In the complex ecosystem of healthcare finance, the Doh 4405 form emerges as a pivotal document, encapsulating the intersection between healthcare facilities and the intricate machinations of Medicaid surcharge payments. Crafted by the New York State Department of Health's Division of Finance and Rate Setting, this form plays a critical role in the administration of the Health Care Reform Act's Public Goods Pool. It effectively serves as the provider election form, enabling healthcare facilities to opt for the Department of Health to withhold HCRA surcharge payments directly from Medicaid assistance payments. This administrative procedure not only streamlines the transfer of funds but also ensures compliance with the Public Health Law, specifically section 2807-j of the PHL. The form requires detailed information including, but not limited to, the facility's Federal Tax Identification Number, provider ID, and the National Provider Identifier (NPI), ensuring a seamless connection between the financial operations of healthcare providers and the overarching goals of the Public Goods Pool. Addressed to Mr. Jerome Alaimo, Office of Pool Administration at Excellus BlueCross BlueShield, the form signifies a structured approach towards managing Medicaid Surcharge Payments under the umbrella of New York State’s Health Care Reform Act, highlighting the procedural and inter-organizational coordination essential for the effective operation of healthcare financing within the state.
| Question | Answer |
|---|---|
| Form Name | Form Doh 4405 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | doh 4405 excellus blue cross blue shield new york state surcharge payment form |
NEW YORK STATE DEPARTMENT OF HEALTH Division of Finance and Rate Setting
Provider Election Form for Medicaid Surcharge Withholding
HEALTH CARE REFORM ACT – PUBLIC GOODS POOL
Mr. Jerome Alaimo, Pool Administrator
Office of Pool Administration
Excellus BlueCross BlueShield
Central New York Region
P.O. Box 4757
Syracuse, New York
Dear Mr. Alaimo:
Re: New York State Health Care Reform Act (HCRA) Medicaid Surcharge Payments
Pursuant to Section
This election, once processed, becomes effective immediately and will remain in effect (pursuant to authorizing statute) unless written revocation is received by the Office of Pool Administration postmarked no later than December 1 in the year immediately preceding the next calendar year.
________________________________________________ |
_______________________ |
Signature - CFO/Controller |
Date |
FEDERAL TAX |
OPERATING |
IDENTIFICATION #: _________________________ |
CERTIFICATE #: _____________________ |
PROVIDER ID: ______________________________ |
NPI: ________________________________ |
(Medicaid Provider ID) |
(Entity National Provider Identifier) |
FACILITY NAME: ____________________________________________________________________
ADDRESS: ___________________________________________________________________________
CONTACT PERSON: ___________________________________________________________________
PHONE#: ______________________________
EMAIL ADDRESS: ____________________________________________________________________
DOH