N.Y. Comp. Codes R. & Regs. tit. 18 § 542.2

Current through Register Vol. 46, No. 51, December 18, 2024

Section 542.2 - Designation of providers as agents to file subrogated claims

(a) If medical care, services or supplies, as described in sections 365-a (2) and 367-a (1) of the Social Services Law, are provided for which payment of part or all of the costs may be claimed by the provider from the medical assistance program in accordance with section 540.6 of this Title, and if the department, a social services district or a social services official is or would be subrogated to the rights a person or a legally responsible relative has to reimbursement from a liable third party as described in section 542.1 of this Part, the provider is authorized by the department to act as its agent for the purpose of submitting a claim for such reimbursement to the liable third party.

(b) If a provider has not been notified or is uncertain whether or not a claim is one to which the department, a social services district or a social services official is subrogated, the provider may request verification of the nature of the claim from the social services district identified as the district responsible for the recipient for whom the claim will be submitted.

(c) A provider may act as an agent for the department and submit claims to liable third parties in the following situations:

(1) when a medical assistance recipient or responsible relative will not submit medical claims to an appropriate insurance carrier or other liable third party;

(2) when a medical assistance recipient or responsible relative has submitted a medical payment claim to an insurance carrier or other liable third party in the past, but has not forwarded any resulting payment to the medical assistance provider;

(3) when the medical assistance provider does not participate in the health delivery or reimbursement plan of an insured recipient or a responsible relative and the recipient or responsible relative acts in the manner described in paragraph (1) or (2) of this subdivision;

(4) when an insurance carrier or other liable third party does not permit assignment of the payment to the medical assistance provider and the medical assistance recipient or responsible relative acts in the manner described in paragraph (1) or (2) of this subdivision; or

(5) when an insurance carrier or other liable third party asserts that only the medical assistance recipient or responsible relative can submit a claim to a health coverage plan or employer for reimbursement and the recipient or responsible relative acts in the manner described in paragraph (1) or (2) of this subdivision.

(d) A provider authorized by this section to act as an agent of the department, a social services district or a social services official must transmit or, in the alternative, provide adequate notification of the submission of such claim or a copy of any submitted claim to the social services district identified as the district responsible for the recipient.

N.Y. Comp. Codes R. & Regs. Tit. 18 § 542.2