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About
MBN-USA

Medicare

Group
Insurance

Individual Insurance

Workplace
Rewards

Forms

Contact

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To find out if your doctor is in our network, please fill out and submit the form below:

    Effective Date: Enter effective date of election. Note: An election application received from any payor or organization shall begin on the first day of the month following the date it was received by the Office of Pool Administration unless a future date is specified.

    Federal Employer Identification # (FEIN): Enter federal employer identification number (FEIN) of the payor. Please note that Section 2807-j(5)(a)(iii)(D) of the Public Health Law requires the New York State Department of Health to publish the FEIN of all electing payors on a secure website.

    Payor Name: Enter name of payor. The payor name is that of the incorporated entity, local government, self-insured fund.

    D/B/As: Enter any assumed name(s) ("d/b/a") under which the entity is doing business.

    Address: Enter address of payor.

    Contact Person: Enter name of contact person that will be responsible for providing the Department with the
    information regarding the payor's election, lines of business and claims processing.

    Phone #: Enter phone number of the contact person.

    E-Mail Address: Enter the e-mail address of the contact person.

    If the above referenced entity is a payor that utilizes a third-party administrator (TPA)/administrative services
    only (ASO) for claims processing, please provide the following information:

    TPA/ASO Name: United HealthCare Services, Inc.
    TPA/ASO FEIN: 41-1289245

    By signature below, the above entity elects to make all public goods surcharge payments directly to the Office of Pool Administration for all its coverages for which it assumes risk for the payment of medical claims and agrees to:

    1. remit to the Department’s Office of Pool Administration required surcharge payments for all applicable services on a monthly basis on or before the 30th day following the calendar month for which monies have been paid to designated providers of service;

    2. provide the Department’s Office of Pool Administration monthly certified reports on or before the 30th day following the calendar month for which monies have been paid which separately report patient service expenditures for services provided by designated provider type(s) (i.e., hospital inpatient, hospital outpatient, diagnostic & treatment center, laboratory1, or ambulatory surgery center) by product line;

    3. provide the Department with certification of data and access to allowance expenditure data upon request for audit verification purposes; and

    4. the jurisdiction of the state to maintain an action in the courts of the State of New York to enforce any provision of section 2807-j of the Public Health Law (see note below).

    5. the Department’s website posting of the above entity’s FEIN in accordance with Public Health Law Section 2807-j(5)(a)(iii)(D).

    By signature below, the above entity also agrees to make public goods covered lives payments directly to the Department’s Office of Pool Administration in instances where it provides inpatient coverage as a corporation organized and operating in accordance with Article 43 of the Insurance Law, an organization operating in accordance with Article 44 of the Public Health Law, a self-insured fund, or an HMO or insurer licensed outside New York State and authorized to write accident and health insurance and whose policy provides inpatient coverage on an expense incurred basis. In such instances the above entity agrees to:

    1. remit to the Department’s Office of Pool Administration within 30 days after the end of each month one twelfth of both the individual and family unit annual assessment amounts for each of the individuals and family units residing in the state which were included on the payor’s membership rolls for all or a portion of the prior month and for which the payor covered general hospital inpatient care, including retroactive additions and deletions;

    2. provide the Department with data certification and access to individual and family unit data, upon request, for audit verification purposes; and

    3. the jurisdiction of the state to maintain an action in the courts of the State of New York to enforce any provision of section 2807-t of the Public Health Law (see note below).

    By signature below, the Chief Financial Officer or other duly authorized individual of the above entity certifies that the data submitted on all applicable attachments have been carefully prepared in accordance with instructions provided, and to the best of his/her knowledge, the information presented is accurate and correct.

    Note: Payors making an election are only agreeing to the jurisdiction of NYS courts for purposes of enforcing payments required under 2807-j and 2807-t. This does not, in any way, preclude a payor from litigating other issues in Federal court such as ERISA based challenges, etc.

    COVERAGE INFORMATION (See Attached For Further Explanation)

    TPA/ASO Name: United HealthCare Services, Inc.

    TPA/ASO Federal ID #: 41-1289245

    Select all applicable types of coverage for each type of payor.

    1. Corporations Organized & Operating in accordance with Article 43 of the NYS Insurance Law


    2. Corporations that are Commercial Insurers licensed in New York State






    3. Corporations Organized & Operating in accordance with Article 44 of the NYS Public Health Law, not incorporated as Commercial Insurers or under Article 43 of the NYS Insurance Law

    4. Self-Insured Fund with No Third Party Administrator/Administrative Services Only Organization for Claims Processing


    5. Self-Insured Fund with a Third Party Administrator/Administrative Services Only Organization for Claims Processing

    6. New York State Governmental Agency/New York State Local Government

    7. Other: Includes: State/Local Governments outside New York for Medical Assistance Programs; insurers licensed outside New York State, authorized to write OTHER than Accident and Health


    8. HMOs and insurers licensed outside New York State, authorized to write Accident and Health

    HEALTH CARE REFORM ACT – PUBLIC GOODS POOL
    COVERAGE INFORMATION

    Payor Type 1: Corporation organized and operating in accordance with Article 43 of the New York State Insurance Law offering:

    → Indemnity Coverage with an expense incurred inpatient hospital component, thus requiring a surcharge obligation on affected services plus regional GME covered lives assessments for NYS resident insureds

    → Indemnity Coverage without an expense incurred inpatient hospital component, thus requiring a surcharge obligation on affected services but no regional GME covered lives assessments for NYS resident insureds

