Division of Rehabilitation and Liquidation
If you do not have a claim for medical services, please go to the applicable General Creditor Link or the Claim Vendor Link for instructions on how to file your claim.
If you are a medical provider who has provided services to more than one subscriber of a Health Maintenence Organization ("HMO"), we require that you itemize your invoices. Itemization allows the Receiver to cost effectively evaluate your claim, which in turn helps maximize the available assets in the receivership estate. Click on the links below to see samples of itemization tables:
Above tables are provided as a Microsoft Excel Spreadsheet. If you do not have this program, you can download a free Microsoft Excel Viewer by clicking here
TIP: Your medical bill processing software or accounting software may be able to produce a report with this same information which you can use as your itemization summary. As long as your report has the minimum detail shown in the table above, in either Excel or Access format, we will accept it as the itemization summary of your claim.
Claims must be submitted by the entity who owns the Federal Tax Identification Number (FEIN) on file with the IRS. This means that if you bill under a FEIN that is assigned to an organization other than your facility, you must coordinate submission of your claim with the organization that owns the FEIN. For example, if your facility bills under the FEIN for ABC Hospital, ABC hospital must submit a single claim along with an itemization on behalf of your facility as well as for all other providers who bill under ABC FEIN.
The total amount claimed should represent the total amount unpaid at the time of the liquidation. Any amounts recommended for payment by the Receiver will be a sum total of the amount owed under each specific FEIN, and the payment will be issued to the owner of the FEIN. The owner of the FEIN will be responsible for distributing payment to the providers who billed under the FEIN.
Please label the CD and CD case with the name of your organization and the Receiver Claim Number (RCN) from your Proof of Claim form. If you are submitting more than one CD due to the volume of your claim, please also indicate on each CD and CD label that the CD is part of a group (i.e., 1 of 5, 2 of 5, etc.). All supporting documentation for all claims submitted in association with your unique TIN should be scanned and submitted together.
Please also complete and Submit an IRS W-9 Form. For additional instructions on downloading a W-9 form, click here.
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