The Section 1011 Provider Payment
Determination form allows hospitals, physicians and ambulance
providers to ascertain and document a patient's eligibility status
under Section 1011 of the Medicare Modernization Act of 2003. The
form is maintained by the provider as documentation of patient
eligibility, for payment and related policy determinations and is
used by the Centers for Medicate & Medicaid Services to ensure
program payments are made only for eligible patients. The "Request
for Section 1011 Hospital On-Call Payments to Physicians" form
allows hospitals to calculate and request federal reimbursement
under section 1011 of the MMA for on-call payments made to
physicians, on a quarterly basis.
PL:
Pub.L. 108 - 179 1011 Name of Law: Federal reimbursement of
emergency health services furnished to undocumented aliens
On behalf of this Federal agency, I certify that
the collection of information encompassed by this request complies
with 5 CFR 1320.9 and the related provisions of 5 CFR
1320.8(b)(3).
The following is a summary of the topics, regarding
the proposed collection of information, that the certification
covers:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a
benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control
number;
If you are unable to certify compliance with any of
these provisions, identify the item by leaving the box unchecked
and explain the reason in the Supporting Statement.