Utilization Review
300 N. San Antonio Rd., Room B100 Santa Barbara, CA93110-1332
805.681.5390 FAX 805.681.5424
TOBACCO SETTLEMENT (TSAC) FUNDING
Services that qualify for payment through the TSAC Fund are uncompensated medical care originating in Santa BarbaraCounty. Emergency, primary and specialty care services provided must occur in the emergency department, inpatient or outpatient hospital setting or in the office following a hospitalization.
Claims for services which have been authorized by UR for Tobacco Settlement (formerly known as TSAC or Tobacco Settlement Advisory Committee) patients must be submitted and will be paid according to the same requirements as for MIA claims.
Claims for unauthorized services submitted for payment under Tobacco Settlement which meet the criteria in the attached Condition Statement must be submitted no sooner than 3 months from the date of service in which time the patient must be billed and no payment was received. Claims received without a Condition Statement and/or claims received after the end of the fiscal year will be returned unpaid. Additionally, if TSAC funding is exhausted at any point during the fiscal year, claims will be returned to you with a letter of explanation.
We require and appreciate due diligence by your billers in determining the correct payer before claims are sent to us. Unfortunately, over the past year we have returned hundreds of claims in which the patient actually had either Medi-Cal coverage, auto insurance, worker’s compensation or some other payer source. Please communicate to your billers that they need to routinely check for other payer sources; it is part of your agreement with the Public Health Department.
To be clear, the following requirements must be met in order for claims to be processed:
- A diligent effort to determine and bill the patient’s primary payer source.
- Documentation that over a 3 month period at least two attempts have been made to collect payment; and no payment has been received for any portion of services or written notification from the patient/responsible party that no payment will be made for services.
- All components of the TSAC Condition Statement have been met.
- One signed TSAC Condition Statement must be attached to each claim being submitted. The Condition Statement confirms the patient meets the income requirements and that there have been reasonable efforts (2 -3 attempts over at least 2 months) to bill the patient or any third party payer. Claims received without a condition statement will be returned.
- Please maintain supporting records, as we sometimes request documentation to process claims or perform audits.
Claims should be sent to:SBCPHD - Utilization Review
300 N. San Antonio Rd., Room B100
Santa Barbara, CA 93110
Thank you for your hard work and continued dedication to our community. Any questions regarding these programs may be directed to Sheri R. Ruiz, UR Program Administrator, at 681-5390.
Healthier communities through leadership, partnership and science.
TS PHYSICIAN SERVICES CONDITION STATEMENT
I, ______, declare the conditions listed below to qualify for reimbursement for uncompensated care under the Tobacco Settlement Physician Services Fund have been met. I understand that the attached claim(s) will be paid at the Medi-Cal rate of reimbursement.
- The patient’s care was initiated in Santa BarbaraCounty; and
- The patient has been queried as to whether there is a responsible third party source for payment.
- The patient cannot afford to pay for services rendered and payment will not be made through any private coverage or by any program funded in whole or in part by federal, state or county programs and whose gross monthly income fall below 250% of the Federal Poverty Guidelines (see attached Poverty Guideline).
- The patient has been billed for payment of services and a reasonable attempt to collect has occurred.
- Any current or further collection efforts will be waived upon receipt of funds from the TSAC Physician Services Fund.
- If, after receiving payment from the Physician Services Fund, there is reimbursement by the patient or responsible third party, the County’s payment amount will be promptly refunded up to the amount received.
- Claims submitted should be supported by maintaining records of services rendered, and any additional information the administering agency may require for a period of 3 years after services were provided.
Please attach a signed copy of this Form to the claim
8/10
2009-2010 - 250% OF FEDERAL POVERTY GUIDELINES
GROSS MONTHLY FAMILY INCOME
FAMILY SIZE* / ANNUAL INCOME / GROSS MONTHLY INCOME1 Person Family / $27,084 / $2,257
2 Person Family / $36,420 / $3,035
3 Person Family / $45,780 / $3,815
4 Person Family / $55,140 / $4,595
5 Person Family / $64,476 / $5,373
6 Person Family / $73,836 / $6,153
7 Person Family / $83,196 / $6,933
8 Person Family / $92,520 / $7,710
9 Person Family / $101,880 / $8,490
10 Person Family / $111,240 / $9,270
For each family member added / $3,740 / $312
* Family Size refers to members of an immediate family living in the same home.
Healthier communities through leadership, partnership and science.