Instructions for State Agency Client Reqest for Reimbursement Report (EF-S-04A-B)

The State Agency Client (SAC) Admission/Discharge Notice (EF-S-04A) report is now combined with the monthly SAC Billing (EF-S-04B) report. This report is now the SAC Request for Reimbursement report (EF-S-04A-B).

The EF-S-04A-B report is to be completed monthly for:

1.) Reporting the admission and/or discharge of all eligible students identified as receiving special education services who are SAC and are residing in a School Administrative Unit (SAU).
2.) Requesting reimbursement for special education and related services costs provided to eligible SAC, in accordance with the student’s Individualized Education Program (IEP).

The EF-S-04A-B report must be submitted by email (the report should be attached to the email as an Excel document) to denise.towers@maine.gov at the Maine Department of Education, Office of Special Services, by the 15th of each month, containing the previous month’s information/charges. Each month’s report must be specifically for that month. At no time should charges for multiple months be on the same report. If this occurs, the report will be returned for correction. If an SAU has no SAC, it is not necessary to submit this report.

 

Specific Instructions

  • Indicate the name of the SAU/private school.
  • Indicate the name of the person completing the form.
  • Indicate the telephone number where that individual can be reached.
  • Indicate if this is an original or amended report.
  • Indicate the month and year for which you are billing.
  • Indicate the total number of pages of the report.

Student Information

  • Last name, first name
  • Date of birth
  • Date student became a SAC
  • Date student’s SAC status ended
  • Primary disability (drop-down box)
  • State Agency with which the student is affiliated (drop-down box)

Educational Placement of the Student

  • Identify the name of the school the student is attending.
  • Identify the type of placement (drop-down box).
    • Regular class placement: Where students with disabilities receive a majority of their educational program with non-disabled students, receiving special education and related services outside of that classroom for less than 21% of the school day. This may include students with disabilities placed in regular class, or regular class with instruction within the regular class and with special education/related services provided outside the regular class.

(Accounting codes: Fund 1000, Program 2100, Function 1000)

    • Resource room placement: Where students with disabilities receive special education and related services outside the regular classroom for 60% or less of the school day and at least 21% of the school day. This may include students with disabilities placed in resource rooms with special education/related services provided within the resource room, or resource rooms with part-time instruction in regular class.

 (Accounting codes: Fund 1000, Program 2200, Function 1000)

    • Self-contained placement: Where students with disabilities receive special education and related services outside the regular classroom for more than 60% of the school day in a self-contained program. This may include students with disabilities placed in self-contained special classrooms with part-time instruction in a regular class or self-contained special classrooms full-time.

 (Accounting codes: Fund 1000, Program 2300, Function 1000)

    • Public separate day school placement: Where students with disabilities receive special education and related services for greater than 50% of the school day in public separate day school facilities.

 (Accounting codes: Fund 1000, Program 2500, Function 2330, Object 5610)

    • Private separate day school placement: Where students with disabilities receive special education and related services for greater than 50% of the school day in private separate day school facilities.

(Accounting codes: Fund 1000, Program 2500, Function 2330, Object 5630)
26. Private residential placement: Where students with disabilities reside and receive special education and related services for greater than 50% of the school day in private residential facilities.
(Accounting codes: Fund 1000, Program 2500, Function 2330, Object 5630 and Object 5130)
27. Homebound/hospital placement: Where students with disabilities receiving special education and related services in a medical treatment facility or at home.
(Accounting codes: Fund 1000, Program 2400, Function 1000)

Date of service provided

  • Provide the date (month, day, year) when the services began and ended during the month for the billing period. For students that either entered after the start of the billing period or left prior to the end of the billing period, provide the date the student actually entered as the first date, or the date the student actually left as the last date.

Related services section
Enter separately each related service provided to each eligible student

  • Indicate the last name of the person providing the service.
  • Indicate the license/certificate number of the person providing the service.
  • Indicate how many units of service provided for the month.
  • Indicate the charge per unit.
  • Identify the type of related service being provided (drop-down box).

