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Request for Billing and Payment Records Letter

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									    Section 1011
Provider Symposium
       December 5, 2007
         Dallas, Texas


       Symposium Topics

1. Program Information

2. Enrollment

3. Eligibility

4. Payment Processing

5. Compliance Reviews

6. Web Updates

                 Section 1011   2
               Section 1011 Provision

 Allows $250 million annually for Fiscal Years
  (FYs) 2005-2008.

 Allows annual state allotments based on the
  state’s relative percentage of undocumented
     Percentage determined by number of undocumented
      aliens who reside in each state divided by the total
      number of undocumented aliens in all states.
        (Data obtained from Census bureau).

                              Section 1011                   3
            Section 1011 Provision

 Two-thirds of funds are divided among 50 states
  and the District of Columbia.

 One-third of funds is divided among six states
  with the largest number of undocumented alien
  apprehensions. (Dept. of Homeland Security data)

                      Section 1011                   4
                                    Pro Rata Reduction

            Section 1011 Pro Rata Reductions Q1 FY 2007 - 10/1/06 to 12/31/06
                          Value of Total       Amount of
        Total Available                                     Value of Final               % of Pro Rata
               Funds          Payments
                                                                             Balance          Reduction

AL      $   144,163.01    $   546,553.27   $   402,392.79   $   144,160.48   $    2.53          73.62%

CT      $ 232,509.72      $ 880,276.05     $ 647,771.08     $ 232,504.97     $    4.75          73.59%

DE      $   133,623.55    $   224,127.84   $    90,504.52   $   133,623.32   $    0.23          40.38%

FL      $ 2,968,403.03    $ 5,435,887.08   $ 2,467,502.67   $ 2,968,384.41   $   18.62          45.39%

KS      $ 286,660.04      $ 590,261.65     $ 303,602.96     $ 286,658.69     $    1.35          51.44%

LA      $    34,698.70    $   131,174.62   $    96,477.59   $    34,697.03   $    1.67          73.55%

NE      $   161,041.89    $   180,148.27   $    19,106.88   $   161,041.39   $    0.50          10.61%

NV      $ 1,032,735.94    $ 1,426,766.31   $ 394,045.65     $ 1,032,720.66   $   15.28          27.62%

              Medicare Similarities

 Section 1011 is contracted by the Centers for
  Medicare & Medicaid Services (CMS).
                 TEXT                  TEXT

 Section 1011 is administered through TrailBlazer
  Health Enterprises, LLC.

 Section 1011 uses the Medicare payment
  methodology (formula) and a replicate of the
  Medicare Part A processing system.

                        Section 1011                 6
              Medicare Differences

 Section 1011 is a quarterly reimbursement
  program, not an “insurance” plan.

 You submit payment requests instead of claims.

 Section 1011 is not a Medicare Carrier, Fiscal
  Intermediary (FI) or Medicare Administrative
  Contractor (MAC).

 Reimbursement based on the Section 1011 Final
  Implementation Notice. Program does not change.
                      Section 1011                 7
  The TrailBlazer Connection


            Centers for Medicare &
              Medicaid Services



                 Section 1011                           8

 Alien – A non U.S. citizen.
      Undocumented alien is a person who enters the U.S.
       without legal permission or who fails to leave when
       permission has expired or Aliens who have been
       paroled into the U.S. at a U.S. port of entry.

 GPNet – Gateway Production Network
  allows electronic connectivity to TrailBlazer’s
  processing system.

                          Section 1011                       9

 Laser Visa – Biometric, machine readable,
  border crossing identification card.

 Pro Rata Reduction – Calculated reduction of
  total payments for a state if available funds are

                       Section 1011                   10

 ACT – Ask the Contractor Teleconference.

 CMS – Centers for Medicare & Medicaid

 DRG – Diagnosis Related Group.
        Payment methodology used in calculating
        1011 payments.

 DDE – Direct Data Entry.

                      Section 1011                11
               Acronyms continued

 EDI – Electronic Data Interchange.

 EFT – Electronic Funds Transfer.

 EMC – Electronic Media Claims.

 EMTALA – Emergency Medical Treatment
      and Labor Act. (Section 1867 of the
        Social Security Act)

 ERA – Electronic Remittance Advice.

