Get Doh4403 2012-2024

NEW YORK STATE DEPARTMENT OF HEALTH Division of Finance and Rate Setting Third Party Administrator TPA or Administrative Services Only ASO Status Change HEALTH CARE REFORM ACT PUBLIC GOODS POOL DOH-4403 INSTRUCTIONS This form is to be completed by a payor whose status has changed from the original election as it relates to whether a TPA/ASO is utilized for claims processing. Effective Date Enter effective date of status change. Payor Information Enter payor name federal identification number FEIN contact person and phone. Type of Status Change If you are adding or changing a TPA/ASO organization check appropriate box on type of status change being submitted* Previous TPA/ASO Information Enter previous TPA/ASO name/FEIN if applicable. New or Additional TPA/ASO Information Enter new or additional TPA/ASO name FEIN address contact person and phone number. Check one of the following Check appropriate box regarding claims run out if applicable. Signature Section An authorized individual from the electing payor s company must sign and date the form* Instructions Page 1 of 1 PAYOR INFORMATION Payor Name Payor FEIN Contact Person Phone Additional TPA/ASO complete Section II only Changing TPA/ASO complete Sections I II III I. PREVIOUS TPA/ASO INFORMATION TPA/ASO Name TPA/ASO FEIN II. NEW or ADDITIONAL TPA/ASO INFORMATION Address TPA/ASO Contact Person TPA/ASO Phone III. CHECK ONE OF THE FOLLOWING a period of one year following the end of the year in which the change in TPA occurred or until all such claims have been adjudicated at which time a final monthly report with a copy of this form indicating same will be filed* All self-insured claims that previous TPA/ASO was responsible for have been adjudicated effective. New TPA/ASO is assuming responsibility for all pending claims and HCRA reporting requirements. Signature of Payor Date Please mail completed form to Mr. Jerome Alaimo Pool Administrator Office of Pool Administration Excellus BlueCross BlueShield Central New York Region P. Payor Information Enter payor name federal identification number FEIN contact person and phone. Type of Status Change If you are adding or changing a TPA/ASO organization check appropriate box on type of status change being submitted* Previous TPA/ASO Information Enter previous TPA/ASO name/FEIN if applicable. New or Additional TPA/ASO Information Enter new or additional TPA/ASO name FEIN address contact person and phone number. New or Additional TPA/ASO Information Enter new or additional TPA/ASO name FEIN address contact person and phone number. Check one of the following Check appropriate box regarding claims run out if applicable. Signature Section An authorized individual from the electing payor s company must sign and date the form* Instructions Page 1 of 1 PAYOR INFORMATION Payor Name Payor FEIN Contact Person Phone Additional TPA/ASO complete Section II only Changing TPA/ASO complete Sections I II III I. Check one of the following Check appropriate box regarding claims run out if applicable. Signature Section An authorized individual from the electing payor s company must sign and date the form* Instructions Page 1 of 1 PAYOR INFORMATION Payor Name Payor FEIN Contact Person Phone Additional TPA/ASO complete Section II only Changing TPA/ASO complete Sections I II III I. PREVIOUS TPA/ASO INFORMATION TPA/ASO Name TPA/ASO FEIN II. NEW or ADDITIONAL TPA/ASO INFORMATION Address TPA/ASO Contact Person TPA/ASO Phone III.