gsa277

State delegation of third party liability collection

AZ | AZBH | CA | CO | CT | DE | DC | FL | FLMH | HI | HIBH | IL | IN | IA | IABH | KS | KY
ME | MD | MA | MABH | MI | MN | MO | MT | NE | NEBH | NV | NH | NJ | NM | NY | NC | ND
OH | OK | ORMH | PA | PABH | RI | SC | TN | TX | UT | UTMH | VA | WA | WV | WI

"40. COORDINATION OF BENEFITS/ THIRD PARTY LIABILITY
By law, AHCCCSA is the payer of last resort. This means AHCCCSA shall be used as a source of payment for covered services only after all other sources of payment have been exhausted. The two methods used in the coordination of benefits are cost avoidance and postpayment recovery...
Cost Avoidance: The Contractor shall cost-avoid all claims or services that are subject to third-party payment and may deny a service to a member if it knows that a third party (i.e. other insurer) will provide the service...

If the Contractor knows that the third party insurer will neither pay for nor provide the covered service, and the service is medically necessary, the Contractor shall not deny the service nor require a written denial letter. If the Contractor does not know whether a particular service is covered by the third party, and the service is medically necessary, the Contractor shall contact the third party and determine whether or not such service is covered rather than requiring the member to do so...

The requirement to cost-avoid applies to all AHCCCS covered services. For pre-natal care and preventive pediatric services, AHCCCS may require the Contractor to provide such service and then coordinate payment with the potentially liable third party ('pay and chase'). In emergencies, the Contractor shall provide the necessary services and then coordinate payment with the third-party payer. The Contractor shall also provide medically necessary transportation so the member can receive third-party benefits...

Postpayment Recoveries: Postpayment recovery is necessary in cases where the Contractor was not aware of third-party coverage at the time services were rendered or paid for, or was unable to cost-avoid. The Contractor shall identify all potentially liable third parties and pursue reimbursement from them except in the circumstances below. The Contractor shall not pursue reimbursement in the following circumstances unless the case has been referred to the Contractor by AHCCCSA or AHCCCSA’s authorized representative:
Uninsured/ underinsured motorist insurance / Adoption recovery
First-and third-party liability insurance / Worker’s Compensation
Tortfeasors / Estate recovery

Special Treatment Trusts recovery
The Contractor shall cooperate with AHCCCSA’s authorized representative in all collection efforts. In joint cases involving both AHCCCS fee-for-service or reinsurance and the Contractor, AHCCCSA’s authorized representative is responsible for performing all research, investigation and payment of lien-related costs. AHCCCSA’s authorized representative is also responsible for negotiating and acting in the best interest of all parties to obtain a reasonable settlement in joint cases and may compromise a settlement in order to maximize overall reimbursement, net of legal and other costs...

The Contractor may retain up to 100% of its third-party collections if all of the following conditions exist: ...

Title XXI (KidsCare): Eligibility for KidsCare benefits requires that the applicant/member not be enrolled with or entitled to any other health insurance benefits. If the Contractor becomes aware of any such potential coverage, the Contractor shall notify AHCCCSA immediately. The Contractor shall follow the same cost avoidance and postpayment recovery practices for the KidsCare population as it does for the Title XIX population, and shall maintain a reporting system which allows Title XIX and KidsCare information to be reported separately." Arizona Contract, pages 43-44.

AZBH

"35. COORDINATION OF BENEFITS AND THIRD PARTY LIABILITY
ADHS shall coordinate benefits, in accordance with ARS 36-2903.G, so that costs for services otherwise payable by ADHS are cost avoided or recovered from a liable first or third-party payer specified in AHCCCS Rule R9-22-1002.A...

By law, AHCCCSA is the payer of last resort. This means AHCCCSA shall be used as a source of payment for covered services only after all other sources of payment have been exhausted. The two methods used in the coordination of benefits are cost avoidance and postpayment recovery...

Cost Avoidance: ADHS shall cost-avoid all claims or services that are subject to third-party payment and may deny a service to a member if it knows that a third party (i.e. other insurer) will provide the service...

If ADHS knows that the third party insurer will neither pay for nor provide the covered service, and the service is medically necessary, ADHS shall not deny the service nor require a written denial letter. If ADHS does not know whether a particular service is covered by the third party, and the service is medically necessary, ADHS shall contact the third party and determine whether or not such service is covered rather than requiring the member to do so...

The requirement to cost-avoid applies to all AHCCCS covered services. In emergencies, ADHS shall provide the necessary services and then coordinate payment with the third-party payer...

