Casualty Third Party Liability (TPL)

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 the New Request Form below for each individual Medicaid member and specific incident. The information contained is required for us to complete the lien and notify the correct parties.

• New Request Form (If you are unable to open any of our forms, please learn more about Dynamic PDF Forms and Web Browser Incompatibility.)

Attorney's NOTE: HIPAA mandates that DVHA also must receive a copy of your client's signed Medical Release Authorization Form.

Question & Answer (Q&A)

Q: What do I need to do to start a new case?

A: Attorney’s, please send a letter of representation, a signed medical authorization (HIPAA release), and a new case form to return via email: AHS.DVHACOBTPL@vermont.gov or fax: 802-241-9070. The New Request Form can be found above.

A: Insurance companies, please fill out our new case form and return via email: AHS.DVHACOBTPL@vermont.gov or fax: 802-241-9070. The New Request Form can be found above.

Q: What is needed for a reduction request?

A:  A written request for a reduction

• Settlement amount
• Date of settlement
• Itemized list of expenses incurred (if applicable)

Q: How do I submit a revision request/remove unrelated claims?

A: For unrelated claims, please use the claim summary sheet the Casualty Team sent with the claim letter and identify the claims that are not part of the injury (Circle, Star, etc.) and email or fax back to the casualty team. Also, provide a summary of why the claims marked are unrelated.

Please send communications to:

Email:

AHS.DVHACOBTPL@vermont.gov

Fax:

802-241-9070

Mail:

Department of Vermont Health Access

Member/Provider Services Unit – Casualty Team

280 State Drive, NOB 1 South

Waterbury, VT 05671-4020

If any questions, please contact:

• Faith Sicard, CPC, CFPC
  DVHA Program Consultant
  AHS.DVHACOBTPL@vermont.gov
  P: 802-241-9333             
  F: 802-241-9070 
• Tracy Wells, CPC, CPB                             
  DVHA Program Consultant                          
  AHS.DVHACOBTPL@vermont.gov
  P: 802-241-9340                                               
  F: 802-241-9070   
• Samantha Prince, BSHCM, COC, CPC, CPB, CPMA
  COB Supervisor
  Samantha.Nye@vermont.gov
  P: 802-241-9330
  F: 802-241-9070