                     Section 1011           12
                  Acronyms continued

 HIPAA – Health Insurance Portability and
          Accountability Act of 1996.
 NPI – National Provider Identifier.
 PR – Payment Request.

 PPD – Provider Payment Determination Form.

 UARS – Undocumented Alien Reimbursement
 UPIN – Unique Physician Identification Number.
                       Section 1011            13
Provider Enrollment

       Section 1011   14
              Enrollment Requirements

 Medicare Participating Providers
     Provider Enrollment Application (CMS Form 10115).

     Authorization Agreement for Electronic Funds
      Transfer – EFT (CMS Form 588).
        Must include voided check, pre-printed deposit slip or
         banking verification letter must be included with EFT.

     Electronic Remittance Advice (ERA) request

                              Section 1011                        15
         Enrollment Requirements continued

 Non Medicare Participating Providers:
     Section 1011 Provider Enrollment Application
      (CMS Form 10115 in hard copy):
        Form 855I - Physicians.
        Form 855B - Ambulance companies.
     Authorization Agreement for Electronic Funds
      Transfer – EFT (CMS form 588).
        Voided check, pre-printed deposit slip or banking verification
         letter must be included with EFT.

     Electronic Remittance Advice (ERA) request
                              Section 1011                            16
                 Provider Enrollment Cycle

Fiscal Year 3,
 4th Quarter

                         Section 1011        17
       Enrollment Application

  2. Applicants Legal Business Name              3. Doing business as (DBA)

 4. Address
 (Include county)

 6. State of Service                            7. Current Fiscal Intermediary / Carrier

                                                9. Applicant’s Medicare ID Number

 10. Hospital election (Hospital only)

11. Physician Privileges (Physician only)

                                 Section 1011                                              18
Enrollment Application page 2

14. Type Name and title of authorized

                                   Section 1011   19
          Hospital Roster

Attachment 1

               Section 1011   20
Physician Privileges Roster

  Attachment 2

                 Section 1011   21
              EFT Authorization

National Provider ID (NPI)

                             Section 1011   22
          ERA Request Form

Existing ERA Receiver ID #, if applicable

Provider Number(s):

                            Section 1011    23
                Enrollment Changes

 Changes may include:
     Enrollment Form Data Changes.

     Roster Changes.

     Hospital Election Changes.

                         Section 1011   24
          Application Change Process

 When changing physical address, hospital
  election, physician privilege, etc., follow these
    Write change at the top.
    Make necessary changes in applicable sections.
    Include Attachment 1 if adding or removing
     physicians from your roster.
    Include Attachment 2 if adding or removing hospital
     facilities from your roster.

                         Section 1011                      25
         Application Change Process

 Enrollment application form must be signed by
  the Authorized Representative.

 Enrollment application form must be mailed and
  not faxed.

 Indicate if the Authorized Representative’s
  information has changed.

                      Section 1011                26
                 Election Changes

 Hospitals choosing to change their election
   Notify all practicing physicians of their intent to
   Submit a new Enrollment application with explanation
    of the change. (Application must have Authorized
    Official’s Signature).

 When a hospital is no longer billing for a
  physician, the physician is withdrawn from the

                        Section 1011                   27
                Election Changes

 When a hospital changes its election to bill for a
  physician and the physician is already enrolled
  in the program, the physician’s PIN for that
  hospital will be terminated.

 Election changes must be made by July 1st of
  the same year.

 Election changes occur annually and are
  effective October 1st of each year.

                       Section 1011                28
           Enrollment Summary

 EFT Agreement and ERA requests are
  required in the enrollment process.
 Changes to the enrollment form must have
  change written at the top of the form and the
  form must be signed by the authorized
 Section 1011 accepts the original signature
  of authorized official on enrollment and EFT
  forms. Photocopies will be returned.
 All incomplete documents are returned to
                   Section 1011               29
Section 1011

    Section 1011   30
            Section 1011 Eligibility

 Eligible services are EMTALA-related services
  (including medical screening) to the point of
  patient stabilization. (FPN notes usually two

 Eligible providers are hospitals, physicians and
  ambulance providers that meet the program

 Eligible aliens are undocumented aliens,
  paroled aliens and Mexican citizens permitted to
  enter the United States for not more than 30
  days under “laser visa” authority.
                      Section 1011                31
             Eligible Services

   “…Health care services required by the
  application of section 1867 [EMTALA] of the
             Social Security Act…”
 and these services include related inpatient,
 outpatient and ambulance services as defined
by the Secretary of Health and Human Services.

