Form 10-5588A Claim for Payment for Nursing Home Care Provided to Vete

OMB No. 2900-0160
Est. Burden: 20 minutes
Expiration Date: February 28, 2019

CLAIM FOR INCREASED PER DIEM PAYMENT FOR
VETERANS AWARDED RETROACTIVE SERVICE CONNECTION
GENERAL INFORMATION
1. VISN

2. STATION NUMBER

4. REPORT QUARTER

3. FOR MONTH ENDING

6. TO (Enter VA Facility)

5. FISCAL YEAR

7. FROM (Enter Name (Level of Care) & Address of State Home)

8. PAY TO

RETROACTIVE CLAIM INFORMATION
9. Name and
Last 4 of SSN

10. Month
and Year

(a)

(b)

11. Days of
Care
Claimed
(c)

12. Basic Per
Diem Rate
Paid
(d)

13. Total
Amount
Claimed
(e)

14. Daily Cost
of Care
Claimed
(f)

15. FY
16. Amount Claimed
Prevailing
at the Service
Per Diem Rate
Connected Rate
(g)
(h)

17. Amount
Due
(i)

18. Total Per Diem Claimed
19. REMARKS

I certify that this report is correct, that all residents included in the report were physically present during the period for which Federal Aid is claimed,
except for authorized absences for which the VA paid per diem.
PRINTED NAME AND TITLE:

20. SIGNATURE OF SVH
ADMINISTRATOR

SIGNATURE:

21. SIGNATURE OF SVH EMPLOYEE
WHEN APPLICABLE

DATE:

PRINTED NAME AND TITLE:
SIGNATURE:

DATE:

TOTAL AMOUNT APPROVED BY VA FOR RETROACTIVE PAYMENT
22. SIGNATURE OF VA STATE HOME
APPROVING OFFICIAL

PRINTED NAME AND TITLE:
SIGNATURE:

DATE:

ACCOUNTING CERTIFICATION - AUDIT BLOCK
23. OBLIGATION NUMBER

24. AMOUNT DUE
PRINTED NAME AND TITLE:

25. SIGNATURE OF AUDITOR

SIGNATURE:

DATE:

VETERAN INFORMATION
All Veterans under VA contract with SVHs are not authorized for retroactive Per Diem payment
26. Name of Veteran
(a)

27. Last 4-Digit
of SSN
(b)

28. SC Award
Effective Date
(c)

29. SC Disability

30. SC Rating

(d)

(e)

PAPERWORK REDUCTION ACT OF 1995 AND PRIVACY ACT STATEMENT
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not
conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will
average 20 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form. Although completion of this form is voluntary, VA will be unable to provide reimbursement for
services rendered without a completed form. Failure to complete the form will have no effect on any other benefits to which you maybe entitled. This information is collected under the authority Of Title 38 CFR Parts
51 and 52. The information requested on this form is solicited under the authority of Title 38, U.S.C., Sections 1741, 1742 and 1743. It is being collected to enable us to determine your eligibility for medical benefits in
the State Home Program and will be used for that purpose. The income and eligibility you supply may be verified through a computer matching program at any time and information may be disclosed outside the VA as
permitted by law; possible disclosures include those described in the "routine uses" identified in the VA system of records 24VA136, Patient Medical Record-VA, published in the Federal Register in accordance with the
Privacy Act of 1974. Disclosure is voluntary; however, the information is required in order for us to determine your eligibility for the medical benefit for which you have applied. Failure to furnish the information will
have no adverse affect on any other benefits to which you may be entitled. Disclosure of Social Security number(s) of those for whom benefits are claimed is requested under the authority of Title 38, U.S.C., and is
voluntary. Social Security numbers will be used in the administration of veterans benefits, in the identification of veterans or persons claiming or receiving VA benefits and their records and may be used for other
purposes where authorized by Title 38, U.S.C., and the Privacy Act of 1974 (5 U.S.C. 552a) or where required by other statute.

VA FORM
AUG 2018

10-5588A

PREVIOUS EDITIONS OF THIS FORM ARE NOT TO BE USED

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INSTRUCTION SHEET: VA FORM 10-5588A

CLAIM FOR INCREASED PER DIEM PAYMENT FOR VETERANS AWARDED RETROACTIVE SERVICE CONNECTION
Completion of this form by State Veteran Home (SVH) to VA for balanced due of a Service Connection (SC) Veteran and is intended to reduce burden
hours for State Homes claiming retroactive payment.
The VA needs the SVH to submit with the retroactive invoice a letter indicating they have or will reimburse any payer sources they have collected from
on behalf of the Veteran. Also, include a copy of the VBA Service Connected Notification letter for SC rating.
1. VISN - Enter the Veterans Integrated Service Networks (VISN).
2. Station Number - Enter the station number where the VA Medical Center of Jurisdiction is located.
3. For Month Ending - Enter the last month and year for the report. Multiple months can be logged on this form within the same quarter and fiscal year.
For example, a single 10-5588A can be used to pay the difference for days of care from October to December 2017; enter Dec 2017.
4. Report Quarter - Enter the Federal fiscal quarter the report is for. The Federal fiscal year starts on October first.
5.
6.
7.
8.

