Notice of Subrogation

State of New York

County of

Notice of Subrogation Pursuant to Section 2559(d) of NYS Public Health Law and Section 3235-a(c) of the Insurance Law

Section 2559(d) of PHL and 10 NYCRR 69-4.22(b) subrogates municipalities to any rights a child eligible for the New York State Early Intervention Program and his or her family may have or be entitled to from third party reimbursement for services covered in their insurance plan to the extent of expenditures by the municipality for early intervention services provided to the child or family. Section 3235-a(c) of the Insurance Law states that a right of subrogation exercised by municipalities under Section 2559 of the Public Health Law is valid and enforceable against the commercial insurer to the extent of benefits available under the insurance policy.

As the insurer of <Name of Child>, you are obligated to accept claims submitted by <Name of Municipality> for early intervention services paid by <Name of Municipality> for <Name of Child> and for which benefits are available to <Name of Child> as the insured.

<Name of County or Designee> is hereby notifying <Name of Insurer> of the intent to exercise our subrogation rights pursuant to the aforementioned sections of NYS Public Health and Insurance Law. We intend to claim reimbursement for early intervention services included in the Individualized Family Service Plan for <Name of Child> and for which <Name of Child> as the insured is eligible. We require a copy of all explanation of benefits that may be sent to clients.

Name of Primary	<To be completed by the municipality>
Primary Social Security Number
Child’s Name
Child’s Date of Birth:
Policy Number:
Name of Child’s Primary Health Care Provider:

Please complete the following requested information regarding <Name of Child’s> benefits as the insured:
Is the child’s health coverage:

a) A commercial policy regulated by New York State Insurance Law?
Yes No

b) Child Health Plus
Yes No

c) Other governmental plan (e.g., CHAMPUS, Medicaid) regulated by other laws?
Yes No

d) A self insured plan governed by ERISA or other plan not subject to the New York State Insurance Law?
Yes No

If the child’s insurance policy IS A COMMERCIAL POLICY REGULATED BY NEW YORK STATE INSURANCE LAW and IS NOT Child Health Plus, Medicaid, Champus, or a self-insured plan or other plan not subject to New York State Insurance Law, PLEASE INDICATE THE NUMBER OF ANNUAL VISITS AVAILABLE TO THE INSURED WHICH <name of municipality> intends to provide based on the child’s IFSP (if no coverage is available, please indicate by placing a 0 in the column labeled "Number of Annual Visits).

Type of Early Intervention Service in IFSP	Number of Annual Visits
<TO BE COMPLETED BY THE MUNICIPALITY>	<TO BE COMPLETED BY THE INSURER>

Is prior authorization for covered services required?
Yes No

Is a referral from the child’s primary health care provider required?
Yes No

Are there specific referral procedures that must be followed when accessing an out-of network provider?
Yes No

If yes, please describe the procedures that must be followed:

______________________________________________________________________________

Please indicate the number of days within which a bill must be submitted:

It is the insurance carrier’s responsibility to notify <Name of County/Agency> about any documentation provided to clients regarding a claim related to covered services provided by the Early Intervention Program in accordance with an approved IFSP.

Please complete and return this form to:

<Name, Address, Telephone Number, Fax, E-mail of County Contact>

If you have any questions, please contact:

<Name, Telephone Number, E-mail of County Contact>

Please provide the name, telephone number, and email of an appropriate contact person if we have questions about the information on this form:

__________________________________________	______________________	__________________________________________
Name	Phone	E-mail

Thank you for your assistance.

Department of Health

Notice of Subrogation