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Section 1011 Provider Payment Determination CMS-10130A - Official Federal Forms
| Section 1011 Provider Payment Determination Form. This is a national form and can be used in Centers For Medicare And Medicaid Services . |
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DEPARTMENTOF HEALTH AND HUMAN SERVICES Form ApprovedCENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0952 SECTION 1011 PROVIDER PAYMENT DETERMINATION The information collected on this form is used to determine whether a pa tients health care provider is eligible to receive Federal payment under section 1011 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. The information on this form is only being collected to claim payment fo r a patients health care. This information will be maintained for health care payment and related policy determinations. Providers may not claim a section 1011 payment for United States citizens, lawful permanent residents with a valid I-551 (i.e., Green Card), aliens with a valid I-688B (Employmen t Authorization Card), or individuals in the United States on a valid non-immigrant visa (such as students, tour ists, business travelers, etc.) EMERGENCYMEDICALTREATMENT AND LABOR ACT SCREENING AND STABILIZATION MUST BE COMPLETED BEFORE REQUESTING ELIGIBILITYINFORMATION Patients Hospital Medical Record Number Patients Place of Birth A provider should not ask a patient if he or she is an undocumented alien. However, if the patient informs you that he or she is undocumented, check (3 ) this box o . If checked, sign and date page 2. The patient is an eligible individual for section 1011 payment purposes. 1. Is the patient eligible for, or enrolled in, Medicaid or emergency Medicaid? o Yes. A section 1011 payment is not generally available for this patient. If checked, sign and date page 2. o No. Provide a reason why the patient is not eligible for Medicaid and go to question 2 below. Reason patient is not eligible:_______________________________________________________________ 2. Is the patient a Mexican citizen with a border-crossing card (i.e., laser visa, Form DSP-150) or has the patient been paroled into the United States at a United States port of e ntry with a Form I-94 that is stamped with term Parole or Parolee? o Yes. Attach a photocopy of the patients Form DSP-150 or I-94. The patient is an eligible individual for section 1011 payment purposes. Skip question 3 below. o No. Go to 3 below. o Patient declines to answer or is unable to provide a copy of Form DSP-15 0 or I-94. Go to 3 below. 3. The combination of a reported foreign place of birth and verification can be used as an affirmative demonstration of eligibility. Please check (3 ) any of the following that apply and attach a photocopy of any documentation obtained to establish payment eligibility. Providers must check at least one box and obtain verification in order to submit an individual payment request. o Foreign birth certificate, a foreign passport, a foreign voting card, an expired visa, invalid border crossing card, foreign driver s license, a Matricula Consular, or other foreign identification card. o Submitted Social Security Number (SSN) is invalid. (Before checking (3 ) this box, the provider is required to verify and maintain evidence that the SSN is invalid.) o Federal or State officer/agent custody. Agency Name Agent Name/ID Form CMS-10130A(05/05) EF (05/2005) 1 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2NOTICE: I certify that the patient has been provided health care services as requi red by the application of section 1867 of the Social Security Act (42 U.S.C. 1395dd) and related services to achieve stabilization. I certify that, to the best of my knowledge and belief, the responses on this form accur ately reflect the information that has been obtained with respect to this patient, and nothing I am aware of is inconsistent with a determinationthat the individual is an undocumented alien or an otherwise eligible alien under section 1011(c)(5). PROVIDER REPRESENTATIVE SIGN AND DATE Signature Date Name of Hospital Providing Emergency Care INSTRUCTIONS FOR COMPLETING SECTION 1011 PROVIDER PAYMENT DETERMINATION In determining a patients eligibility status, a provider is responsible for completing, signing, and dating this form and obtaining the documents to affirmatively determine patient eligibility. Enter the patients hospital medical record number and place of birth. A section 1011 payment is not available for individuals born in the United States. A providershould not ask a patient if he orshe is an undocumented alien.However, if a patient voluntarily informs you that he or she is an undocumented alien, please check the box provided, sign, and date. The patient is an eligible individual for section 1011 payment purposes. QUESTION 1 Determine whether the patient is eligible for, or enrolled in, Medicaid or emergency Medicaid. If the patient is not eligible for Medicaid or emergency Medicaid, state the reason. QUESTION 2 Enter the patients response to question 2. If the patient states that he or she is in the United States with a border-crossing card or has been paroled into the United States, copy and retain the patient s Form DSP-150 or I-94. If the patient declines to answer or is unable to provide a copy of Form DSP-150 or I-94, a section 1011 payment is not available. QUESTION 3 A provider may claim a section 1011 payment when a patient reports a foreign place of birth and the provider verifies eligibility in one of the following ways. FOREIGN DOCUMENTATION VERIFICATION: Patients reporting a foreign place of birth must submit one of the documents listed as proof of their eligibility. The provider must maintain verification information. SOCIALSECURITYNUMBER VERIFICATION: Immigrants who are not legally able to obtain a Social Security number are not required to have one. If the patient provides a Social Security number voluntarily and it is determined to be invalid, the provider may check the Submitted Social Security number (SSN) is i nvalid box. While the Social Security Administration cannot validate Social Security numbers for section 1011 payment purposes, providers may use their current practices and procedures or internal documentation to verify the authenticity of the S ocial Security number provided. The provider must maintain verification information. FEDERAL OR STATE CUSTODY VERIFICATION: When a Federal or State officer or agent brings a patient into the emergency room, enter the name of the Federal or State Agency and the name and/or badge number of the officer or agent. Obtaining this information may not delay EMTALAscreening and stabilization. RETENTION: Once complete, a provider must main
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