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For the period of January 1, 20__ through December 31, 20__

I, _______________________________________________, on behalf of_________________________________________________, [hereinafter "Plan"], hereby attest to the following:

  1. I have the authority to make this attestation legally binding on Plan.
  2. Plan acknowledges that it is subject to the New York State Medicaid Program's Managed Care Manual, Stop Loss Policy and Procedures and all revisions thereto, and that all staff having pertinent responsibilities have read and arefamiliar with those documents. All claims from Plan are made in full compliance with the pertinent provisions of theNew York State Medicaid Program's Managed Care Manual, Stop Loss Policy and Procedures and all revisions thereto.Plan further acknowledges that the New York State Department of Health Stop Loss Website contains filespecifications, frequently asked questions (FAQ) and other information pertinent to the submission of Stop Loss claims.
  3. Each Stop Loss claim submitted by Plan is for an identified Plan enrollee for which a Stop Loss payment is due. Plan acknowledges that submission of a Stop Loss claim does not guarantee payment for that Stop Loss claim.
  4. Satisfactory documentation, including proof of payment to providers for all claims for Plan's enrollees submitted for Stop Loss re-insurance submission, will be provided upon request or pursuant to any audit or other inquiry conducted by the State of New York to verify the appropriateness of Stop Loss payment.
  5. Plan acknowledges that New York State has the right to recoup part or all of any monies paid by the State of New York to the Plan for Stop Loss claims for inappropriate, incomplete or inaccurate or unavailable supporting documentation.
  6. All information provided on this statement and any accompanying form(s) is true, accurate and complete to the best of my knowledge and no material fact has been omitted.
  7. This attestation applies to all Stop Loss claims, whether submitted electronically or on paper, using Plan's NPI or Medicaid provider identification number, and remains in effect unless expressly superseded by a subsequent properly executed attestation statement.

Signature__________________________ Print/Type Name__________________________

Title_______________________ Name of Plan________________________ Plan ID#______________

State of____________________________ County Of________________________________

On this ____ day of ____________, 20__, before me personally appeared ____________________, to me known and known to be the individual described in and who executed the foregoing instrument, and (s) he acknowledged to me that (s) he executed the same.

[SEAL]                 NOTARY PUBLIC______________________