Definitions of these related services can be found in 34 CFR 300.16.
Diagnostic services should be reported under the appropriate related service code.

  • Psychological services

(Accounting codes: Fund 1000, Program 2800, Function 2140)

  • School social work services

(Accounting codes: Fund 1000, Program 2800, Function 2110)

  • Occupational therapy

(Accounting codes: Fund 1000, Program 2800, Function 2160)

  • Speech and language services

(Accounting codes: Fund 1000, Program 2800, Function 2150)
Note: Do not use this code for students with speech/language impairment (table I, code 4) as their primary disability.

  • Audiological services

(Accounting codes: Fund 1000, Program 2800, Function 2170)

  • Recreational services

(Accounting codes: Fund 1000, Program 2800, Function 2190)

  • Physical therapy

(Accounting codes: Fund 1000, Program 2800, Function 2180)

  • Transportation services (special transportation arrangements)

(Accounting codes: Fund 1000, Program 0000, Function 2750)

  • School health services

(Accounting codes: Fund 1000, Program 2800, Function 2130)

  • Counseling services

(Accounting codes: Fund 1000, Program 2800, Function 2120)

  • Other related services (must specify)

(Accounting codes: Fund 1000, Program 2800, Function 2190)

  • Other direct service

(Accounting codes: Fund 1000, Program 2500, Function 2330)

  • Other special educational costs

(Accounting codes: codes above for each of the specific costs)

  • Out-of-district tuition*
  • Tutoring services*

*Additional public school unit accounting codes for special education are available at the following website: http://www.maine.gov/education/data/handbook/handbookmenu/htm

Transportation charges
Enter separately each transportation cost for each eligible student

  • Transportation is considered a related service and must be listed on the SAC’s IEP.
  • Transportation includes, travel to and from school, and travel in and around school buildings, specialized equipment and a student monitor to accompany the SAC during transportation.

Other direct special education services
Enter separately each direct services provided to each eligible student

  • Unit of time x hourly rate of the Special Education Director (030) related to IEP process and consultation on each SAC.
  • Unit of time x hourly rate of the Assistant Special Education Director (078) related to IEP process and consultation on each SAC.
  • Unit of time x hourly rate of the special education clerical support who helped prepare documents for the IEP process and organized meetings for each SAC.

Other special educational costs
Enter separately each special educational cost for each eligible student

  • Unit of time x hourly rate of special education teacher divided by number of students in class to obtain unit cost for each SAC.
  • Unit of time x hourly rate of education technician divided by number of students in class to obtain unit cost for each SAC.
  • Unit of time x hourly rate of 1-1 education technician assigned to SACs.
  • Tutorial costs for SACs.
  • Unit of time x hourly rate of special education consultant (079), school psychological services provider (093), vocational education evaluator (094), teacher sever impairments (286), teacher hearing impairments (292), teacher visual impairments (291), adapted physical education (515).

Total charges
This column is formulated to calculate the page total and the total of all pages.

Signature of superintendent or designee
It is required that the first EF-S-04A-B report submitted for each school year be signed and dated by the superintendent or superintendent’s designee of the SAU. The first EF-S-04A-B of each school year must be submitted by mail as well as by email (the report should be attached to the email as an Excel document) to denise.towers@maine.gov at the Maine Department of Education, Office of Special Services.

 

Instructions to amend an EF-S-04A-B report

An amendment is submitted when information needs to be added or deleted from a report that has already been submitted to the Maine Department of Education, Office of Special Services. An amended report must contain all of the previously reported information with the exception of the information that you are adding or deleting.

    • Indicate at the top of the report that it is an “amended” report.
    • Either add or delete necessary information from the report that was previously submitted.
    • Submit the amended report by email (the report should be attached to the email as an Excel document) to denise.towers@maine.gov at the Maine Department of Education, Office of Special Services.