Vermont Statutes Title 33 Sec. 1909
Terms Used In Vermont Statutes Title 33 Sec. 1909
- Agency: means the Agency of Human Services. See
- Contract: A legal written agreement that becomes binding when signed.
- following: when used by way of reference to a section of the law shall mean the next preceding or following section. See
- Insurer: means any insurance company, prepaid health care delivery plan, self-funded employee benefit plan, pension fund, hospital or medical service corporation, managed care organization, pharmacy benefit manager, prescription drug plan, retirement system, or similar entity that is under an obligation to make payments for medical services as a result of an injury, illness, or disease suffered by an individual. See
- Legally liable representative: means a parent or person with an obligation of support to a recipient whether by contract, court order, or statute. See
- Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
- Person: shall include any natural person, corporation, municipality, the State of Vermont or any department, agency, or subdivision of the State, and any partnership, unincorporated association, or other legal entity. See
- Provider: means any person who has entered into an agreement with the State to provide any medical service. See
- Recipient: means any person or group of persons who receive Medicaid. See
- State: when applied to the different parts of the United States may apply to the District of Columbia and any territory and the Commonwealth of Puerto Rico. See
§ 1909. Direct payments to Agency; discharge of insurer‘s obligation
(a) When a recipient who is covered by the recipient’s or a legally liable representative‘s insurer receives medical benefits under this subchapter, payment for covered services or notice of denial shall be issued directly to the provider.
(b) A provider shall indicate on any claim form submitted to an insurer for covered services whether or not the person receiving treatment is a recipient.
(c)(1) An insurer that receives notice that the Agency has made payments to the provider shall pay benefits or send notice of denial directly to the Agency. Receipt of an Agency claim form by an insurer constitutes notice that payment of the claim was made by the Agency to the provider and that form supersedes any contract requirements of the insurer relating to the form of submission.
(2) An insurer shall respond to any request made by the Agency regarding a claim for payment for any health care item or service that is submitted not later than three years after the date of the provision of such health care item or service.
(3) An insurer shall not:
(A) deny a claim submitted by the Agency solely on the basis of the date of submission of the claim, the type or format of the claim form, or a failure to present proper documentation at the point-of-sale that is the basis of the claim, if the claim is submitted by the Agency within the three-year period beginning on the date on which the item or service was furnished and any action by the Agency to enforce its rights with respect to a claim is commenced within six years following the Agency’s submission of the claim; or
(B) deny a claim submitted by the Agency on the basis of failing to obtain a prior authorization for the item or service for which the claim is being submitted, if the Agency has transmitted authorization that the item or service is covered by the Medicaid state plan or waiver under subdivision 1908(d)(2) of this title.
(d) An insurer that has been notified of a claim by the Agency under this section and proceeds to pay the claim to a person other than the Agency is not discharged from payment of the Agency’s claim.
(e) Payment to the Agency by an insurer under this section discharges the insurer’s obligation for further payment on the claim to the extent of the amount paid. (Added 1995, No. 152 (Adj. Sess.), § 3; amended 2007, No. 65, § 110d; 2023, No. 51, § 2, eff. July 1, 2023.)