Form CMS-10130B REQUEST FOR SECTION 1011 HOSPITAL ON-CALL PAYMENTS TO PH

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
OMB No. 0938-0952

REQUEST FOR SECTION 1011 HOSPITAL ON-CALL PAYMENTS TO PHYSICIANS
PROVIDER NUMBER

ON-CALL PERIOD
TO

FROM

PART I
1. Section 1011 (c)(3)(C)(ii) of MMA 2003 provides for the election by a hospital for a portion of the on-call
payments made by the hospital to physicians. If your hospital made the election under section 1011(c)(3)(C)(ii),
check “Yes” and complete the entire form. If “No” you are not eligible to claim on-call payments made to
o No
physicians. o Yes
PART II – IDENTIFICATION DATA
2. NAME OF HOSPITAL
3. STREET ADDRESS

P.O. BOX

4. CITY

STATE

ZIP CODE

COUNTY

PART III – CALCULATION SUMMARY
ON-CALL
CALCULATION

5. Enter the charges made by the hospital for providing Emergency Department
services to individuals identified in section 1011(c)(5) (see instructions).
6. Enter the total charges made by a hospital for providing Emergency Department
services to all patients (see instructions).
7. Apportionment ratio (Line 5 divided by line 6).
8. Total On-Call Costs (see instructions).
9. On-Call Payment Amount (Line 7 times Line 8).
PART IV – CERTIFICATION
Misrepresentation or falsification of any information contained in this report may be punishable by criminal,
civil and administrative action, fine and/or imprisonment under Federal Law. Furthermore, if services identified
in this report were provided or procured through the payment directly or indirectly of a kickback or where
otherwise illegal, criminal, civil and administrative action, fines and/or imprisonment may result.
A hospital receiving Section 1011 payments (hereinafter “payee”) acknowledges that those payments may be
retroactively adjusted at the end of each fiscal year in accordance with subsection (c)(2) of Section 1011. If
CMS determines that payments must be retroactively adjusted, the payee agrees that it will promptly remit the
full amount of the reduction to CMS in accordance with instructions provided with the Notice of Retroactive
Adjustment. Payee acknowledges that there will be no appeal or review of the determination of retroactive
adjustment. Any payment owed to CMS must be remitted promptly, but in no event later than 30 days after
notice.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0938-0952. The time required to complete this information collection is estimated to average 45 minutes per response, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please
write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.

Form CMS-10130B (05/05) EF (05/2005)

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CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDER(S)
I HEREBY CERTIFY that I have read the above statement and that I have examined the manually submitted
report by ______________________________________________________ (Provider Name(s) and
Number(s)) for the reporting period beginning __________________ and ending ___________________ and
that to the best of my knowledge and belief, it is a true, correct and complete statement prepared from the
books and records of the provider in accordance with applicable instructions, except as noted. I further certify
that I am familiar with the laws and regulations regarding the provision of health care services and that the
services identified in this report were provided in compliance with such laws and regulations.

(Signed) ____________________________________________
Office or Administrator of Provider(s)
____________________________________________
Title
____________________________________________
Date

Form CMS-10130B (05/05) EF (05/2005)

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INSTRUCTIONS FOR COMPLETING THE REQUEST FOR SECTION 1011
HOSPITAL ON-CALL PAYMENTS TO PHYSICIANS FORM
PART I
LINE 1 — If the hospital made the election under section 1011(c)(3)(C)(ii) of the Medicare Modernization Act of 2003 to
seek payment for a portion of on-call payments made to physicians, check “Yes,” and complete all parts of this form. If the
response is “No,” your facility is not eligible to claim on-call payments made to physicians.
PART II — IDENTIFICATION DATA
The information required in this section is needed to properly identify the provider.
LINE 2 — Enter the hospital name.
LINE 3 — Enter the street address and P.O. Box (if applicable) for the facility.
LINE 4 — Enter the city, state, ZIP code, and county information for the facility.
PART III — CALCULATION SUMMARY
Part III determines the allowable on-call costs for emergency health services furnished to section 1011(c)(5) individuals by
apportioning costs on the basis of applying the ratio of Emergency Department charges for section 1011(c)(5) individuals
divided by total Emergency Department charges for the entire hospital multiplied by the total Emergency Department costs
for the entire hospital. This calculation is applied on a Federal fiscal quarterly basis.
LINE 5 — Enter from your accounting books and/or records the charges recorded by the hospital for providing Emergency
Department services to individuals identified in section 1011(c)(5) of MMA 2003 during the quarter.
LINE 6 — Enter from your accounting books and/or records the total charges recorded by the hospital for providing
Emergency Department services to all patients during the quarter.
LINE 7 — Determine the apportionment ratio by dividing the amount on line 5 by the amount on line 6. Round the result to
six decimal places.
LINE 8 — Enter from your accounting books and/or records the total cost for on-call physician services furnished to all
patients during the quarter.
LINE 9 — Determine the allowable on-call payment amount claimed by multiplying the ratio on line 7 times the amount on
line 8 and enter the result.
PART IV — CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDER(S)
This certification is read, prepared, and signed after the cost statement has been completed in its entirety. The cost statement
will not be accepted by the contractor unless it contains an original signature.
GENERAL
This form is used only by hospitals identified in section 1011 (e)(3) of the MMA and who have enrolled in the section 1011
program and who are seeking payment for on-call payments made to physicians.
In completing this form, the information reported must be obtained from the accounting books and records of the hospital.
DUE DATE
This form must be filed with the designated contractor within 180 days following the end of each Federal fiscal quarter.

Form CMS-10130B (05/05) EF (05/2005)

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