Section 1011 Medical Review

Medical review for the Section 1011 program was established to ensure payment to eligible providers for billed emergency health services rendered to undocumented and other specified aliens and examine the necessity of stabilizing treatment as it relates to the Emergency Medical Treatment and Labor Act (EMTALA).

The following guidelines are listed on page 25 of the Section 1011 Final Policy:

• EMTALA-related services are all the medically necessary inpatient or outpatient services occurring prior to stabilization.
• Medical records must document completely the reasons for the stabilization determination.
• If a determination is not properly documented, stabilization is deemed to have occurred on the second day of the stay.

To streamline the review process, effective July 2, 2007, providers now receive one letter requesting records and documentation for both medical review and compliance review. 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 department verifies patient eligibility.

New Process for Reduced 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.

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 stabilization.
• 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 frames.

Additional Development Request (ADR) Letter

An Additional Development Request (ADR) is sent to applicable providers requesting the following information:

1. Detailed itemized bill with a UB-04 claim form (CMS-1450).
2. Patient registration form.
3. Emergency room records.
4. History and physical.
5. Physician orders.
6. Nursing notes.
7. Progress notes.
8. Discharge summary.
9. Anesthesia record, if applicable.
10. Operative report, if applicable.
11. Case manager notes, if applicable.
12. Social worker notes, if applicable.
13. Ambulance run sheet, if applicable.
14. Transfer form, if applicable.

The provider is asked to select and mark those records that apply to the payment request and then send photocopies of the letter and documents to TrailBlazer. While the records shown in bold print are required, only the provider can determine if the documents labeled if applicable relate to their payment request.

Ambulance providers are requested to submit the following documentation:

• Patient demographics form.
• Billing statement.
• Ambulance run sheet and any other pertinent medical documentation.

Eligibility Documentation

In addition to the noted medical records, providers are also required to submit eligibility information in response to all ADRs:

• A signed copy of the Provider Payment Determination (PPD) 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 should submit 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.

Click here to access the Section 1011 PPD form.
Click here to access instructions on how to complete the PPD form.

Receipt of Records

Requested records must be received within 30 calendar days from the date of the ADR letter. When insufficient medical or eligibility documentation is provided, payment requests for reimbursement are not reviewed and payment is denied.

Keeping Medical Records Contact Information Current

Providers who have not designated a contact name and address for medical review purposes need to do so. If there is not a medical review contact and address on file, the ADR letters are sent to the contact person designated on the enrollment application. If that individual does not handle medical records requests, it is the provider's responsibility to route ADR letters to the correct contact person to ensure expeditious processing of requests. The provider then must notify TrailBlazer to update the medical records contact information on file as follows:

• Identify the contact person for medical records, and include a statement to update our database along with the person's name, address and telephone number of the facility.
• Send an e-mail to Section.1011@trailblazerhealth.com.

Medical Review Mailing Addresses

Mail information requested in the ADR letter to the following post office box address:

TrailBlazer Health Enterprises, LLC
Section 1011 – Medical Review
P.O. Box 660529
Dallas, TX 75266-0529

Requested medical information may also be shipped overnight to our physical address:

TrailBlazer Health Enterprises, LLC
Section 1011 - Medical Review
Executive Center III
8330 LBJ Freeway
Dallas, TX 75243-1213

Medical Review and Compliance Review Determinations

TrailBlazer reviews medical records and eligibility documentation submitted by providers and makes a determination within 30 calendar days of receipt of the records. Should TrailBlazer determine any part of the payment request is not reimbursable, denial reason codes are assigned to the denied services and dates of service. The codes are available either in the Undocumented Alien Request System (UARS) or on the quarterly Electronic Remittance Advice (ERA).

When a payment request is under medical review or compliance review at the end of a payment cycle (end of a fiscal quarter), TrailBlazer finalizes the payment request based on the submitted charges. Should a medical review determination or a compliance review determination result in a denial, the provider is informed as follows:

• Section 1011 mails a letter to the provider notifying them of the postpayment determination and the intent to withhold funds from the next quarter’s eligible payment.
• A second letter is sent to the provider by the Section 1011 Reimbursement and Reporting department disclosing the dollar amount to be withheld. When the provider does not have sufficient reimbursement available in the next quarter, Reimbursement and Reporting notifies the provider of the applicable dollar amount they must refund to Section 1011.

Providers may dispute a decision but may not challenge the payment methodology established in the Section 1011 Final Policy Notice. The request for a dispute resolution must be made no later than 45 calendar days after the payment date for the quarter in which the disputed payment request was billed or no later than 45 calendar days after the payment date in which any postpayment activity was taken on the payment request in question. For instructions, forms and time requirements regarding the Section 1011 Payment Dispute Process, refer to the Dispute Resolution page at:

Section 1011 Excluded Services

Based on the EMTALA regulations, certain revenue centers are not considered emergency services and are excluded from Section 1011 program payment. Additionally, certain diagnosis codes, when used as the primary diagnosis, are also excluded from Section 1011 program payment. Review the Section 1011 Exclusion List.

Customer Service

For further information or questions about medical review determinations, feel free to contact Section 1011 Customer Service toll-free at (866) 860-1011. Representatives are available to assist you Monday - Friday from 8 a.m. - 5 p.m. CT.