Reporting Requirements

CBAS Emergency Remote Services (ERS) Initiation Form(CEIF) (CDA 4000)
See reporting guidelines table below.
- Instructions (CDA 4000i)
ERS Monthly Report
See reporting guidelines table below.
- Instructions
Discharge Summary Report (CDA 4008)
See reporting guidelines table below.
- Discharge Summary Report
- Instructions
Incident Report (CDA 4009)
See reporting guidelines table below.
- Incident Report (CDA 4009)
- Instructions
Monthly Statistical Summary Report (MSSR)
See reporting guidelines table below.
- Instructions
Participant Characteristics Report (PCR) (CDA CBAS 293)
See reporting guidelines table below.

Reporting Guidelines

REPORT	DUE DATE	REPORTING PERIOD	SUBMISSION PROTOCOL
CEIF	Upon Initiation of ERS	N/A	Submit using the Peach Provider Portal at https://peach.aging.ca.gov/
ERS Monthly Report	By the 10th of each month	For the previous month if ERS provided	Submit using the Peach Provider Portal at https://peach.aging.ca.gov/
Discharge Report	Upon discharge of Fee-For-Service participant	Cumulative for each calendar year	Submit using the Peach Provider Portal at https://peach.aging.ca.gov/
Incident Report	24 or 48 hours from time of incident (see instructions for specifics)	N/A	Submit using the Peach Provider Portal at https://peach.aging.ca.gov/
MSSR	By the 10th of each month	For the previous month	Submit using the Peach Provider Portal at https://peach.aging.ca.gov/
PCR	January 31st	Preceding December	Submit using the Peach Provider Portal at https://peach.aging.ca.gov/

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires health care providers and organizations, as well as their business associates, to comply with Federal HIPAA standards and provisions detailed in 45 CFR. This includes developing and following procedures that ensure the confidentiality, privacy, and security of patient healthcare records, plans and Protected Health Information (PHI) when it is transferred, received, handled, or shared. This applies to all forms of PHI, including paper, oral, and electronic.

Failure to follow these procedures may compromise the security and privacy of PHI, thereby resulting in a potential HIPAA violation and fine. In these instances, CDA’s Information Security Officer will be notified and will contact the center.