Payee Data Record (STD.204)
Third Party Liability and Recovery Division (TPLRD) may process a payment request to reimburse overpayments, misdirected payments, and duplicate payments, made by health insurance carriers, providers, Medi-Cal beneficiaries, and attorneys. Other payments include the Breast and Cervical Cancer Treatment Program (BCCTP) and the Health Insurance Premium Payment (HIPP) Program.
TPLRD’s payment process has changed. Both state and federal laws require that all reportable payments be identified and reported in the Payee Data Record (STD. 204) form. This includes any state department that participates in a transaction resulting in a payment to any individual or
entity that is not a governmental entity.
Effective January 1, 2012, TPLRD will require
all payments to any individual or entity that is not a governmental entity to complete a STD. 204 form. This form must be completed by the payee and will be retained in a confidential file by the Department of Health Care Services (DHCS) before requesting a refund or payment.
The form is available for download using this link:
STD. 204.Please carefully read the instructions provided on the second page of the STD. 204 before completing the form. If a STD. 204 is not completed as indicated in the instructions and filed with DHCS, your refund or payment request is subject to rejection. If the payee’s name and/or address changes, the payee must submit a new STD. 204 with their current information.
The payee seeking payment is to contact their TPLRD program representative for instructions on how to fax or electronically send a copy of your completed STD. 204. The
original signed copy of your completed STD. 204
must be mailed to one of the following addresses below, as instructed by your program representative.