fy19 uncompensated trauma care applicationuncompensated trauma care and used to calculate the...

Source: Office of EMS/Trauma Systems UPDATED- NOVEMBER 2019 of 13

Department of State Health Services (DSHS)

Office of EMS/Trauma Systems (OEMS/TS)

Fiscal Year 2019Uncompensated Trauma Care Application

DUE FEBRUARY 28, 2020

ELIGIBILITY PROVISIONS

A DSHS-designated trauma facility in receipt of funding that fails to maintain its

designation must return an amount as follows to the account by no later than 90

days after noncompliance is determined:

(i).

(ii).

(iii).

1 to 60 days expired/suspended designation: 0% of the facility’s hospital

allocation for the state biennium when the expiration/suspension occurred;61 to 180 days expired/suspended designation: 25% of the facility’s hospital

allocation for the state biennium when the expiration/suspension occurred

plus a penalty of 10%; orgreater than 180 days expired/suspended designation: 100% of the facility’s

hospital allocation for the state biennium when the expiration/suspension

occurred plus a penalty of 10%

• An undesignated facility recognized as “in active pursuit of designation”

If a trauma designation is not attained by an undesignated facility in active pursuit of

designation on or before the second anniversary of the date the facility wasrecognized by the department, any funds received by the undesignated facility for

unreimbursed trauma services must be returned to the state, plus a penalty of 10%,

no later than 90 days after noncompliance is determined.

• Prior to receiving any future disbursements from DSHS, a facility must have paid, in

full, all outstanding balances owed to DSHS.

APPLICATION INFORMATION

PARTS A, B, & C

Application must be received by email on or before FEBRUARY 28, 2020

All parts (Parts A, B, and C) of the application must be emailed as a single submission

to: [email protected]. The file name(s) submitted must include the name of the

facility for identification purposes (Example: Subject line – Happy Days Hospital).

Confirmation of receipt will be sent within 24 – 48 hours. Please note confirmation receipt does

not imply the submission has been reviewed. If you have not received a confirmation email

within 24-48 hours, you may contact Indra Hernandez at the OEMS/TS for further instructions

by phone: (512) 834-6669 or by email: [email protected].

mailto:[email protected]?subject=FY18-UCC%20application%20submission%20(Hospital%20Name%20here)

mailto:[email protected]?subject=FY18-UCC%20application%20confirmation%20inquiry


Department of State Health Services (DSHS) Office of EMS/Trauma Systems (OEMS/TS)



INFORMATION FOR COMPLETING THE APPLICATION (Designated facilities under a multi-location license must apply individually)

PART A – APPLICATION

Item Description

Facility Name Enter the business name of the hospital—not the name of the

organization that owns the hospital.

License

Number

A unique number assigned by the Texas Department of State Health

Services to identify licensed hospitals in the state of Texas. Please refer

to the following link if you are unable to locate your hospital’s license

number: http://dshs.texas.gov/facilities/find-a-licensee.aspx

Mailing

Address

Enter the facility’s mailing address, city, state, and zip code.

Contact Enter the name, title and phone number for the contact person who

can verify questions on this application.

TPI # The Texas Provider Identifier (TPI) number is a nine-digit number that

uniquely identifies a Texas Medicaid billing provider.

NPI# The National Provider Identifier (NPI) is a unique 10-digit number

acquired by healthcare providers to identify themselves in a standard

way throughout their industry. The NPI is issued by the U.S. Centers

for Medicare & Medicaid Services (CMS) through the CMS National Plan

and Provider Enumeration System (NPPES).

Designation

Status

If the facility currently has a trauma designation, indicate what the

level of designation is at the time of completing the application.

If the facility is an undesignated facility “in active pursuit” of

designation (IAP), the following requirements must be met prior to the

application deadline:

Submitted to the department a “letter of intent” to trauma

designate and a timely and sufficient complete application (with

fee) to the department’s trauma facility designation program

Evidence of participation in your Trauma Services Area (TSA)

Regional Advisory Council (RAC) initiatives

Evidence of a hospital trauma performance improvement

committee

Submitted data to DSHS EMS/Trauma Registry.