                  Section 1011               32
            Eligible Services continued

 Covered services for hospitals begin
  when EMTALA begins and continue until
  the point of stabilization.

 There is no EMTALA obligation after patient

 Triage (screening) services are covered and
  billable to Section 1011.

                     Section 1011               33
                   Eligible Providers

 Hospitals:
   Medicare participating hospitals that meet the
    program requirements
   Indian Health Service (IHS) facilities.

 Providers of ambulance services:
     State licensed providers of ambulance services for
      covered transports to a hospital ER or from one
      hospital to another.

                         Section 1011                      34
              Eligible Providers continued

 Eligible physicians:
    Doctors of medicine.
    Doctors of osteopathy.

 Under statutory restrictions,
  legislation allows if EMTALA
    Doctors of podiatric medicine.
    Doctors of optometry.
    Doctors of dental surgery.
    Chiropractors.
                         Section 1011        35
            Ineligible for Section 1011

 Mid-level practitioners.
      Nurse practitioners.

      Physician assistants.

      Clinical nurse specialists.

      Certified Registered Nurse
       Anesthetists (CRNAs).

                          Section 1011    36
                 Determining Eligibility

 Complete and sign the PPD (or other acceptable
  collection instrument).

 Section 1011 asks that you not ask if a patient is
  an undocumented alien.
    Follow normal screening procedures.
    Can your form be used to answer the PPD?

 If patient refuses (or is unable) to provide proof of
  eligibility, do not submit a payment request.
      Additional 10 percent reimbursement for outpatient
       payment requests.

                           Section 1011                     37
          Determining Eligibility continued

 Some acceptable forms of ID:
   Foreign voting card, driver’s license or passport.
   Matricula Consular card (Mexican Gov’t).
   Border-crossing card (“laser visa”).
   Form I-94 stamped Parole or Parolee.

 Some unacceptable forms of ID:
   Foreign student ID.
   Resident Alien card (green card) issued by U. S.
    Citizenship & Naturalization Services.
    Patient is documented, unless green card has

                         Section 1011                    38
                   Ineligible Patients

   US Citizens.
   Permanent Residents.
   Aliens with employment authorization.
   Individuals with valid non-immigrant visas:
     Tourists.
     Students.
     Business travelers.

                            Section 1011          39
Provider Payment Determination

           PPD Page 1            40
                     Eligibility Summary

 Eligible Section 1011 services must be EMTALA–related
  services to the point of stabilization.

 When completing the PPD form (CMS 10130A) to
  determine patient eligibility:
      If you checked yes – stop. Sign and date.
      If you checked no – continue to the next question.

 If you choose an alternative collection document, it must
  capture the same data as the PPD to be acceptable.

 Section 1011 asks that you not inquire if a patient is an
  undocumented alien.

                               Section 1011                 41
 Undocumented Alien
Reimbursement System

       Section 1011    42

 Undocumented Alien Reimbursement System,
  designed for processing and paying Section
  1011 payment requests exclusively.

 Ensures all payment requests are submitted
  electronically in a HIPAA-compliant format.

 Replicate of the Fiscal Intermediary Shared
  System (FISS).

                      Section 1011              43
                       UARS continued

 All provider types can access UARS and submit
  payment requests through Direct Data Entry

 Hospitals also have the option to submit
  payment requests via Electronic Media Claims

 Electronic PR submissions only:
     Final Policy details that payment requests cannot be
      submitted hard copy.
                          Section 1011                       44
UARS Entry continued

     Section 1011      45
UARS Entry continued

     Section 1011      46
UARS Entry continued

     Section 1011      47
UARS Entry continued

     Section 1011      48
UARS Entry continued


         Section 1011   49
UARS Entry continued

     Section 1011      50
UARS Entry continued

     Section 1011      51
                      UARS Availability

 UARS hours of availability:

     Monday through Friday
        7 a.m. – 8 p.m. (CT)

     Weekends and holidays
        7 a.m. – 2 p.m. (CT)

                                Section 1011   52
                  Billing Example

 If patient or third party payment is received prior
  to billing Section 1011, the payment is reported
  on the payment request in the value codes field
  and is subtracted from the Section 1011

 Example:
    Hospital submits payment request for $1000.
    The Section 1011 reimbursement amount is $600.
    Patient pays $100.
    Section 1011 subtracts the $100 payment and
     reimburses the hospital $500.

