The Texas 5913 form is a document used to report suspected provider fraud within the Texas Department of Aging and Disability Services. It serves as a referral for the Consumer Rights and Services team, facilitating the investigation of potential fraudulent activities related to various types of providers. Accurate completion of this form is essential for ensuring accountability and protecting consumer rights in the state’s healthcare system.
The Texas 5913 form serves as a critical tool for reporting suspected provider fraud within the state's aging and disability services framework. Designed specifically for use by the Department of Aging and Disability Services (DADS), this form facilitates the referral process for cases where fraudulent activities are suspected in various provider settings, such as nursing facilities, assisted living, and adult foster care. It captures essential information, including the details of the provider and the nature of the suspected fraud, which may encompass billing irregularities or falsification of records. The form also requires the submission of contact information for both the DADS staff member submitting the referral and any witnesses who may have pertinent information regarding the alleged fraudulent activities. Additionally, it prompts the reporter to indicate whether law enforcement or other entities have been notified, ensuring a comprehensive approach to addressing potential fraud. The urgency of accurately completing this form cannot be overstated, as it plays a vital role in protecting consumer rights and maintaining the integrity of services provided to vulnerable populations in Texas.
Texas Department of Aging
Form 5913
and Disability Services
August 2012-E
DADS Suspected Provider Fraud Referral
For Consumer Rights and Services (CRS) Use Only
Date Fraud Referral Received by CRS
Date Fraud Referral Sent to HHSC OIG
Fraud Referral Log Data Entry Completed By
CRS Fraud Referral Log No.
OIG Fraud Referral No.
Contact Information for DADS Staff Submitting Referral
Name of Staff
Title or Position
DADS Area
State Office
Region No.
A&I
RS
CFO
COS
SSLC
Other (specify)
DADS Office Street Address
Mail Code
City
State
ZIP Code
Area Code and Telephone No.
Ext.
Email Address
Contact Information for Witness With Information About Suspected Fraudulent Activity
N/A
Individual's Name
Relationship to Provider
Physical Address (Street, City, State, ZIP Code)
Law Enforcement Agency Notified?
Yes
No
Name of Law Enforcement Agency
Date Notified
Name of Individual Contacted
Case No.
Other Entity Notified? (i.e., Insurance Co., Bank, Subcontrator, etc.)
Name of Entity
Provider Information
Name of Legal Entity (Owner)
Doing Business As (d.b.a.), if applicable
Comp. Texas ID No. (TIN)
Contract No.
License No.
License Type
Facility ID No.
Provider Identifier No. (NPI/API)
Business Mailing Address (P.O. Box or Street, City, State, ZIP Code)
Same as provider's physical address
Physical Address Where Suspected Fraudulent Activity Occurred (Street, City, State, ZIP Code)
Page 2 / 08-2012-E
Type of Provider
1
Adult Foster Care
15
Hospice
2
Area Agencies on Aging
16
Intermediate Care Facilities
3
Assisted Living/Residential Care
17
Medically Dependent Children Program
4
CCAD Residential Care
18
Medicaid Administrative Claiming
5
CLASS (CMA, DSA, SFS)
19
ID Service Coordination
6
Client Managed Personal Attendant Services
20
Nursing Facilities
7
Consumer Directed Services
21
Out-of-Home Respite
8
Day Activity and Health Services
22
Performance Contract (with Local Authorities)
9
Deaf Blind with Multiple Disabilities
23
PHC/FC/CAS
10 Emergency Response Services
24 PACE
11
Guardianship
25
Relocation Assistance Services
12 Home and Community-based Services
26 SSPD/SSPD-SAC
13 HCSSA
27 Texas Home Living
14
Home-Delivered Meals
28
Transition Assistance Services
Type of Suspected Fraudulent Activity
1 Billing Irregularities If Other, specify
2 Falsification/Alteration of Records
3 Trust Fund Irregularities
4 Other
Date or Date Range of Suspected Fraudulent Activity
Type of Review
Administrative Review
Investigation On Site
HCS/TxHml Certification Review
Trust Fund Monitoring
Billing and Payment
Investigation Desk Review
HCS/TxHml Follow-up Review
Other
Formal Monitoring
Follow-up Investigation On Site
HCS/TxHml Intermittent Review
Follow-up Monitoring
Follow-up Investigation Desk Review
Regulatory Services Survey
Review Information
Review Period
Total Sample Size
Total Individuals Served
Was suspected fraudulent activity noted outside the sample or review period?
Unknown
Was corrected action or recoupment requested as a result of this review?
Corrective Action
Recoupment
Amount due DADS as a result of this review
How much of this amount is suspected to be fraudulent?
Other Information (as of date of referral)
Has the provider received technical assistance on billing during the past two years?
Date(s) technical assistance was provided:
For HCSSA, Adult Day Care and Assisted Living licensed providers only, use the links below to enter the number of level B citations issued for the license associated with this contract.
http://dadsview.dads.state.tx.us/coo/contract/hcssadirectory.html or http://dadsview.dads.state.tx.us/coo/contract/adcalfdirectory.html
Number of Level B Citations:
OIG/OAG Investigator Only
For more information about skilled nursing facilities ratings score, go to the DADS Long Term Care Quality Reporting System (QRS) website at: http://facilityquality.dads.state.tx.us/qrs/public/qrs.do?page=geoArea&serviceType=nh&lang=en&mode=P&dataSet=1&ctx=807802
Regulatory Services Only
Compliance Review ID No.
Exit Date
Page 3 / 08-2012-E
Provide a detailed description of the suspected fraudulent activity.
Access to Care
If the provider's payments are suspended as a result of this referral and the provider must cease operations or significantly curtail services, would access to care be jeopardized for displaced individuals?
If yes, provide a detailed explanation below.
Page 4 / 08-2012-E
No Unknown
Suspension of Payments
Are you aware of any reason why the provider's payments should not be suspended or suspended only in part?
Regional and state office management: After reviewing the referral form, email form to Providerfraud@dads.state.tx.us.
OIG/OAG investigator: Contact COS at contractoversight@dads.state.tx.us if additional contract information is needed.
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