Section 1011 Reimbursement and Compliance Reviews

Compliance Reviews

Compliance Reviews for the Section 1011 program were established to ensure that payments are made for emergency services provided to eligible patients only. The Compliance Review process is also designed to ensure that on-call payments to physicians are properly calculated.

Page 67 of the Final Policy notes, “… establish measures to ensure that inappropriate, excessive, or fraudulent payments are not made from the state allotments, including a certification by eligible providers of the veracity of the payment request. To ensure claim submissions are supported by clinical and non-clinical documentation, we are adopting a position of compliance reviews. These reviews may be based on, among other things, identified aberrancies and claims volume.”

TrailBlazer selects and reviews payment requests from each provider type, including hospitals, physicians and ambulance, as well as on-call payments to physicians.  Effective July 2, 2007, compliance reviews are conducted in conjunction with medical reviews and providers receive one letter requesting documentation for both Medical Review and Compliance Review.

Compliance Review Request Letters

TrailBlazer contacts providers by letter requesting the following:

• For payment requests:
  
  A signed copy of the Section 1011 Provider Payment Determination form (Form CMS 10130A 05/05) or other equivalent form prepared by the provider. If the Undocumented Alien box is not checked on the form, the provider submits one of the following items:
  • Copy of form DSP-150 or I-94, stamped with term “Parole” or “Parolee.”
  • Copy of foreign birth certificate, foreign passport, foreign voting card, expired visa, invalid border crossing card, foreign driver’s license, “Matricula Consular” or other foreign identification card.
  • Copy of documentation and verification of an invalid Social Security Number (SSN). Providers are required to verify and maintain evidence that the SSN is invalid.

• For on-call payments to physicians:
  • A summary of emergency department charges (revenue code 450), classified by date of service and/or Patient Identification Number (HIC number field in processing system) for all Section 1011 patients.
  • A summary of the hospital’s total revenue classified by revenue codes.
  • A summary of the general ledger expense account of the on-call cost paid to physicians, with accrued expenses clearly identified.

Providers are to send supporting documentation within 14 days to TrailBlazer Health Enterprises.

Requested documentation may also be shipped on an overnight basis to our physical address:

Withholdings

To simplify the administration of the Section 1011 program, TrailBlazer withholds the dollar amount of any identified overpayment from the provider’s next quarterly Section 1011 payment. If the provider does not have a sufficient balance to repay the overpayment in full, then the provider will have 30 days to repay the overpayment without accrual of interest. TrailBlazer will continue to withhold payment from the quarterly payment until the overpayment is repaid.

More information on the withholding of overpayments is located on pages 67 and 68 of the Section 1011 Final Policy.

Third-Party or Patient Payment Notification after Section 1011 Reimbursement

As stated on page 35 of the Section 1011 Final Policy, providers are required to notify TrailBlazer of any payment made by a third party or patient subsequent to any Section 1011 reimbursement. An overpayment may occur if a provider receives payments in excess of the approved payment amount.

Page 67 of the Section 1011 Final Policy indicates that each Section 1011 participating provider agrees to repay any assessed payment. Below is an explanation of the process:

• TrailBlazer withholds any identified overpayments from the next quarterly payment.
• In the event there is an insufficient balance in the next quarterly payment to repay the overpayment in full, Trailblazer notifies the provider via certified letter.
• The provider has 30 days to repay the remaining overpayment balance without accruing interest.
• Upon notification of an existing overpayment, a provider who fails to repay the overpayment within 30 days will accrue and be responsible for any interest determined to be applicable. Currently, the interest rate is 12.625 percent.
• Unpaid overpayments are referred to an appropriate debt collection agency or the United States Department of the Treasury consistent with the requirements of the Debt Collection Improvement Act.

Notifying TrailBlazer of a Potential Overpayment

To notify TrailBlazer of a potential overpayment, submit written notification as follows:

• Send notification to the Director of Reimbursement and Reporting on corporate letterhead or via e-mail to section.1011@trailblazerhealth.com.
• Mail or overnight the notification to one of the Trailblazer addresses shown above.
• Include a copy of the notification letter received.
• Provide all vital information relating to the potential overpayment as listed below.

The overpayment notification must contain the following information:

• HIC/Patient Identifier Number.
• Document Control Number (DCN).
• Provider name.
• Section 1011 Provider Identifier Number (PIN).
• Date(s) of service.
• Amount of payment.
• Reason for overpayment. When naming third parties, be specific (i.e., Medicare, Homeland Security, attorney, etc.)
• Provider contact title, phone number and e-mail address.

Submitting Multiple Overpayments

Multiple overpayments (defined as five or more), can be submitted for processing in the most efficient manner by following these simple steps:

• Send e-mail to section.1011@trailblazerhealth.com with “Overpayment” noted in the subject line.
• Attach a spreadsheet containing all the multiple overpayments. If the spreadsheet is password secured, also include the password in the e-mail.
• All notifications of potential overpayment(s), either multiples or individual ones, must include the required information as listed above.

Fiscal Year (FY) 2007 Section 1011 State Allocations

Click here to review FY 07 Section 1011 state allocations.

Quarterly Section 1011 Program Payments

Quarterly Section 1011 program allocations (amount allocated for that quarter per state) and value of payments (the actual dollar amounts that were paid, excluding overpayments and withholdings) are outlined below for the provider's convenience.

Note: Total Available Funds is the allocation plus the amount that was rolled over from previous quarter(s) plus any payments received from providers.

• Click here to review Third Quarter FY 05 Program Payments.
• Click here to review Fourth Quarter FY 05 Program Payments.
• Click here to review First Quarter FY 06 Program Payments.
• Click here to review Second Quarter FY 06 Program Payments.
• Click here to review Third Quarter FY 06 Program Payments.
• Click here to review Fourth Quarter FY 06 Program Payments.
• Click here to review First Quarter FY 07 Program Payments.
• Click here to review Second Quarter FY 07 Program Payments.
• Click here to review Third Quarter FY 07 Program Payments.