Pt. Records in

TR

Total number of patients entered in to the facility’s Trauma Registry by

your facility for calendar year 2017. Please consult with your Trauma

Nurse Coordinator/Trauma Program Manager for this information.

Trauma

Activations

Total number of times the trauma team was activated in the facility for

calendar year 2017. Please consult your Trauma Nurse

Coordinator/Trauma Program Manager for this information.

ED Visits Total number of all patients evaluated in and discharged from your

emergency department for calendar year 2017.

http://dshs.texas.gov/facilities/find-a-licensee.aspx






Facility

Charges

Uncompensated Trauma Care Charges for trauma patient discharges occurring in calendar year 2017 (sum of uncompensated trauma care

classified as charity care or bad debt according to the Hospital’s policy).

PatientRecords

Reported

The total number of patient accounts defined or identified as

uncompensated trauma care and used to calculate the facility’s total

uncompensated trauma care charges listed in Facility Charges

Example: Facility's trauma registry has 200 patient accounts. Of these accounts, 52 are uncompensated trauma care. The 52 accounts will be

reported and included in the total Facility Charges portion of the

application.

Collections Total collections received on uncompensated patient accounts

submitted in previous Uncompensated Trauma Care Applications from

2005 to 2018 AND not previously reported as collected.

Uncompensated Trauma Care - The sum of “bad debt” and “charity care” resulting

from trauma care after due diligence to collect. Contractual adjustments in

reimbursement for trauma services based upon an agreement with a payor (to include

but not limited to Medicaid, Medicare, Children’s Health Insurance Program (CHIP), Crime

Victims Account, etc.) are not uncompensated trauma care.

1. Bad debt-- The unreimbursed cost to a hospital providing health care

services on an inpatient or emergency department basis to a person who is

financially unable to pay, in whole or in part, for the services rendered and

whose account has been classified as bad debt based upon the hospital’s bad

debt policy. A hospital’s bad debt policy should be in accordance with

generally accepted accounting principles.

2. Charity care-- The unreimbursed cost to a hospital providing health care

services on an inpatient or emergency department basis to a person classified

by the hospital as “financially indigent” or “medically indigent”.

Financially indigent-- An uninsured or underinsured person who is

accepted for care with no obligation or a discounted obligation to pay for

the services rendered based on the hospital’s eligibility system.

Medically indigent-- A person whose medical or hospital bills after

payment by third-party payors (to include but not limited to Medicaid,

Medicare, CHIP, etc.) exceed a specified percentage of the patient’s

annual gross income, determined in accordance with the hospital’s

eligibility system, and the person is financially unable to pay the

remaining bill.

PART B – AFFIDAVIT

This form must be completed and signed by all individuals listed to be eligible for funding. The application must be signed and sworn to, before a Texas Notary Public by the Chief ExecutiveOfficer, Chief Financial Officer, and the Chairman of the facility's board of directors.






PART C – SUPPORTING DATA SUBMISSION

Submit via email detailed data for patient accounts and claims in Part A – Application. The

Facility Charges and Patient Records Reported on Part A – Application must match the

information submitted in Part C – Supporting Data Submission.

DSHS will determine the facility’s uncompensated trauma care costs by utilizing the cost-to-

charge ratio provided by the Texas Health and Human Services Commission (HHSC) Rate

Analysis Section.

Cost-to-charge ratio – A Hospital's overall cost-to-charge ratio determined by HHSC from

the hospital’s Medicaid cost report. The hospital's latest available cost-to-charge ratio shall

be used to calculate its uncompensated trauma care costs.

If a facility does not have a Medicaid cost-to-charge ratio determined by the HHSC from the

hospital’s Medicaid cost report, the facility’s cost-to-charge ratio will be derived from an

average of the cost-to-charge ratios provided by qualified hospitals that year.

