,354.62
Vendor Name: Bank Name:
California Department of Health Care Services US Bank
PUBLIC PROVIDER GROUND EMERGENCY MEDICAL TRANSPORTATION (PP-GEMT) PROGRAM MANAGED CARE AND FEE FOR SERVICE — INVOICE
Provider Name:
City Of Chula Vista
NPI: