Texas Form 5913 PDF Details

The Texas Department of Aging and Disability Services (DADS) Form 5913 serves as a crucial tool in the ongoing effort to uphold integrity within service provision, designed for reporting suspected fraudulent activities by providers. Established in August 2012, this form facilitates a streamlined process for DADS staff to report inconsistencies or irregularities directly to the Consumer Rights and Services (CRS) for further investigation. With detailed sections for providing contact information of the reporting staff, witnesses, involved law enforcement agencies, and specific details about the provider under suspicion, Form 5913 encompasses extensive fields to capture the essence of the suspected fraud. Additionally, it categorizes the type of provider and suspected fraudulent activities, ranging from billing irregularities to falsification of records. Moreover, it sets a foundation for the necessary administrative review or investigation, indicating whether suspected activities fall within or outside the sample or review period, and outlines the resultant actions, such as corrective measures or recoupment efforts. For providers, it also assesses the impact of potential payment suspension on service continuity and care access for clients. This form not only aims at curbing fraudulent practices within the Texas aging and disability services spectrum but also ensures a mechanism is in place for accountability and correction, maintaining the sector’s integrity.

QuestionAnswer
Form NameTexas Form 5913
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesdads referral, CMA, Texas, dadsview

Form Preview 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

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

 

 

 

 

 

 

 

 

 

 

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

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

No

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

No

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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