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Blank Texas 5913 PDF Template

The Texas 5913 form is a crucial document utilized for reporting suspected provider fraud within the Texas Department of Aging and Disability Services. This form facilitates the referral process for cases that may involve fraudulent activities affecting consumers receiving services. By ensuring proper documentation and communication, it plays an essential role in protecting the rights and well-being of vulnerable individuals in the community.

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Contents

Form Example

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

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

Area Code and Telephone No.

Relationship to Provider

Physical Address (Street, City, State, ZIP Code)

Individual's Name

Area Code and Telephone No.

Relationship to Provider

Physical Address (Street, City, State, ZIP Code)

Law Enforcement Agency Notified?

Yes

Name of Law Enforcement Agency

Date Notified

Name of Individual Contacted

Title or Position

Area Code and Telephone No.

Ext.

Email Address

Case No.

Other Entity Notified? (i.e., Insurance Co., Bank, Subcontrator, etc.)

Yes

Name of Entity

Date Notified

Name of Individual Contacted

Title or Position

Area Code and Telephone No.

Ext.

Email Address

Case No.

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)

Physical Address (Street, City, State, ZIP Code)

Area Code and Telephone No.

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)

Same as provider's physical address

Form 5913

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?				Yes	No	Unknown
Was corrected action or recoupment requested as a result of this review?				Yes	No
Corrective Action	Recoupment	Other (specify)

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:

Yes

Unknown

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

Form 5913

Page 3 / 08-2012-E

Regulatory Services Only

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.

Yes

Form 5913

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?

If yes, provide a detailed explanation below.

Yes

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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Common mistakes

Incomplete Contact Information: Failing to provide complete contact details for both the staff submitting the referral and any witnesses can delay the investigation process.
Incorrect Provider Information: Submitting inaccurate details about the provider, such as the Texas ID Number or license number, can lead to confusion and misdirected inquiries.
Neglecting to Specify the Type of Fraud: Not clearly identifying the type of suspected fraudulent activity, such as billing irregularities or record falsification, may hinder the investigation's focus.
Omitting Dates of Fraudulent Activity: Failing to provide specific dates or date ranges for the suspected fraudulent activities can make it difficult for investigators to establish a timeline.
Inadequate Description of the Fraud: Providing a vague or overly brief description of the suspected fraudulent activity does not give investigators enough context to understand the situation.
Not Notifying Law Enforcement: If law enforcement has been involved, failing to include this information can lead to missed opportunities for collaboration on the investigation.
Ignoring Follow-up Actions: Not indicating whether corrective actions or recoupment requests were made can obscure the seriousness of the situation and the steps taken to address it.

Key takeaways

Purpose of the Form: The Texas 5913 form is used to report suspected provider fraud to the Department of Aging and Disability Services (DADS).
Submission Process: The form must be completed and submitted to the Consumer Rights and Services (CRS) for processing.
Contact Information: Accurate contact details for both the DADS staff submitting the referral and witnesses with information about the suspected fraud must be provided.
Provider Details: Essential information about the provider, including legal entity name, Texas ID number, and physical address, must be included.
Type of Fraud: Indicate the type of suspected fraudulent activity, such as billing irregularities or falsification of records.
Review Type: Specify the type of review conducted, whether it be an administrative review, investigation, or on-site certification review.
Corrective Actions: Note if any corrective actions or recoupments were requested as a result of the review.
Access to Care: Consider if suspending the provider's payments would jeopardize access to care for individuals receiving services.

⇓ Texas 5913 PDF

Steps to Using Texas 5913

Filling out the Texas 5913 form is a straightforward process that requires careful attention to detail. This form is used to report suspected provider fraud and must be completed accurately to ensure that the appropriate actions can be taken. Below are the steps to follow when filling out the form.

Start by entering the date the fraud referral is received by CRS and the date it is sent to HHSC OIG.
Fill in the Fraud Referral Log Data Entry details, including the name of the staff member submitting the referral, their title, and the DADS Area State Office Region number.
Provide the contact information for the DADS staff member, including the street address, mail code, city, state, ZIP code, area code, telephone number, and email address.
If there are witnesses with information about the suspected fraudulent activity, include their names, telephone numbers, relationships to the provider, and physical addresses.
Indicate whether a law enforcement agency has been notified. If yes, provide the agency's name, date notified, and contact details of the individual contacted.
Note if any other entities (like insurance companies or banks) have been notified, and provide their names and contact information.
Enter the provider information, including the name of the legal entity, doing business as (d.b.a.), Texas ID number, contract number, license number, license type, facility ID number, and provider identifier number.
Complete the physical address and business mailing address for the provider. Indicate if the mailing address is the same as the physical address.
Specify the physical address where the suspected fraudulent activity occurred, noting if it is the same as the provider's physical address.
Select the type of provider from the list provided.
Choose the type of suspected fraudulent activity from the options given.
Provide the date or date range of the suspected fraudulent activity.
Select the type of review that was conducted.
Fill in the review period, total sample size, and total individuals served. Indicate if suspected fraudulent activity was noted outside the sample or review period.
Indicate whether corrective action or recoupment was requested as a result of the review, and specify the amount due to DADS.
Answer whether the provider has received technical assistance on billing in the past two years and provide the dates if applicable.
For HCSSA, Adult Day Care, and Assisted Living providers, enter the number of Level B citations issued for the license associated with the contract.
Provide a detailed description of the suspected fraudulent activity.
Answer whether the suspension of payments would jeopardize access to care for displaced individuals and provide a detailed explanation if necessary.
Finally, indicate if there is any reason why the provider's payments should not be suspended and provide an explanation if applicable.

After completing the form, ensure that all information is accurate and clear. The form should then be emailed to the designated address for further processing. This step is crucial to ensure that the referral is handled appropriately and efficiently.