10-5588A Claim for Payment for Nursing Home Care Provided to Vete

OMB Approval No. 2900-0160
Estimated Burden: Avg. 20 min.
Exp: xx/xx/xxx
VA FORM 10-5588A
CLAIM FOR PAYMENT FOR NURSING HOME CARE PROVIDED TO
VETERANS AWARDED RETROACTIVE SERVICE CONNECTION
GENERAL INFORMATION
1. VISN

2. STATION
NUMBER

3. FOR MONTH
ENDING
7. FROM:

6. TO:
Enter VA Facility

4. REPORT
QUARTER

5. FISCAL
YEAR

Enter Name & Address of State Home

8. PAY TO:
9. Name and
Last 4 of
SSN
(a)

10. Month
11. Days of
and Year
Care
Claimed
(b)
(c)

18.

RETROACTIVE CLAIM INFORMATION
12. Basic Per 13. Total
14. Daily Cost 15. FY Prevailing 16. Amount Claimed at 17. Amount Due
Diem Rate
Amount
of Care
Per Diem
the Service
Paid
Claimed
Claimed
Rate
Connected Rate
(d)
(e)
(f)
(g)
(h)
(i)
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Total Per Diem Claimed
$0.00

19. Remarks:

I certify that this report is correct, that all residents included in the report were physically present during the period for which Federal Aid is claimed,
except for authorized absences for which the VA paid per diem.
20.

21.

Signature of
SVH Administrator
Signature of SVH Employee
When Applicable

Printed Name & Title:
Date:

Signature:
Printed Name & Title:

Date:

Signature:
TOTAL AMOUNT APPROVED BY VA FOR RETROACTIVE PAYMENT

22. Signature of VA State Home
Approving Official

Printed Name & Title:
Signature:

Date:

ACCOUNTING CERTIFICATION - AUDIT BLOCK
23. Control Number
26.

24. Amount Due

Signature of
Auditor

25. Date

Printed Name & Title:
Signature:

Date:
VETERAN INFORMATION

ALL VETERANS UNDER VA CONTRACT WITH SVHs ARE NOT AUTHORIZED FOR RETROACTIVE PER DIEM PAYMENT
27. Name of Veteran
28. Last 4-Digit 29. SC Award
30. SC Disability
31. SC Rating
of SSN
Effective Date
(a)

(b)

(c)

(d)

(e)

PAPERWORK REDUCTION ACT OF 1995 AND PRIVACY ACT STATEMENT
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995.
We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who
must complete this form will average 30 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form. Although completion of this form is voluntary, VA
will be unable to provide reimbursement for services rendered without a completed form. Failure to complete the form will have no effect on any other benefits to which you maybe entitled. This
information is collected under the authority Of Title 38 CFR Parts 51 and 52. The information requested on this form is solicited under the authority of Title 38, U.S.C., Sections 1741, 1742 and 1743. It is
being collected to enable us to determine your eligibility for medical benefits in the State Home Program and will be used for that purpose. The income and eligibility you supply may be verified through a
computer matching program at any time and information may be disclosed outside the VA as permitted by law; possible disclosures include those described in the "routine uses" identified in the VA
system of records 24VA136, Patient Medical Record-VA, published in the Federal Register in accordance with the Privacy Act of 1974. Disclosure is voluntary; however, the information is required in
order for us to determine your eligibility for the medical benefit for which you have applied. Failure to furnish the information will have no adverse affect on any other benefits to which you may be entitled.
Disclosure of Social Security number(s) of those for whom benefits are claimed is requested under the authority of Title 38, U.S.C., and is voluntary. Social Security numbers will be used in the
administration of veterans benefits, in the identification of veterans or persons claiming or receiving VA benefits and their records and may be used for other purposes where authorized by Title 38,
U.S.C., and the Privacy Act of 1974 (5 U.S.C. 552a) or where required by other statute.

