Casualty TPL subrogation is responsible for collecting funds paid out by Vermont Medicaid when another party is found responsible for payment, such as, a property insurance, auto insurance, workers compensation insurance, or another responsible party.
Please complete and submit the secure online form depending on who you are:
VT Medicaid Member – complete the Accident Injury Questionnaire and see the Member Related information section. One form should be completed for each individual Medicaid member and specific incident. The information contained is required for us to complete the lien and notify the correct parties.
Attorney or Insurance – complete the New Request Form for each individual Medicaid member and specific incident. The information contained is required for us to complete the lien and notify the correct parties.
Attorney's NOTE: HIPAA mandates that DVHA also must receive a copy of your client's signed Medical Release Authorization Form.
*DVHA allows 6 months for filing of a claim* Please contact us at AHS.DVHACasualty@vermont.gov if you have any questions about claims submission.
Question & Answer (Q&A) for Attorneys and Insurances
Q: What do I need to do to start a new case?
A: Attorney’s, please complete the New Request Form and attach a letter of representation and a signed medical authorization (HIPAA release).
A: Insurance companies, please fill out our new case form found above.
Q: How do I request the addition of missing claims or an updated claims summary?
A: Email AHS.DVHACasualty@vermont.gov with the email subject as Update Request for, and the Members UID (Example: Update Request for UID 99999999). It must include the below:
- The date of injury (sometimes members have multiple injuries) and/or;
- A list of anything identified as missing such as specific dates of service, specific providers, or specific injuries.
Q: How do I submit a revision request/remove unrelated claims?
A: Email AHS.DVHACasualty@vermont.gov with the email subject as Revision Request for, and the Members UID (Example: Revision for UID 99999999). It must include the below:
- A copy of the last letter & claim summary from the Casualty Team
- Identify the claims that are not part of the injury (highlight, circle, star, etc.)
- Provide the reason why the claims marked are unrelated
Q: What is needed for a reduction request?
A: Email AHS.DVHACasualty@vermont.gov with the email subject as Reduction for, and the Members UID (Example: Reduction for UID 99999999). It must include the below:
- Settlement amount (in dollars)
- Date of settlement
- The attorney's fee (in dollars, not percent)
- A copy of the attorney/client fee agreement signed by the member
- Itemized list of expenses incurred (if applicable)
Q: What is the ACO WHPP column in the claims summary?
A: ACO WHPP stands for Accountable Care Organization Would Have Paid Provider. Some Vermont Medicaid members are attributed to an Accountable Care Organization (ACO). When a member is attributed to an ACO, Vermont Medicaid prospectively pays for certain services included in the ACO program, often including services a member receives in casualty cases. The ACO WHPP column shows what services were reimbursed through the ACO program rather than through the traditional fee-for-service model for DVHA’s internal recordkeeping purposes. When a member is attributed to an ACO, Vermont Medicaid’s claim is the sum of all dollars paid for fee-for-service claims as well as the ACO WHPP column.
Q: We have a date for mediation. What now?
A: Email AHS.DVHACasualty@vermont.gov with the email subject as Mediation for, and the Members UID (Example: Mediation for UID 99999999). Once received we will prepare an updated claims summary. It must include the below:
- The mediation date
Please send questions & communications to:
Email: AHS.DVHACasualty@vermont.gov
Phone: 802-241-9971
Fax: 802-241-9070
Mail: Department of Vermont Health Access
Member & Provider Services - Casualty Team
280 State Drive, NOB 1 South
Waterbury, VT 05671
Question & Answer (Q&A) for Members:
Q: Do I need to complete the Accident Injury Questionnaire?
A: Yes, you can choose to complete the electronic form OR the paper form and mail it in. You do not need to complete both ways.
Q: I already received and responded to a questionnaire, and I got another. Do I need to complete the additional Accident Injury Questionnaires?
A: Yes. An accident injury questionnaire is sent for each provider visit. You can choose to complete the electronic form OR the paper form and mail it in. You do not need to complete both ways.
Q: Who do I contact if I need help completing the form?
A: Accident Questionnaire Team
Email: Vt-tpl@Gainwelltechnologies.com
Phone: 800-925-1706, Option 5
Member Procedure for Medicaid Recovery Accidents/Injuries
Medicaid and/or Gainwell Technologies Identifies Potential Third-Party Liability
The Department of Vermont Health Access in conjunction with Gainwell Technologies reviews bills paid by VT Medicaid. When it appears that a VT Medicaid member may have been involved in an accident or injury, the following steps are taken to determine whether recovery of Medicaid expenses should be pursued:
- Vermont Medicaid/Gainwell sends a cover letter with an Accident/Injury Questionnaire (AIQ). These are sent to the injured person. They are sent to both active and inactive Medicaid recipients. A 10-day deadline is given to return the form to Medicaid/Gainwell.
A follow-up letter & AIQ is sent if a response is not received. An additional 10-day deadline has been given.
For example: Michelle Jones and her three children receive Medicaid. Medicaid has paid for an emergency room visit, leg cast and follow-up visits for Suzy (age 6). It appears that Suzy was involved in an accident. The AIQ is sent to Suzy.
- Vermont Medicaid/Gainwell receives notification from the representative for the member:
- Representing Attorney
- The alleged liability party’s insurance
- Via a Department of Motor Vehicles data Match
- The member themselves or guardian
- Other
- Vermont Medicaid conducts claim research and sends a claim letter to the attorney or insurance to recover claims paid by VT Medicaid.
Please send questions & communications to:
Email: AHS.DVHACasualty@vermont.gov
Phone: 802-241-9971
Fax: 802-241-9070
Mail: Department of Vermont Health Access
Member & Provider Services - Casualty Team
280 State Drive, NOB 1 South
Waterbury, VT 05671