    → HMO non-Medicaid managed care coverage, thus requiring a surcharge obligation on affected services plus regional GME covered lives assessments for NYS resident non-Medicaid insureds

    → HMO Medicaid managed care coverage, thus requiring a surcharge obligation on affected services but no regional GME covered lives assessments for NYS resident Medicaid managed care enrollees

    Payor Type 2: Commercial Insurance Corporation licensed by New York State offering:

    → Indemnity Coverage with an expense incurred inpatient hospital component, thus requiring a surcharge obligation on affected services plus regional GME covered lives assessments for NYS resident insureds

    → Indemnity Coverage without an expense incurred inpatient hospital component, thus requiring a surcharge obligation on affected services but no regional GME covered lives assessments for NYS resident insureds

    → HMO non-Medicaid managed care coverage, thus requiring a surcharge obligation on affected services plus regional GME covered lives assessments for NYS resident non-Medicaid insureds

    → HMO Medicaid managed care coverage, thus requiring a surcharge obligation on affected services but no regional GME covered lives assessments for NYS resident Medicaid insureds

    → New York State Workers Compensation Law coverage, thus requiring a surcharge obligation on affected services but no regional GME covered lives assessments for NYS resident insureds

    → New York State Motor Vehicles Reparations Act coverage, thus requiring a surcharge obligation on affected services but no regional GME covered lives assessments for NYS resident insureds

    → New York State Volunteer Ambulance Workers Benefit Law coverage, thus requiring a surcharge obligation on affected services but no regional GME covered lives assessments for NYS resident insureds

    → New York State Volunteer Firefighters Benefit Law coverage, thus requiring a surcharge obligation on affected services but no regional GME covered lives assessments for NYS resident insureds

    Payor Type 3: Corporation organized and operating in accordance with Article 44 of the New York State Public Health Law not incorporated as a NYS licensed commercial insurer or under Article 43 of the New York State Insurance Law offering:

    → HMO non-Medicaid managed care coverage, thus requiring a surcharge obligation on affected services plus regional GME covered lives assessments for NYS resident non-Medicaid managed care enrollees

    → HMO Medicaid managed care coverage, thus requiring a surcharge obligation on affected services but no regional GME covered lives assessments for NYS resident Medicaid managed care enrollees

    Payor Type 4/5: Self insured fund offering:

    → self insured employee health coverage with an expense incurred inpatient hospital component, thus requiring a surcharge obligation on affected services and regional GME covered lives assessments for NYS resident plan participants

    → self insured employee health coverage without an expense incurred inpatient hospital component, thus requiring a surcharge obligation on affected services but no regional GME covered lives assessments for NYS resident plan participants

    → self insured New York State Workers Compensation Law coverage, thus requiring a surcharge obligation on affected services but no regional GME covered lives assessments for NYS resident plan participants

    → self insured non-New York State Workers Compensation Law coverage, thus requiring a surcharge obligation on affected services and a regional GME covered lives assessments (if coverage includes expense incurred inpatient hospital care) for NYS resident plan participants

    → self insured New York State Motor Vehicles Reparation Act coverage, thus requiring a surcharge obligation on affected services but no regional GME covered lives assessments for NYS resident plan participants

    → self insured non-New York State Motor Vehicles Reparations Act coverage, thus requiring a surcharge obligation on affected services and a regional GME covered lives assessments (if coverage includes expense incurred inpatient hospital care) for NYS resident plan participants

    Payor Type 6: New York State Governmental Agency/ New York State Local Government:

    → New York State political subdivision for New York State county corrections, New York City corrections, and, New York State governmental agencies for New York State administered payments that reimburse hospitals for rendered inpatient services to eligible patients. (e.g. Office of Mental Health payments for services provided to individuals residing in New York State operated developmental centers), thus requiring a surcharge obligation on affected services but no regional GME covered lives assessment

    Payor Type 7: Other

    → Insurers licensed outside New York State, authorized to write OTHER than Accident and Health thus requiring a surcharge obligation on affected services but no regional GME covered lives assessments for NYS resident insureds

    → States other than New York State and localities other than New York State political subdivisions for medical assistance program expenses (i.e. Medicaid Programs in states OTHER than New York State), thus requiring a surcharge obligation on affected services but no regional GME covered lives assessment

    → NYS licensed fraternal benefit societies offering coverage with or without an expense incurred inpatient hospital component, requiring a surcharge obligation on affected services but no regional GME covered lives assessments for NYS resident insureds

    Payor Type 8: HMOs and insurers licensed outside New York State, authorized to write Accident and Health:

    → Indemnity Coverage with an expense incurred inpatient hospital component, thus requiring a surcharge obligation on affected services plus regional GME covered lives assessments for NYS resident insureds

    → Indemnity Coverage without an expense incurred inpatient hospital component, thus requiring a surcharge obligation on affected services but no regional GME covered lives assessments for NYS resident insureds

    → HMOs organized and operating outside New York State Insurance and Public Health Laws, thus requiring a surcharge obligation on affected services plus regional GME covered lives assessments for NYS resident insureds

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    CMS (Centers for Medicare and Medicaid Services) requires the following statement on all correspondence with Medicare Beneficiaries:

    “We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all your options.”

    110 Roessler Rd, Suite 100

    Pittsburgh, PA 15220

    Phone Number:

    412.341.1400

    Office Hours:

    9AM - 4PM, Monday - Friday

    506 Washington Road

    Washington, PA 15301

    Serving Allegheny, Beaver, Butler, Cambria, Greene, Lawrence, Mercer, Washington, and Westmoreland Counties into some counties of West Virginia