Free 46596.pdf - Indiana

TB HOSPITAL REIMBURSEMENT CLAIM
State Form 46596 (R3/9-04) Approved by the State Board of Accounts, 2004 INDIANA STATE DEPARTMENT OF HEALTH

Instructions: 1. Follow the attached instructions and guidelines. 2. Submit pages 1 and 2 and all supporting documentation the Indiana State Department of Health.

The purpose of the Tuberculosis Hospital Fund is to reimburse those hospitals that provide inpatient care for patients who have tuberculosis, are uninsured, and have no other sources of payment. This fund is administered in accordance with IC 16-21-7. Hospital name: County: ______________________

Hospital address: _____________________________________________________ ______________________________________________________ Patient hospital number: _________________________________________________ Patient's name: (Last) Age: Date of birth: (First) (Middle) Race: ________________________ Discharge date: _________________ (To) _________________________ Sex: _________

Admission date: Period of this claim: (From)

Amount being claimed $___________________________ Name and signature of hospital representative. Pursuant to IC 16-21-7-1, I certify that the patient has no other sources of reimbursement. __________________________________________ Printed name and title Phone: ( ) _______________________ ________________________________ Signature

TB HOSPITAL REIMBURSEMENTCLAIM (continued) When submitting this application, please include the following to support your claim: 1. Pages 1 and 2 of this claim summary; 2. An itemized list of all charges incurred in the treatment of tuberculosis for this patient; 3. Both the admission history and physical and discharge summary indicating that tuberculosis was included in the differential diagnosis. Refer to the "Guidelines for the Tuberculosis Hospital Fund" for typical expenses. Reimbursement of room charges covers only those days the patient was hospitalized for tuberculosis treatment. Charges not directly related to the treatment of tuberculosis cannot be reimbursed from this fund. Submit the claim summaries and all supporting documentation to: Indiana State Department of Health Tuberculosis Control Program 2 North Meridian Street, 6-A Indianapolis, IN 46204 +++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ Room and Board $_______________

________days @ $__________ per day Laboratory tests, radiology, medications, etc. Total Amount Being Claimed $_______________

$ _________________

Claims cannot be processed without the attending physician's original signature. I certify that the above charges were incurred during the course of treatment for this patient who was being evaluated for tuberculosis. Printed Name of Attending Physician Phone: ( ) _______________________________________ Signature of Attending Physician

This information is confidential in accordance with IC 16-41-8-1 and 410 IAC 1-2.3, and is necessary for processing this claim.

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Guidelines for Claim Submission
Tuberculosis is an infectious, communicable disease that can be transmitted to others if not diagnosed promptly and the patient treated appropriately. In-patient care is sometimes required during the infectious stage. Indiana hospitals that treat or care for a patient with tuberculosis may be eligible for reimbursement of unrecovered hospital expenses. The Indiana State Department of Health (ISDH) will reimburse a hospital for charges associated with the tuberculosis diagnosis. If the patient being evaluated and treated for tuberculosis has no source of payment for services rendered, the hospital may apply for reimbursement from ISDH under the Hospital Tuberculosis Fund. Funds are appropriated on an annual basis and will be dispersed until the fund is exhausted. To be considered for reimbursement, the following criteria must be met: 1. 2. The case must have been reported to the local health department; ISDH must have a copy of that report in accordance with IC 16-41-2-2 and 410 IAC 1-2.3. There must be no other sources for reimbursement. This absence of payment sources must be documented in writing. Examples of reimbursement resources include, but are not limited to: a. patient resources b. health insurance c. medical assistance payments d. hospital care for the indigent e. charitable contributions The discharge summary must reflect tuberculosis as the diagnosis.

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When all the criteria are met and funds are available, the ISDH will determine the reimbursement amount for room charges and reimbursement for those treatments, medications, etc., deemed necessary for the treatment of tuberculosis. The Tuberculosis Hospital Fund will reimburse a hospital if the case is reported as a tuberculosis suspect. Class V suspect status and all charges are subject to the review and approval of the ISDH Tuberculosis Control Program. Patient information is confidential pursuant to IC 16-41-8-1 and 410 IAC 1-2.3(50). This agency is requesting information that is necessary to accomplish the statutory purpose of this program. The diagnosis of TB and its treatment must be apparent in the patient discharge summary. Questionable or doubtful charges will not be reimbursed without proper documentation of the TB diagnosis. (a) (b) (c) Claims shall be submitted for reimbursement no later than three (3) months after patient discharge from the applying hospital. All claims will be processed in the order received by ISDH. Incomplete forms will be returned. If there are insufficient funds to pay the claim, all paperwork will be returned to the submitter with an explanation to that effect. That claim can be resubmitted after July 1 of the new state fiscal year if funding has been appropriated. 3

For Confirmed Tuberculosis Cases Room and board will be paid for the duration of the TB-related stay as well as those charges deemed appropriate for the in-patient care and treatment of TB patients. Please refer to the sample list of TB-related items. For Tuberculosis Suspects · "Suspect Case" means a person whose medical history and symptoms suggest that this person has signs and symptoms that are compatible with TB disease, e.g., a prolonged, productive cough, hemoptysis, weight loss, fever, night sweats, or fatigue. · · · · · An overnight hospital stay might be appropriate if the person represents a flight risk prior to completing the TB evaluation. Room and board are eligible charges. Room and board during the rule out period are eligible. When TB has been ruled out, room charges and other costs are no longer reimbursable. Those tests necessary to rule out or confirm a TB diagnosis are eligible. TB medications are eligible for the duration of the stay. If TB relevance is not shown, the charges are not reimbursed.

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Sample List of TB-related Items
ROOM AND BOARD Room Charges RADIOLOGY Chest X-rays: PA, lateral, lordotic CT scan of suspected TB disease site Special studies to localize extra-pulmonary TB, e.g., x-ray of spine, bones or CT of abdomen, pelvis EXTRA-PULMONARY DIAGNOSIS Pleural fluid: cell count, differential, chemistries Cerebral Spinal Fluid: cell count, differential, chemistries Biopsy of extrapulmonary disease site Other fluid cell count or chemistry analysis, such as synovial fluid or peritoneal fluid LABORATORY SERVICES Smear for acid-fast bacilli Culture for mycobacteria TB blood culture Rapid nucleic acid amplification tests used in accordance with FDA guidelines Drug susceptibility testing for M. tuberculosis isolates Initial CBC & platelet count Initial serum electrolytes Initial serum creatinine, BUN, uric acid Initial liver function tests HIV antibody test Initial hepatitis B and C panel Drug levels of anti-TB drugs RESPIRATORY CARE Sputum Induction

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Pharmacy PPD/Tuberculin (not Tine) First-line TB Drugs Isoniazid Rifampin Ethambutol Pyrazinamide Rifater Rifamate Rifabutin. Reimbursement will only be made for TB patients who (1) have HIV infection and are on concurrent anti- retroviral therapy with protease inhibitors or NNRTIs that cannot be given safely with rifampin, or (2) are on other medications that have unacceptable interactions with rifampin. Second-line TB drugs Streptomycin Ethionamide Cycloserine Levofloxacin Gatofloxacin Moxifloxacin PAS Kanamycin Amikacin Capreomycin Other Pyridoxine (vitamin B6)

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