This section last updated on Dec 15, 2023

Section G Payment Adjustments

Manual Claims

Child Care Claim, Form 10AD121E (ADM-12-S) is used by child care centers and homes whenever an adjustment is requested. You must clearly document why attendance was not correctly recorded on the POS machine. These forms are available in Section K, Links and Forms. Only one Child Care Claim form per month per child will be accepted and all changes made for that month must be included on the same form. The form needs to be submitted to Finance by email to

If there is more than one child for whom you are filing a manual claim, you must complete a separate claim form for each of them. DHS will return all claim forms that are not properly completed. DHS will also return any claim form unpaid that does not clearly document that there was an extenuating reason why attendance could not be entered on the POS machine, such as a worker or system error.

You should only file manual claims under the following circumstances:

  • Point of service (POS) machine is not issued within 10 days of care being authorized and all paperwork is completed with the EBT contractor, Conduent.
  • The client or authorized representative was not able to swipe attendance within the 10 day time frame due to extenuating circumstances beyond their control such as emergency hospitalization of the client, POS machine failure that cannot be resolved within 10 days, emergency weather conditions, or unexpected termination of care of the child in which the client did not return to the facility to swipe attendance. Remember, DHS will NOT pay for care in most instances where accurate attendance was not recorded in the system unless extenuating circumstances exist.You must document why accurate attendance could not be recorded. In general, the client’s failure to swipe attendance is not considered extenuating circumstances.
  • The client or authorized representative has been swiping attendance, received a denied message and too much time has passed for the client to complete previous in and out swipes once the benefits are approved. Before you submit the form, check the Provider Web to be sure the authorization shows approved for that time period. Remember, submitting the manual claim form does not guarantee payment. The client must be eligible and care must be approved at your facility before payment can be made.
  • ECC Connect App errors or failures will not be paid on a manual claim. The provider should use the Provider Web often to verify attendance is recorded correctly. An EBT card should be used when there are ECC Connect App errors or failures that recorded attendance is not showing on the Provider Web.

Manual claims are not processed until after the 20th of the month following the claim month. This is to allow the system to pay all possible electronic payments first. After this time frame, you can contact Finance – EPS to check on the status of the adjustment request.

If you have any problems filling out this form or have any questions about getting paid, contact Finance at

NOTE: Any days included in a manual claim that are over 90 days old will be rejected.

Payment Adjustments Made by the Client’s Worker

Many times a correction or change is made by DHS that affects the payment amount on attendance information the client already entered into the EBT system. Examples of this include:

  • decreasing the co-payment amount;
  • increasing the amount of care authorized – such as changing part-time to full-time days, approving additional days of use, or increasing a rate to special needs;
  • correcting an incorrect Star status of your facility; or
  • correcting a child’s date of birth which changes the rate of payment for his or her care based on age.

When these changes are made to take effect for dates in the past, or “retroactively,” Finance will adjust your payment upon receipt of the Report of EBT Child Care Payment Adjustments, Form 10EB004E (EBT-4) submitted by the client’s worker. Once the request has been verified and the claim is processed, an adjustment will be made through the EBT system and the deposit made in your weekly payment. Finance staff will wait to process adjustment forms until that month has been paid electronically. Payment adjustments are not made until after the 20th of the month following the claim month. This is to allow the system to pay all possible electronic payments first.