Frequently Asked Questions
TRAUMA CENTER FINANCIAL WORKSHOP
FREQUENTLY ASKED QUESTIONS AND CONTRACT REQUIREMENTS
Who is eligible for this program?
Only patients who meet the indigent definition and meet the trauma criteria who are unable to pay for services and for whom there is no third-party coverage in part or in whole for trauma services provided qualify under this funding program. No reimbursement shall be provided for patient care if the patient has the ability to pay for the service but refuses or fails to pay for it.
When can I bill the program?
To bill County, Contractor must at a minimum show that it has made reasonable efforts to secure payment for the patient by billing (at least monthly) for an additional period of not less than two (2) months after the date Contractor first billed the patient.
REFERENCE: EXHIBIT B PAGE 2
What documents do I have to submit to bill the program?
- A completedOriginalUB-04 form
- A completedOriginalTSCE form (Attachment U-1)
- AcompletedOriginal Inability to Cooperate form (Attachment U-2)
- A printout of the data in the Trauma and Emergency Information System(TEMIS)
Hospitals must ensure that all data elements from UB-04 match the data elements from TEMIS. Claims eligible for inclusion in the County’s payment methodology shall only include claims for which all required documentation matches TEMIS.
When can an Inability to Cooperate Form (U-2) be submitted?
If a TSCE Agreement form cannot be secured because the patient is unable to cooperate in providing the necessary financial information, then a Contractor certification to that effect (Attachment U-2), Hospital Certification of Inability to Cooperate form must be completed.
Examples include, but are not necessarily limited to, situations where the patient has expired, or is comatose or otherwise, mentally incompetent.
What is the difference between Cash/Self and CHIP Eligible?
There is no difference as far as reimbursement goes. They are defined in the Trauma Data
Dictionary as follows:Cash/Self: Individuals who are not insured and do not qualify for other funding source based on ability to pay in accordance with the hospital’s charity care policy, as determined by the hospital’s finance department. For County facilities this includes ATP (Ability to Pay).
Chip Eligible: Individuals who qualify for California Healthcare for Indigents Program which provides limited funds to compensate for patients who cannot afford to pay for services rendered and for whom payment will not be made through any private coverage or by any program funded in whole or in part by the State or Federal government including Medi-Cal or Victims of Crime.
Some Trauma Centers use both they enter either CHIP or Cash as the first payer, or use only Cash and some use only CHIP. Claims submitted are reimbursed if TEMIS has either CASH/Self or CHIP Eligible in any combination. Technically, all patients for whom claims are submitted should have CHIP Eligible as either the first or 2nd payer, but as long as no other payer is in TEMIS, the County will pay.
What are the policies on refunding the County if the hospital receives payment from a patient or third party payer for claims previously paid by the County?
Any and all payments received by the Contractor must immediately be reported and the County’s payment must be refunded. Each refund should have a Trauma Hospital Payment Refund Form (Attachment B-6) attached.
REFERENCE: EXHIBIT B PAGE 8
What if the hospital has submitted a claim and payment has not been issued by the County, but Contractor is informed that there is Third Party Liability (TPL)?
Contractor must pursue the TPL and withdraw the claim by notifying the County indicating that there is pending TPL to the EMS Agency Reimbursement Coordinator at (562) 347-1590.
REFERENCE: EXHIBIT B PAGES 8 & 9
Should the hospital continue to pursue third party payer coverage once the claim has been submitted to the County for reimbursement?
No, the Contractor shall only submit claims that they have determined do not have any other payor source and the patient is indigent. If after the claims is submitted the Contractor finds out the patient does have insurance coverage, the Contractor shall notify the County and refer the payor to the County as the Contractor subrogates all their rights to the claim once they submit the claim.
What are the procedures if a provider is contacted by a third party representative (e.g., insurance claim adjuster) or a patient’s attorney regarding pending litigation for a previously submitted claim?
Contractor shall indicate that the claim for services provided to their client is assigned and subrogated to the County and refer such representatives to the designated County contact. (Contractor shall reasonably cooperate with County in its collection efforts).
What rates would the Contractor be paid if patient is admitted (i.e. on June 29th and discharged on July 5th)?
This claim would be part of the fiscal year that ended in June. Payment by County to Contractor for such patients shall be at the rates in effect on the date.
Can a claim be submitted if there is pending third party liability?
Yes, but these claims should not be submitted until the December 31st deadline nears. These claims may not be paid but will be counted towards the Medi-Cal match total.
Who is considered the last resort of payment, the County or Victims of Crime (VOC)?
A victim of Crime is considered the last resort of payment.
REFERENCE: ATTACHED VOC LETTER
Can a provider bill Victims of Crimes Program (VCP) and submit the claim to the Trauma Reimbursement Program?
No, at any point during the claiming period, the hospital has a choice of the following:
- Submit the claim to VCP and DO NOT SUBMIT to the County or
- Submit the claim to the County andDO NOT SUBMIT TO VCP
If the claim is submitted to the County and then a hospital receives payment from VCP the hospital must surrender the payment from VCP to the County.
What if a payment is received from a third party payer and they are offering less than what the County reimbursed? Can I refuse to take their payment?
No. You must immediately notify the County and refund the County’s payment.
Are in-custody patients covered by this program?
Since In-Custody claims are paid at a low rate, additional funding will be included from the Under–insured bucket when payment is issued to the trauma centers for In-Custody Claims.
1.What are the procedures if payment is received for In-Custody Claims?
- Do not submit claim if payment is received for In-Custody Claim
- Update the TEMIS database to indicate Payor 1 as In-Custody.
- TEMIS will capture the data for claims considered In Custody.
2.What are the procedures if no-payment is received on In-Custody claims?
- Submit claim if payment is not received for In-Custody Claim
- Include a copy of the denial letter from law enforcement or
- The patient notes which indicate the reason why the claim was denied.
- The TEMIS database should indicate Payor 1 as County Indigent.
What is the basis for number of hospital days reimbursed?
The number of hospital days paid will be based upon the number of hospital day room charges on the UB-92, but shall not exceed the number of days calculated between admission and discharge dates. Claims which include hospital day room charges on the UB-92 that exceed the calculated number of days between hospital admission and discharge will be returned for correction.ing hospitalization, they are not eligible. (The key is the status while hospitalized).