VA FORM
May 2015

10-5588A

INSTRUCTION SHEET: VA FORM 10-5588A
CLAIM FOR PAYMENT FOR NURSING HOME CARE PROVIDED TO VETERANS AWARDED RETROACTIVE SERVICE CONNECTION
Completion of this form is optional and intended to reduce burden hours for State Homes claiming retroactive State Home Per Diem payments.
All Veteran Under VA Contract With State Veteran Homes Are Not Authorized To Collected Retroactive Per Diem Payment For Care Provided After
February 2, 2013, however they are eligible for retroactive payments prior to February 2, 2013.
Completed by: Veteran Affairs Employees
1. VISN-Enter the Veterans Integrated Service Networks (VISN)
2. Station Number-Enter the station number where the VA Medical Center of Jurisdiction is located.
Completed by: State Home Employees
3. Month Ending-Enter the month and year for the report e.g., Oct 2012.
4. Report Quarter-Enter the Federal fiscal quarter the report is for. The Federal fiscal year starts on October 1st, which is the first day of the 1st.
Quarter.
**A completed 10-5588A form is requested in addition to VA Form 10-5588 for eligible Veterans in the SVH for which a retroactive claim is being
requested. Do not claim days of care for which the Veteran is not present in the facility unless the Veteran is on VA approved paid bed hold for
overnight hospital stay or non-hospital leave. VA paid bed hold will be paid for the first 10 consecutive days during which the Veteran is admitted as a
patient for any stay in a VA or other hospital which may occur more than once in a calendar year, and only for the first 12 days in a calendar year during
which the Veteran is absent for purposes other than receiving hospital care. Do not claim days of care when the facility's daily occupancy rate is below
90 percent. Note: A Veteran can have multiple hospitalizations and only 12 days for nonmedical leave within a calendar year.
**The VA recommends that the State Veteran home submit with the retroactive payment a letter indicating they have or will reimburse any payer
sources they have collected from on behalf of the Veteran.
5.
6.
7.
8.

Fiscal Year-The claim period is based on a Federal Fiscal year from September to October.
To-Enter the name and address of the VA Medical Center of Jurisdiction.
From-Enter the name of State Home and address.
Pay to-Enter the name and address where the payment is to be sent

RETROACTIVE CLAIM INFORMATION
9. Name and last four, column (a) - enter the first initial of the last name and the last four digits of the Veteran's social security number.
10. Month and Year of Claim, column (b) - enter the month and fiscal year for the month being claimed.
11. Days of Care Claimed, column (c) - enter the number of days of care per diem is being claimed.
12. Fiscal Year Basic Per Diem Rate Paid, column (d) - enter the basic per diem rate claimed on 15(h) on the original 10-5588 claim.
13. Total Fiscal Year Basic Rate Claimed, column (e) - Multiply column (c) times column (d).
14. Daily Cost of Care Claimed, column (f) - enter the daily cost of care reported on the original 10-5588. If the SVH used an average daily cost of
care or allowable cost from the prior year in the original 10-5588 claim when completing this retroactive form, enter the actual daily cost of care and
provide supporting documentation to support this claim. If filing for a retroactive payment for periods after February 1, 2013 leave this block blank as
the prevailing rate will be paid rather than the lesser of either the daily cost of care or prevailing rate.
15. Fiscal Year Prevailing Rate, column (g) - enter the prevailing rate for the Fiscal year for which the retroactive claim is being requested.
16. Amount Claimed at the Service Connected Rate, column (h) - If the retroactive claim is for a period prior to February 2, 2013, multiply column (c)
(days of care) by the lesser of either columns (f) (daily cost of care claimed) or (g) (prevailing per diem rate). For retroactive claims from February 2,
2013 forward, leave column (f) (daily cost of care) blank and multiply column (c) (days of care) by column (g) (prevailing per diem rate). Note: All per
diem paid after February 2, 2013 should be the prevailing rate times the days of care.
17. Amount Due - Subtract column (e) (total amount claimed) from column (h). (amount claimed at the service connected rate)
18. Total Amount - Add column (i)
19. Remarks- provide any supporting comments regarding the claims above
CERTIFICATION OF STATE HOME PERSONNEL
20. Signature of State Veteran Home Administrator
21. Signature of State Veteran Home Employee when Applicable
CERTIFICATION BY CONTRACTING OFFICER OR AGREEMENT COORDINATOR
22. Signature of VA State Home Approving Official
23. Control Number
24. Amount Due
VETERAN INFORMATION
27.
28.
29.
30.
31.

Name of Veteran- Enter the last name, first name and middle initial.
SSN - enter the last four digit of Social Security Number of the Veteran.
Service Connected Award Date - enter the effective date of service connected rating.
Service Connected (SC) Disability - enter the medical condition for the increase in SC.
Service Connected Rating - enter the new SC awarded.

VA FORM
May 2015

10-5588A