                       Section 1011                   53
              UARS Common Mistakes

 Billing mistakes:
      Professional fees should not be submitted with type of
       bill (TOB) 111. Only hospitals can submit TOB 111.

      Duplicate charges which occur because the patient
       HIC is used on more than one payment request
       (system retains information from initial submission).

 Coding mistakes:
      Many providers fail to include the ICD-9 procedure
       code and procedure dates while billing operating
       room charges (revenue codes with 036X prefix) .

                            Section 1011                       54
         UARS Common Mistakes continued

 Anesthesia billing mistakes:
     Submit payment requests with the inappropriate

     Submit the anesthesia duration in minutes only. Time
      can be two or three digits and must be entered in the
      total covered (TOT COV) field.
        Example: If the anesthesia duration is 2 hours, enter the
         duration as 120 instead of 002.

                              Section 1011                           55
                   UARS Corrections

 UARS does not allow online corrections or
  adjustments. If an error is discovered:
     Identify the error via fax or e-mail and include the

     E-mail correction to:
        Subject: Payment Request Correction Needed.

     Or, fax correction to (469) 372- 6143.
        Subject: Payment Request Correction Needed.

                           Section 1011                       56
                 UARS Corrections                continued

 Body of e-mail or fax must contain:
   Section 1011 PIN.
   Patient Identification number.
   Patient control number.
   Medical record number.
   Payment request dollar amount.
   Date(s) of service.
   How the error should be corrected.

     Name, title and telephone number of billing contact

                          Section 1011                       57
                  Payer of Last Resort

 Section 1011 is payer of last resort
     You should seek payment from all available funding
      sources prior to billing Section 1011.

     This includes federal, state and third party payers:
        Department of Homeland Security.
        Medicaid or State Children’s Health Insurance Program.
        Private insurers or Health Maintenance Organizations
        Patients.

     This process is consistent with the statute and it limits
      reimbursement to instances where no other
      reimbursement will likely be received.
                             Section 1011                         58

 Receipt of a payment from the patient or third
  party subsequent to Section 1011 payment.

 Assessed due to Medical Review and
  Compliance Review findings.

 Providers should notify Section 1011 that an
  overpayment has occurred.

 Withhold overpayments from the next quarterly
  Section 1011 payment.
                      Section 1011                 59

If the balance is not a sufficient balance in the
      next quarterly payment (to repay the
overpayment in full), TrailBlazer will notify you
 and allow 30 days to repay the overpayment
           without accrual of interest.

                   Section 1011                     60
               Excluded Services

 Based on EMTALA regulations, certain revenue
  centers are not considered emergency services
  and are excluded from 1011 payment.

 Additionally, certain diagnosis codes, when used
  as the primary diagnosis, are excluded from the
  1011 program.

                     Section 1011                61
                Excluded Codes

 View the Revenue Center Exclusion List for
  excluded codes. The following revenue codes
  are always excluded from Section 1011
   0960
     0961
     0962
     0964
     0969

                    Section 1011                62
               Professional Fees

 Professional fees are outpatient charges and are
  billed under the physician’s Provider
  Identification Number (PIN) with bill type 131.

 Specific revenue codes apply only to physicians’
  services for billing purposes. For the billing
  codes, see Revenue Codes for Physicians on
  the Section 1011 website under payment
  request processing.

                      Section 1011               63
                    UARS Summary

 UARS is an electronic system:
     Submit through DDE (all provider types) or EMC
      (facility charges only).

     Section 1011 does not accept hardcopy payment

     Corrections may not be made online (you should fax or
      e-mail the corrections).

     Revenue code 036X must have procedure code(s) and
      procedure date(s).

     Bill type 111 is for Inpatient and 131 is for Outpatient.
                           Section 1011                     64
Compliance Reviews

      Section 1011   65
               Compliance Reviews

Why conduct Compliance Reviews?
  1.   To ensure payments are made to providers for
       eligible services.