Please refer to the following Texas Health and Safety Codes for the statute that authorizes

uncompensated trauma care:

Texas Health & Safety Code; Title 9, Safety

Chapter 773. Emergency Medical Services

Chapter 780 Trauma Facilities and Emergency Medical Services

Please refer to the following Texas Administrative Codes that outline the Hospital Allocation

process:

Title 25, Part 1, Chapter 157.130, EMS and Trauma Care System Account

Title 25, Part 1, Chapter 157.131, Designated Trauma Facility and Emergency

Medical Services Account

http://www.statutes.legis.state.tx.us/Docs/HS/htm/HS.773.htm

http://www.statutes.legis.state.tx.us/Docs/HS/htm/HS.780.htm

http://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=25&pt=1&ch=157&rl=130



Out of the 86th Texas Legislature, Regular Session, Senate Bill (SB) 500 provided supplemental appropriations to the Department of State Health Services (DSHS) from the economic stabilization fund for increasing trauma capacity and improving related trauma response infrastructure under EMS and Trauma Care Systems. Of the amount appropriated, $15,000,000 may be used only to provide funding in accordance with Section 780.004, Health and Safety Code, to hospitals that demonstrate regional need and the ability to efficiently and effectively increase trauma capacity and improve related trauma response infrastructure. The Department of State Health Services shall allocate not more than 40 percent of the appropriated amount to provide funding to hospitals located in a region directly affected by Hurricane Harvey.

Pursuant to his powers as Governor of the State of Texas, Greg Abbott issued a proclamation stating that a state of disaster continues to exist in Texas as a result of catastrophic damage caused by Hurricane Harvey in the following counties: Angelina, Aransas, Atascosa, Austin, Bastrop, Bee, Bexar, Brazoria, Brazos, Burleson, Caldwell, Calhoun, Cameron, Chambers, Colorado, Comal, DeWitt, Fayette, Fort Bend, Galveston, Goliad, Gonzales, Grimes, Guadalupe, Hardin, Harris, Jackson, Jasper, Jefferson, Jim Wells, Karnes, Kerr, Kleberg, Lavaca, Lee, Leon, Liberty, Live Oak, Madison, Matagorda, Milam, Montgomery, Newton, Nueces, Orange, Polk, Refugio, Sabine, San Patricio, San Augustine, San Jacinto, Trinity, Tyler, Victoria, Walker, Waller, Washington, Wharton, Willacy, and Wilson.

To be considered eligible for these allocated funds for Harvey-affected areas, the facility submitting this application must be located in one of the counties identified by the proclamation issued by Governor of Texas.





DUE FEBRUARY 28, 2020Senate Bill (SB) 500 Funds for Hospitals in Harvey-Affected Regions


Fiscal Year 2019 Uncompensated Trauma Care Application


Senate Bill (SB) 500 Funds for Hospitals in Rural Counties Not Affected by Hurricane Harvey

Out of the 86th Texas Legislature, Regular Session, Senate Bill (SB) 500 provided supplemental appropriations to the Department of State Health Services (DSHS) from the economic stabilization fund for increasing trauma capacity and improving related trauma response infrastructure under EMS and Trauma Care Systems. Of the amount appropriated, $15,000,000 may be used only to provide funding in accordance with Section 780.004, Health and Safety Code, to hospitals that demonstrate regional need and the ability to efficiently and effectively increase trauma capacity and improve related trauma response infrastructure. The Department of State Health Services shall allocate not more than 20 percent of the appropriation remaining to provide funding to hospitals located in rural counties in Texas that were not affected by Hurricane Harvey.

Pursuant to definition described in Texas Administrative Code, Title 25, Part 1, Chapter 157, Sub-Chapter G, Rules 157.130 and 157.131, the Department of State Health Services, Office of EMS/Trauma Systems has deemed following counties as rural:

