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Provider Enrollment Application - CMS-10115 (located in the Downloads section below) The application provides an opportunity for eligible providers to receive payment for some or all of their un-reimbursed costs of providing emergency health care required under Section 1867 of the Social Security Act and related hospital inpatient, outpatient and ambulance services to eligible individuals. Hospital On-Call Payment Form - CMS-10130B (located in the Downloads section below)
The information collected on this form will be used to make payments to hospitals electing to receive on-call payments under Section 1011(c)(3)(C)(ii) of the Medicare Prescription Drug, Improvement and Modernization Act of 2003. Provider Payment Determination Form - CMS-10130A (located in the Downloads section below) The information collected on this form will be used by providers to determine whether a patient's health care provider is eligible to receive Federal payment under Section 1011 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003. The information on this form is only being collected to claim payment for a patient's health care. Section 1011 Dispute Resolution Request (located in the Downloads section below) If you wish to request a dispute resolution on a payment request determination, please fill out this form and mail it, along with documentation.
Page Last Modified: 12/18/2006 12:00:00 AM
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