  2.   To ensure hospital on-call payments to physicians
       are properly calculated.

  3.   To ensure inappropriate, excessive or fraudulent
       payments are not made from state allotments.

  4.   To ensure PR submissions are supported by clinical
       and non-clinical documentation.

                         Section 1011                      66
                     Basis for Reviews

 Included but not limited to:
      Identified billing inconsistencies.

      High utilization rates or high denial rates.

                             Section 1011             67
        Compliance Review Process

 Two types of Compliance reviews:
            performed in conjunction with
   In-house,
   Medical Review.

   On-site,more detailed reviews performed at
   the provider facility.

                    Section 1011                 68
        In-House Compliance Review

 Payment requests selected for Medical Review
  and Compliance Review.

 You are required to furnish PPD form (or other
  acceptable collection instrument) and applicable
  supporting documents in a hardcopy format.

 PPD form (or other acceptable collection
  instrument) must be consistent with medical
  records and other supporting documents
  associated with the services rendered.

                      Section 1011               69
                    On-Site Review

 You will be notified six to eight weeks prior to the
  scheduled review.

 Compliance auditors come to your site to review:
    Patient eligibility documentation.
    Medical records.
    Social workers notes.
    Patient accounts receivable.

                          Section 1011              70
                 On-Site Review

 Conduct an entrance conference to
  communicate review purpose.

 Review your policies and procedures to
  determine patient eligibility.

 Interview staff members associated with
  admitting patients and completing the Provider
  Payment Determination (PPD) form.

                      Section 1011                 71
                 On-Site Review

 Review business records to ensure collection
  efforts from all payment sources have been

 Review medical records to ensure patient
  information is complete and consistent.

 Communicate daily audit findings to provider.

 Conduct an exit conference to communicate
  audit findings and recommendations.
                      Section 1011                72
         On-Site Review Preparation

 If eligibility data is stored electronically, be
  prepared to provide a copy of the form(s) used
  to determine eligibility.

 Ensure availability of all records associated
  with the payment requests being reviewed.

                      Section 1011                   73
       Compliance Review Summary

 Ensures integrity of the Section 1011 program.

 Ensures eligibility, accuracy and consistency of
  patient’s medical records.

 Ensures payments are not fraudulent or

                      Section 1011                 74
Medical Review

    Section 1011   75
                  Medical Review

 July 2, 2007 – the Medical & Compliance
  Review processes were streamlined.
   Providers now receive one letter.
   Payment requests selected for Medical Review are
    also reviewed for eligibility.
   Every payment request sent to TrailBlazer is subject
    to review by two Section 1011 departments.
 The Medical Review department examines all
  billed services, while the Compliance Review
  department verifies patient eligibility.

                        Section 1011                       76
                    Medical Review

 New Process for Reducing Payment Requests:
     When the number of days submitted in a payment
      request is reduced by Medical Review, this is referred
      to as a reduction to the point of stabilization.

     Effective Monday, November 12, 2007, Medical
      Review implemented a new process for handling
      these reductions.

                          Section 1011                     77
                              Medical Review

 Providers will now receive a letter notifying them of the number of
  days approved and requesting the following documentation relating
  to those days:

       A corrected hard copy bill in the form of a UB-04 (CMS-1450) for the
        payment requests that were reviewed and reduced to the point of

       An itemized bill showing charges for room and board only and
        ancillary expenses associated with the days approved.

       A hard copy of the notification letter received to help expedite
        the match-up and processing of the corrected bill to the provider file.

 Providers will have 30 days to submit the corrected bill before the
  payment request is denied or funds are set up to be withheld.
  Medical Review decisions may be disputed within the allowable time

                                    Section 1011                                  78
Dispute Resolution

      Section 1011   79
          Dispute Resolution Process

 Most disputes received are the result of Compliance
  Review denials.
 Submit disputes no later than 45 days after payment
  date or any post-pay activity.
    Must submit PPD (and supporting documents) along
     with the completed dispute request form. If disputing
     a medical decision, all applicable documentation that
     supports the dispute should be submitted.
    Once dispute is received, a second review is
    Dispute decisions are final and may not be appealed.

                         Section 1011                    80
Web Navigation

    Section 1011   81
                    Web Navigation

 Let’s navigate the following web links:
   ListServ.
                Section 1011 hospitals.
   Participating
   Questions and Answer document.
   Program payments.

                       Section 1011         82
 Thank you
for attending!

    Section 1011   83

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