N.Y. Comp. Codes R. & Regs. Tit. 10 §§ 69-4.22

Current through Register Vol. 46, No. 45, November 2, 2024

Section 69-4.22 - Third-party payments

(a) Providers shall, in the first instance and where applicable, seek payment from all third party payors, including governmental agencies, prior to claiming payment from a given municipality for evaluations conducted under the program and for services rendered to eligible children residing in the municipality and their families, provided, however, that the provider shall not obtain payment from a third party payor who is not prohibited from applying such payment, and may apply such payment, to an annual or lifetime limit specified in the insured's policy.

(1) A municipality, or its designee, and a provider shall be subrogated, to the extent of the expenditures by such municipality or for early intervention services furnished to an eligible child or parent, to any rights the child or parent may have or be entitled to for third party reimbursement.

(2) The provider shall submit notice to the insurer or plan administrator of his or her exercise of the right of subrogation upon the provider's assignment as the early intervention service provider for the child.

(i) The right of subrogation does not attach to benefits paid or provided under any health insurance policy or health benefits prior to written notice of the exercise of subrogation rights by the insurer.

(3) Providers shall utilize the department's fiscal agent and data system for claiming payment for evaluations and services rendered under the Early Intervention Program.

(i) Providers shall enroll, on request of the department or the department's fiscal agent, with one or more health care clearinghouses, as necessary, for processing of claims to third party payors and for receipt of remittance advices in standard electronic format and in compliance with any applicable Federal or State regulations with respect to electronic claims transactions.

(4) Providers shall submit all claims for payment of evaluations and services within 90 days of the date of service, unless the submission is delayed due to extraordinary circumstances documented by the provider and the department's fiscal agent has been notified of the extraordinary circumstances and has provided written acknowledgement.

(i) All claims submitted after 90 days shall be submitted within 30 days from the time the provider was relieved from the extraordinary circumstances that previously delayed a timely submission.

(ii) Claims that are not submitted within timeframes set forth shall not be reimbursed by the department's fiscal agent from the escrow account funded by municipal governmental payors.

(b) The municipality shall pay all co-payments and deductibles to meet any requirement of an insurance policy or health benefit plan in accessing funds applied to payment for early intervention services. These payments will be subject to the same level of State reimbursement as all other payments by the municipality for early intervention services.

(1) The municipality shall establish a procedure to ensure that the parent does not make a first instance payment for co-pays and deductibles. Such procedures may include an arrangement between the municipality and the provider for payment of co-payments and deductibles to the provider directly.

N.Y. Comp. Codes R. & Regs. Tit. 10 §§ 69-4.22

Amended New York State Register November 30, 2016/Volume XXXVIII, Issue 48, eff. 11/30/2016

Amended New York State Register December 5, 2018/Volume XL, Issue 49, eff. 12/5/2018

Amended New York State Register November 13, 2019/Volume XLI, Issue 46, eff. 11/13/2019