Rekord ng Data ng Binabayaran (STD 204)
Maaaring iproseso ng Third Party Liability and Recovery Division (TPLRD) ang isang kahilingan sa pagbabayad upang ibalik ang mga sobrang bayad, mga maling pagbabayad, at mga dobleng pagbabayad, na ginawa ng mga tagadala ng health insurance, provider, miyembro ng Medi-Cal, at abogado. Kasama sa iba pang mga pagbabayad ang Breast and Cervical Cancer Treatment Program (BCCTP) at ang 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.
Awtoridad ng Batas:
- Mga seksyon ng State Administrative Manual 8422.19 at 8422.190
- Seksyon 3402(t)Code ng Panloob na Kita
Epektibo sa Enero 1, 2012, kakailanganin ng TPLRD ang lahat ng mga pagbabayad sa sinumang indibidwal o entity na hindi entity ng pamahalaan na kumpletuhin ang isang STD 204 na form. Ang form na ito ay dapat kumpletuhin ng nagbabayad at pananatilihin sa isang kumpidensyal na file ng Department of Health Care Services (DHCS) bago humiling ng refund o pagbabayad.
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 an STD 204 is not properly 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 could contact their TPLRD program representative for instructions on electronically sending a copy of the completed STD 204. The original signed copy of the completed STD 204 must be mailed to one of the following addresses below, or as instructed by your program representative.
TPLRD Mailing Address:
Department of Health Care Services
Third Party Liability and Recovery Division, MS 4720
PO Box 997425
Sacramento, CA 95899-7425