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Adminstrative Manual Section: General Administrative Procedures and Compliance Policy Manual Number: 200.025 Chapter: Assignment of Third Party Medical Support

January 29, 2016 HCFA 2 • Any identifying information required to claim payment such as the subscriber’s information, the subscriber’s Social Security Number (SSN), the policy number, and the group or certification number; • Household members covered by a health insurance policy; and • The individual’s signature on all forms required for reimbursement. The individual is required to cooperate in any other way with the State in obtaining the medical support or payments to which he or she is entitled. 4. Refusal to Cooperate In Assignment The refusal to cooperate with the State in reporting and obtaining medical support, or in the assignment of such support or third party payment to the State results in the individual’s ineligibility for program benefits. 5. Medical Trust Fund The individual is required to provide information regarding a medical trust fund established to defray or to entirely absorb his or her medical expenses including but not limited to the following: • Location of the account; • Account trustee; • Account number; and • Availability of the funds (e.g. limitations on disbursement). 6. Individual Responsibilities The individual is required to provide sufficient information to obtain the third party medical support to which he or she is entitled such as: • The name(s) of the third party; • The address; • Any identifying information required to claim payment such as the subscriber’s information, the subscriber’s Social Security Number (SSN), the policy number, and the group or certification number; • Household members covered by a health insurance policy; and • The individual’s signature on all forms required for reimbursement. The individual is required to cooperate with the State in any collection efforts including but not limited to his or her signature on all forms required to obtain reimbursement.