Proof of Claim Form Information – MD Medicare Choice, Inc. ("MDMC")

Why do I have to fill out an itemization table?

Itemization allows the Receiver to cost effectively evaluate your claim, which in turn helps maximize the available assets in the MDMC estate. If invoices or bills are submitted without itemization, the Receiver incurs additional administrative costs to process them. These additional costs reduce the funds available for distribution (payment) to claimants. You may find that your medical bill processing software or accounting software can produce a report with the same information as our itemization table. If you choose this option, we would require that the report be exported to an electronic spreadsheet in either Excel or Access format.

Am I required to send paper copies of all applicable bills?

Your claim must include supporting documentation in the form of HCFA or UB 04 forms. Because of the cost to the MDMC estate to handle and store large amounts of paper bills, the preferred filing method is that you image the HCFA or UB 04 forms onto a CD and submit the CD to us with the itemization table. Sending a CD rather than paper forms may also result in reduced shipping costs for your facility.

Do I still have to fill out a spreadsheet if I have only a few bills and/or do not have Microsoft Excel?

All bills should be itemized.

What if I don’t itemize my claim?

Your claim may be considered an incomplete submission and denied accordingly.

Why did I receive a proof of claim form?

The Receiver mailed proof of claim forms and instructions to all parties except subscribers (members) that the Receiver identified as possibly having a claim in the MDMC estate. If you feel you have amounts owed from the receivership estate of MDMC to you or your business, this is your opportunity to file a proof of claim form with the Receiver. The claims filing deadline is Wednesday, September 30, 2009.

If applicable, proof of claim forms must be accompanied by a Form W-9. Please refer to the form and instructions to determine whether or not you need to complete a Form W-9 along with your proof of claim form submission.

I am a past subscriber (member) of MDMC who has out of pocket expenses but I did not receive a proof of claim form. Can I still file a proof of claim form with the Receiver?

Yes, you may still file a proof of claim with the Receiver. Due to the fact that coverage with MDMC was terminated on September 30, 2008 and new coverage with Humana began on October 1, 2008, the majority of subscribers should not have had out of pocket expenses. As a result, the Court granted the Receiver permission to not mail proof of claim forms to approximately 16,600 subscribers due to the administrative costs associated with mailing the proof of claim forms.

However if you are a subscriber (member) and believe you may have a claim in the receivership of MDMC, please contact the Receiver by using the "Contact Us" form to request a proof of claim form be mailed. You may also reach the Receiver by calling # 850-413-3081
.

If I did not receive a proof of claim form and need to file a claim against MDMC, how do I go about getting a proof of claim form?

On July 1, 2009 the Receiver mailed proof of claim notices to all parties except subscribers (members) that the Receiver identified as possibly having a claim in the MDMC estate. If you believe you may have a claim in the receivership of MDMC and you did not receive a proof of claim form, please contact the Receiver by using the "Contact Us" form to request a proof of claim form. You may also reach the Receiver by calling # 850-413-3081
.

What is a Master Claim Itemization Table and how do I know if I need to submit one along with my proof of claim form?

If you have provided services to a multitude of clients, you will need to complete the Master Claim Itemization Table, copy it to a CD and submit it to the Receiver along with your proof of claim form. A good example of someone that needs to complete a Master Claim itemization table would be a medical provider. The medical provider would have one claim that amounted to all the subscribers of MDMC to whom they provided services. For more information on the Master Claim Itemization Table requirements, click here.

What happens if I don’t mail my proof of claim form by the September 30, 2009 deadline? May I still file a proof of claim?

Yes, you may still file a proof of claim after the September 30, 2009 claims filing deadline but any proof of claim form postmarked after September 30, 2009 will be processed as “late-filed”. Please note that the filing deadline will not be extended.

For any who feel that their proof should be considered timely-filed, Chapter 631, Florida Statutes gives the right to petition the Receivership court (Second Judicial Circuit Court, Tallahassee, Leon County Florida, case number 2008-CA-3191) to accept a claim as timely-filed.

How do I obtain an IRS W-9 Form?

In order to submit a IRS W-9 Form along with your claim submission, you will need to visit the Internal Revenue web site at www.irs.gov and download the form and instructions.

Can you verify receipt of my proof of claim and W-9 forms?

If you would like to verify receipt of your proof of claim form submission, the Receiver suggests that you send your completed forms by US Postal Service certified mail, return-receipt requested or by a delivery service like UPS or FedEx and keep the certification cards as proof of mailing. We are unable to send receipt confirmations.

When will my claim be paid and how much will I receive?

The amount of any potential payment is unknown until after the amount of all liabilities has been established and all reasonable efforts to recover and liquidate assets have been exhausted. Please be advised that it may take several years before a distribution of assets, if any, is made in this receivership.

What if I don’t know the exact amount of my claim or don’t have all the documentation available at the time I submit my proof of claim?

If you don’t know the exact amount of the claim, enter “$1.00” in the amount claimed field on the proof of claim form. Be sure to put your Receiver Claim Number (“RCN”) on all documentation so it can be matched to your proof of claim.

The proof of claim form has a box for indicating whether the claim is a secured claim. I don't understand what this means?

"Secured claim" means any claim secured by mortgage, trust deed, pledge, deposit as security, escrow, or otherwise but does not include a special deposit claim, a claim against general assets, or a claim based on mere possession. In other words, if a claim involves some form of collateral of MDMC that you hold, it’s considered a secured claim.

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