Andrews, Archer, Armstrong, Bailey, Bandera, Baylor, Blanco, Borden, Bosque, Brewster, Briscoe, Brooks, Brown, Burnet, Callahan, Camp, Carson, Cass, Castro, Childress, Clay, Cochran, Coke, Coleman, Collingsworth, Comanche, Concho, Cooke, Cottle, Crane, Crockett, Crosby, Culberson, Dallam, Dawson, Deaf Smith, Delta, Dickens, Dimmit, Donley, Duval, Eastland, Edwards, Erath, Falls, Fannin, Fisher, Floyd, Foard, Franklin, Freestone, Frio, Gaines, Garza, Gillespie, Glasscock, Gray, Hale, Hall, Hamilton, Hansford, Hardeman, Hartley, Haskell, Hemphill, Hill, Hockley, Hopkins, Houston, Howard, Hudspeth, Hutchinson, Irion, Jack, Jeff Davis, Jim Hogg, Jones, Kendall, Kenedy, Kent, Kimble, King, Kinney, Knox, La Salle, Lamar, Lamb, Lampasas, Limestone, Lipscomb, Llano, Loving, Lynn, Marion, Martin, Mason, McCulloch, McMullen, Medina, Menard, Mills, Mitchell, Montague, Moore, Morris, Motley, Navarro, Nolan, Ochiltree, Oldham, Palo Pinto, Panola, Parmer, Pecos, Presidio, Rains, Reagan, Real, Red River, Reeves, Roberts, Robertson, Runnels, San Saba, Schleicher, Scurry, Shackelford, Shelby, Sherman, Somervell, Stephens, Sterling, Stonewall, Sutton, Swisher, Terrell, Terry, Throckmorton, Titus, Tyler, Upshur, Upton, Uvalde, Val Verde, Ward, Wheeler, Wilbarger, Winkler, Wood, Yoakum, Young, Zapata, and Zavala

To be considered eligible for these funds for rural counties, the facility submitting this application must be located in one of the counties identified as rural by the Department of State Health Services.






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PART A – APPLICATION

For assistance with any part of this application, please contact Indra Hernandez

(512)834-6669 or [email protected])

Facility and Trauma Patient Information:

City/State/Zip:

Hospital Name

Mailing Address

Contact Name/Title

Phone Hospital License Number

Texas Provider Identifier # (TPI)

National Provider Identifier # (NPI)

Hospital is currently a Designated Trauma Facility? Yes No Level

If not currently designated, hospital has met “in active pursuit of designation”

requirements before this application’s due date? Yes No N/A

Number of patients entered into the facility’s Trauma Registry from

January 1, 2017 thru December 31, 2017:

Number of trauma team activations at the facility from

January 1, 2017 thru December 31, 2017:

Total number of all patients evaluated in the emergency department from January 1, 2017 thru December 31, 2017:

Financial Information

Facility’s Charges - Use patient discharges from January 1, 2017 thru December 31, 2017 to complete this section

$

$

For uncompensated trauma care:

(Sum of uncompensated trauma care classified as charity care or bad debt according to the Hospital’s policy)

Number of patient accounts used to calculate the facility’s

uncompensated trauma care charges

Collections received on uncompensated patient accounts

submitted in previous Uncompensated Trauma Care

Applications AND not previously reported as collected

Source: Office of EMS/Trauma Systems UPDATED- NOVEMBER 2019

mailto:[email protected]





PART B – AFFIDAVIT (NOTE: This form must be completed with required signatures individually notarized

to be eligible for funding)

I, __________________________________________, Chief Executive Officer for

the hospital named above, swear or affirm that the information contained in this

application is true and correct. I also swear or affirm that I have fully read and

understand the stipulations listed in this application.

Furthermore, I am attesting to eligibility for the SB500 funds for the following county (select one):

REQUIRED:

Subscribed and sworn before me, a Notary Public, on _________________ (date).

__________________________,

Notary Public

County: ____________________

State of ____________________

My Commission expires:

_________________________

__________________________

Notary’s printed name:

__________________________

Chief Executive Officer:

__________________________

Name (printed or typed) Signature

Harvey-affected County: Rural County:






I, __________________________________________, Chairman of the Board of

Directors for the hospital named above, swear or affirm that the information

contained in this application is true and correct. I also swear or affirm that I have

fully read and understand the stipulations listed in this application.


REQUIRED:


__________________________,

Notary Public

County: ____________________

State of ____________________

Notary’s printed name: My Commission expires:

__________________________ _________________________

Chairman of the Board of Directors:

__________________________ __________________________



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I, __________________________________________, Chief Financial Officer for

the hospital named above, swear or affirm that the information contained in this

application is true and correct. I also swear or affirm that I have fully read and

understand the stipulations listed in this application.


