CMS-10785 Air Ambulance Template - Plan Issuers Carriers

Air Ambulance Data Report – Group Health Plans, Health Insurance Issuers, and FEHB Carriers
Organization Information
O1

Reporting Period

Submitting Entity Information
O2
Entity Name
O3
FEIN
O4
Point of Contact: Name
O5
Point of Contact: E-mail
Responsible Entity Information
O6
Entity Name
O7
FEIN

OMB Control Number: 0938-XXXX
Expiration Date: xx/xx/xxxx

Air Ambulance Data Report – Group Health Plans, Health Insurance Issuers, and FEHB Carriers
Claims Data
C1

C2

C3

C4

C5

C6

Plan
Name

Issuer or
Plan
Sponsor
Name

Issuer or
Plan
Sponsor
FEIN

Market
Type

FEHB
Plan
Code

Date of
Service

C14

C15

C16

C18

C19

Pick-up
Location
Zipcode

C27
Submitted
Charge –
Other

Drop-off
Location
Zipcode

C28
Paid
Amount –
Base Rate

Aircraft
Type

C17

Contracted
Provider

C29
Paid
Amount –
Mileage

C30
Paid
Amount
– Other

Emergent
Transport

InterFacility
Transport

C7

C8

NPI

NPI
Street
Address NPI City NPI State

C20

Delivery
Model

C9

C21

Was
Claim
Denied?

C10

C11

OMB Control Number: 0938-XXXX
Expiration Date: xx/xx/xxxx

C12

C13

CPT /
HCPCS
NPI
Zipcode Code

C22

C23

C24

Denial
Reason

Was
Claim
Was Claim Paid
after
Denial
Appealed? Appeal?

Loaded
Statute
Miles

C25

C26

Submitted
Charge –
Base Rate

Submitted
Charge –
Mileage

C31
Cost
Sharing
Amount

Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid Office of Management and
Budget (OMB) control number. The valid OMB control number for this information collection is 0938-XXXX. The time required to complete this information collection is
estimated to average 24 hours per response, including the time to review instructions, to make IT changes to collect, consolidate and report the required information, in
the required format, to HHS. 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, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.