section 1011 undocumented alien program edna buffington-price

1. 1 Section 1011Undocumented Alien Program

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3. 3 Section 1011 Eligibility Eligible patients: Undocumented Aliens who enter the United States without legal permission or who fail to leave when his or her permission to remain in the US has expired Aliens who have been paroled into the US at a port of entry for the purpose of receiving eligible services Mexican citizens permitted to enter the US for not more than 30 days under the authority of a laser visa Section 1011 is a payer of last resort.

4. 4 Section 1011 Payments can be made to Hospitals, Physicians or Ambulance providers that have enrolled in the Section 1011 program. Providers must complete a Section 1011 Provider Enrollment application, EFT authorization and ERA request form. Once the Section 1011 enrollment has been processed, an EDI enrollment form must be completed to submit claim electronically. Paper claims are not permitted.

5. 5 Section 1011 A Provider Payment Determination Form must be completed for each patient. The Patient�s Medical Record number and place of birth (city and state) must be recorded. A baby born within the US does not qualify for Section 1011 although the parent may. This form is not submitted at the time of billing but must be kept on file in case it is requested by Trailblazers. The hospital representative is not allowed to ask the patient directly if they are undocumented.

6. 6 Questions that can be asked to determine eligibility If the patient does not have a SSN ask why If the patient does not have a SSN, ask if they have a visa or permanent residence card. If not, ask why. The patient presents an expired boarder crossing card, visa or permanent residence status card. If the patient provides none of the supporting documentation, ask the patient if they would like to apply for the Section 1011 program. You can explain what the program entails. If the patient volunteers that they are Undocumented, they are eligible for Section 1011. You should document in your records how this was communicated to Hospital

7. 7 How Eligibility Vendors can help: Screening for 1011 coverage Understanding the program Who is eligible What services are covered Good documentation in account notes, screening process

8. 8 How Eligibility Vendors can help: Assure the patient that we are not asking these questions for immigration. Work with local churches and shelters to help identify patients that may qualify for this service

9. 9 Supporting Documents The following supporting documents are accepted: Border Crossing Card (only allowed 25 miles within a boarder zone of TX, NM and CA and 75 miles within the boarder of AZ) Form I-94 that is stamped �Parole� or �Parolee� Foreign Birth Certificate Foreign Passport Foreign Voting Card Expired Visa Invalid Boarder Crossing Card Foreign Driver�s License Other Foreign ID Card including Matricula Consular Federal or State Officer/Agency Custody (Must obtain the Agency Name and Agent Name and ID Submitted an Invalid Social Security Number (can be verified via Equifax or other credit reporting tool)

10. 10 Eligible Services Health care services covered under EMTALA and related inpatient, Emergency Room and ambulance services Inpatient services up to the point of stabilization defined as �A patient�s emergency medical condition must be resolved, even though the underlying medical condition may persist�. Example of stabilization point �A patient presents with an asthma attack. The asthma attack is resolved although the medical condition still exists�. Section 1011 believes that most patients are stabilized within 2 days. Any inpatient admissions that are billed for more than 2 days will prompt an automatic request of medical records.

11. 11 Excluded Services Certain Revenue Codes and Diagnosis Codes are not eligible for billing Some revenue codes not eligible: 253, 259, 28X, 29X, 33X, 34X, 40X, 42X, 43X, 44X, 47X, 52X, 77X, 91X, 94X Example DX not eligible: Screenings, Physical Therapy, Most V codes, Chemotherapy, Pre-OP Exclusion List can be found at: http://www.trailblazerhealth.com/Section1011/Documents/FinalExclusionList.pdf

12. 12 Billing for Services Providers must bill electronic claims via DDE or their electronic billing vendor (if available). Section 1011 has adopted most Medicare billing requirements such as 72 hour rule, NCDs, CCI edits, etc.

13. 13 Billing for Services Payment received by any other service or by the patient must be reported as a third party payment Section 1011 can be billed for the Medicaid or other payer deductible or copay Providers can balance bill patients for any non-covered services not paid by Section 1011

14. 14 Billing for Services It is important for facilities to have their Case Manager to determine the point of stabilization if the patient was admitted and stayed over 2 days. A hospital representative should notate in the account that all documentation and provider payment forms were obtained so that billers can be certain account is eligible for billing Timely Filing: Claims are to be billed within 180 days after the end of the quarter of the date of service (ie Service date: 8/24/07, quarter ending date: 9/30/07, timely filing date: 3/28/08)

15. 15 Payment and Reimbursement Reimbursement is made according to the Medicare DRG, APC or fee schedule. The Medicare payment may be adjusted according to the amount allotted to the state and the amount of claims that have been submitted for the quarter Claims are paid 60 days after the timely filing date The facility must receive payment via EFT and ERA.

16. 16 Payment and Reimbursement ERAs can be retrieved via the Trailblazer Bulletin Board System. Trailblazers will assign a PV ID, password and BBS instructions. This will be faxed to the contact person. The facility can post the ERA via their electronic remit posting vendor or manually depending on volume. If manually posting, the remit can be retrieved via GPNet (hyperterminal) and translated/printed via PC Print. PC Print can be downloaded via the Section 1011 website. http://www.trailblazerhealth.com/Section1011/Resources.aspx This should be posted as a �other governmental� payer.

17. 17 Medical Review and Compliance Review Requests Compliance requests should be submitted with a completed Provider Payment Determination form and copies of supporting documentation Medical review requests should be submitted with the Provider Payment Determination Form, supporting documentation, itemized bill with the UB-04 form, ER records, H&P, Physician orders, Nursing Notes, Progress notes and Discharge Summary. ER report, anesthesia reports and ambulance run sheet should also be sent if applicable.

18. 18 Other Items Any changes to claims cannot be made online once the claim is submitted. A change must be made by either calling Trailblazers customer service (866-860-1011) or sending an email (section.1011@trailblazerhealth.com) with a subject line of Payment Request Correction needed. Facilities can submit a dispute request form within 45 days of the post-payment activity. The dispute form and requirements can be found at http://www.trailblazerhealth.com/Section1011/DisputeResolution.aspx

19. 19 Final Thoughts Questions and Answers can be found at the Section 1011 website: http://www.trailblazerhealth.com/Section1011/Default.aspx Providers can sign up for the Listserv via the website above

20. 20 Life After 1011 How will these patients obtain health insurance Screening services with Eligibility vendors will be important to establish Self Pay Initiatives will need to be in place in order to collect POS Review Charity Policies Possible Bad Debt increases due to no coverage or assistance.