REQUIRED:


__________________________, Notary Public

County: ____________________

State of ____________________

My Commission expires:

_________________________

__________________________

Notary’s print name:

__________________________

Chief Financial Officer:

__________________________

Name (printed or typed)

Source: Office of EMS/Trauma Systems UPDATED- NOVEMBER 2019

Signature






I, __________________________________________, Trauma Medical Director for

the hospital named above, acknowledge that a copy of this application was made

available for my review.

Trauma Medical Director:

__________________________ _________________________


I, __________________________________________, Trauma Program Manager

for the hospital named above, acknowledge that a copy of this application was

made available for my review prior to submission.

Trauma Program Manager:

__________________________ _________________________







PART C – SUPPORTING DATA SUBMISSION Uncompensated Trauma Care Charges (for discharges occurring in calendar year 2017),

INCLUSION CRITERIA: Trauma care – Care provided to patients who: (each checkbox below must be checked to include as eligible patient)

met the facility’s trauma team activation criteria and/or were entered into the

facility’s Trauma Registry.

underwent treatment specified in at least one of the following International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10 CM) codes:

S00-S99 with 7th character modifiers of A, B, or C ONLY. (Injuriesto specific body parts – initial encounter)

T07 (unspecified multiple injuries) T14 (injury of unspecified body region) T20-T28 with 7th character modifier of A ONLY (burns by specific

body parts – initial encounter) T30-T32 (burn by TBSA percentages) T79.A1-T79.A9 with 7th character modifier of A ONLY (Traumatic

Compartment Syndrome – initial encounter) Excluding the following isolated injuryies:

o S00 (Superficial injuries of the head)o S10 (Superficial injuries of the neck)o S20 (Superficial injuries of the thorax)o S30 (Superficial injuries of the abdomen, pelvis, lower

back, and external genitals)

o S40 (Superficial injuries of shoulder and upper arm)o S50 (Superficial injuries of elbow and forearm)o S60 (Superficial injuries of wrist, hand, and fingers)o S70 (Superficial injuries of hip and thigh)o S80 (Superficial injuries of knee and lower leg)o S90 (Superficial injuries of ankle, foot, and toes)o Late effect codes, which are represented using the

same range of injury diagnosis codes but with the 7th

digit modifier code of D through S, are also excluded

MEETS at least one of the following criteria:

were transferred into or out of the hospital.

underwent an operative intervention (See definition below); were admitted as an inpatient for greater than 23-hours; died after receiving any emergency department evaluation or

treatment; or were dead on arrival to the facility leaves hospital against the advice of the doctor (AMA)

Operative intervention-- Any surgical procedure resulting from a patient being taken directly from

the emergency department to an operating suite regardless of whether the patient was admitted to the hospital.


Office of EMS/Trauma Systems(OEMS/TS)

Fiscal Year 2019 Uncompensated Trauma Care Application



Guidance for completing form:

(Do not use medical records or Social Security Numbers in submission)

For Trauma Services (columns in blue)

• Unique Patient Identifier: (determined by facility)

• Pt in Trauma Registry: (Yes or No)

• Meets Facility Trauma Team Activation Criteria:

(Yes or No, e.g. Alert, Consult, Activation, Met but not activated)

• TRAUMA ICD-10 codes (Provide only codes that meet inclusion criteria)

• Transferred in or out: (Yes or No)

• Disposition from Emergency Department: (e.g. Admitted, ED to OR, Death, AMA,

Transfer)

• Admitted: (Yes or No)

• Admit Date: (Month / Date / Year)

• Admit Time: (Military Time)

• Discharge Date: (Month / Date / Year)

• Discharge Time: (Military Time)

For Finance (columns in green)

• Uncompensated charges (amount claimed in the Application): sum total of the

spreadsheet must be consistent with information entered into the application above.

• Original Amount Billed to Patient: total amount before payment made by third-party

payors (Medicaid, Medicare, CHIP, etc.) OR total amount before applying calculated

charitable dollar amounts.

fy19 uncompensated trauma care applicationuncompensated trauma care and used to calculate the...

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