Texas Form 5913 PDF Details

Are you looking for information about Texas Form 5913? You’ve come to the right place! This blog post will walk you through everything you need to know about filing this form, from legal requirements and exemptions to how to properly complete it. We’ll even provide helpful tips on what documents may be required and give examples of frequently asked questions. Whether you’re a business owner in Texas, or just someone wanting to learn more about what this form means and how it could affect your taxes, the goal of this guide is that by the end – you will have all the knowledge and confidence necessary when completing your Form 5913. So let's get started!

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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1. Whenever completing the how to make a referral to dads in dallas texas, make certain to incorporate all important blank fields in the relevant form section. This will help hasten the process, enabling your information to be processed fast and accurately.

Find out how to prepare recoupment step 1

2. Once your current task is complete, take the next step – fill out all of these fields - 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 ie Insurance, Yes, Name of Entity, Date Notified, and Name of Individual Contacted with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

recoupment writing process described (part 2)

Regarding Yes and Date Notified, be sure that you get them right in this current part. These are definitely the most important ones in this document.

3. In this particular step, take a look at Comp Texas ID No TIN Contract No, License No, License Type, Facility ID No, Provider Identifier No NPIAPI, Physical Address Street City State, Area Code and Telephone No, Business Mailing Address PO Box or, Physical Address Where Suspected, Same as providers physical address, and Same as providers physical address. All these should be taken care of with highest attention to detail.

Step number 3 in filling in recoupment

4. Filling out Type of Provider, Adult Foster Care, Area Agencies on Aging, Hospice, Intermediate Care Facilities, Assisted LivingResidential Care, Medically Dependent Children, CCAD Residential Care, CLASS CMA DSA SFS, Medicaid Administrative Claiming, ID Service Coordination, Client Managed Personal Attendant, Nursing Facilities, Consumer Directed Services, and Day Activity and Health Services is key in this stage - be sure to be patient and fill in each field!

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