Fiscal Year - The claim period is based on a Federal Fiscal year from September to October.
To - Enter the name and address of the VA Medical Center of Jurisdiction.
From - Enter the name of State Home (level of care) and address. For example, level of care use NHC for Nursing Home Care.
Pay to - Enter the name and address where the payment is to be sent.

RETROACTIVE CLAIM INFORMATION
9. Name and last four, column (a) - Enter the first initial of the last name and the last four digits of the Veteran's social security number.
10. Month and Year of Claim, column (b) - Enter the month and year for the month being claimed.
11. Days of Care Claimed, column (c) - Enter the number of days of care per diem is being claimed for the month indicated in item (b). Do not enter
more than one month of days of care per line.
12. Basic Per Diem Rate Paid, column (d) - Enter the basic per diem rate paid in column E from the original 10-5588 invoice.
13. Total Amount Claimed, column (e) - Multiply column (c) times column (d).
14. If filing for a Nursing Home Care retroactive payment for periods after February 1, 2013 leave this block blank as the prevailing rate will be paid
rather than the lesser of either the daily cost of care or prevailing rate. Daily Cost of Care Claimed, column 14(f) - Enter the daily cost of care
reported on the original 10-5588. If the SVH used an average daily cost of care or allowable cost from the prior year in the original 10-5588 claim
when completing this retroactive form, enter the amount from the original 10-5588 and provide supporting documentation to support this claim.
When filing for an Adult Day Health Care (ADHC) retroactive payment, leave column 14(f) block blank.
15. Fiscal Year Prevailing Rate, column (g) - Enter the prevailing rate for the Fiscal year for which the retroactive claim is being requested.
16. For retroactive claims from February 2, 2013 forward, leave column (f) (daily cost of care) blank and multiply column (c) (days of care) by column (g)
(prevailing per diem rate). Note: All per diem paid after February 2, 2013 should be the prevailing rate times the days of care. Amount Claimed at the
Service Connected Rate, column (h) If the retroactive claim is for a period prior to February 2, 2013, multiply column (c) (days of care) by the lesser
of either columns (f) (daily cost of care claimed) or (g) (prevailing per diem rate). For ADHC, retroactive payment only goes back to the date of PL
115-159 was signed, March 27, 2018.
17. Amount Due - Subtract column (e) (total amount claimed) from column (h) (amount claimed at the service connected rate).
18. Total Per Diem Claimed - Add the amounts from item 17 (i).
19. Remarks - Provide any supporting comments regarding the claims above.
CERTIFICATION OF STATE HOME PERSONNEL
20. Signature of SVH Administrator - Print name and title of SVH Administrator; sign and date.
21. Signature of State Employee When Applicable - Print name and title of State Employee, sign and date. When the facility is operated by an entity
contracting with the State, the State must assign a State employee to monitor the operations of the facility on a full-time, on site basis. This State
employee must certify that the information in the report is correct by signing and dating the report. If the facility is under contract, the signature of the
SVH Administrator is not required.
TOTAL AMOUNT APPROVED BY VA FOR RETROACTIVE PAYMENT AND AUDIT BLOCK
22. Signature of VA State Home Approving Official - Print name and title of Approving Official, sign and date.
23. Obligation Number - Enter Obligation Number for prevailing rate.
24. Amount Due - Enter total amount of per diem for payment due.
25. Signature of Auditor - Print name and title of Auditor, sign and date.
VETERAN INFORMATION
26.
27.
28.
29.

Name of Veteran - Enter the last name, first name, and middle initial.
SSN - Enter the last four digits of the Veteran's Social Security Number.
Service Connected Award Date - Enter the effective date of service connected rating.
Service Connected (SC) Disability - Enter the medical condition for the increased SC Disability rating.

30. Service Connected (SC) Rating - Enter the new combined SC Disability rating awarded (percentage).

VA FORM
AUG 2018

10-5588A

PREVIOUS EDITIONS OF THIS FORM ARE NOT TO BE USED

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