Postpayment Recoveries: Postpayment recovery is necessary in cases where ADHS was not aware of third-party coverage at the time services were rendered or paid for, or was unable to cost avoid. ADHS shall identify all potentially liable third parties and pursue reimbursement from them except in the circumstances below. ADHS shall not pursue reimbursement in the following circumstances unless the case has been referred to ADHS by AHCCCSA or AHCCCSA's authorized representative:
     Uninsured/underinsured motorist insurance
     First and third-party liability insurance
     Tortfeasors
     Adoptions
     Worker's Compensation
     Estates
     Special Treatment Trusts...

ADHS shall cooperate with AHCCCSA's authorized representative in all collection efforts. In joint cases involving both AHCCCS fee-for-service or reinsurance and ADHS, AHCCCSA's authorized representative is responsible for performing all research, investigation and payment of lien-related costs...

ADHS may retain up to 100% of its third-party collections if all of the following conditions exist:
a. Total collections received do not exceed the total amount of ADHS financial liability for the member
b. There are no payments made by AHCCCS related to fee-for-service, reinsurance or administrative costs (i.e. lien filing, etc.)
c. Such recovery is not prohibited by state or federal law." Arizona Behavioral Health Contract, pages 29-30.

"43. SUBCONTRACTS...
In addition, each contract with a RBHA and each RBHA subcontract with a provider must contain the following provisions: ...
f. The specific duties of the subcontractor relating to coordination of benefits and determination of third-party liability.
g. A provision that the subcontractor agrees to identify Medicare and other third-party liability coverage and to seek such Medicare or third-party liability payment before submitting claims to ADHS…" Arizona Behavioral Health Contract, page 34.

"3.41 COST AVOIDANCE AND POST-PAYMENT RECOVERY OF OTHER HEALTH COVERAGE SOURCES
A. Contractor shall Cost Avoid or make a Post-Payment Recovery for the reasonable value of services paid for by Contractor and rendered to a Member whenever a Member's OHCS covers the same services, either fully or partially...

B. All monies recovered by Contractor are retained by Contractor.

C. Contractor shall coordinate benefits with other coverage programs or entitlements, recognizing the OHCS as primary and the Medi-Cal program as the payor of last resort.

D. Cost Avoidance
1. If Contractor reimburses the provider on a fee-for-service basis, Contractor shall not pay claims for services provided to a Member whose Medi-Cal eligibility record indicates third party coverage, designated by a Other Health Coverage (OHC) code or Medicare coverage, without proof that the provider has first exhausted all sources of other payments...
2. Proof of third party billing is not required prior to payment for services provided to Members with OHC codes A, M, X, Y, or Z.

E. Post-Payment Recovery
1. If Contractor reimburses the provider on a fee-for-service basis, Contractor shall pay the provider's claim and then seek to recover the cost of the claim by billing the liable third parties:
a. For services provided to Members with OHC codes A, M, X, Y, or Z;
b. For services defined by DHS as prenatal or preventive pediatric services; or
c. In child-support enforcement cases, identifiable by Contractor...

2. In instances where Contractor does not reimburse the provider on a fee-for-service basis, Contractor shall pay for services provided to a Member whose eligibility record indicates third party coverage, designated by a OHC code or Medicare coverage, and then shall bill the liable third parties for the cost of actual services rendered.

3. Contractor shall also bill the liable third parties for the cost of services provided to Members who are retroactively identified by Contractor or DHS as having OHC...

3.42 THIRD-PARTY TORT LIABILITY/ESTATE RECOVERY
Contractor shall identify and notify DHS' Third Party Liability Branch of all instances or cases in which Contractor believes an action by the Medi-Cal Member involving the tort or Workers' Compensation liability of a third party or estate recovery could result in recovery by the Member of funds to which DHS has lien rights under Article 3.5 (commencing with Section 14124.70), Part 3, Division 9, Welfare and Institutions Code. Contractor shall make no claim for recovery of the value of Covered Services rendered to a Member in such cases or instances and shall be referred to DHS' Third Party Liability Branch within ten (10) days of discovery..." California Contract, pages 45-48.

"V. COSTS AND REIMBURSEMENT
D. Third Party Liability
1. All Members are required to assign their rights to any benefits to the Department and agree to cooperate with the Department in identifying third parties who may be liable for all or part of the costs for providing services to the Member, as a condition for participation in the Medicaid program. The Contractor is authorized to act as the Department’s agent under this Contract in enforcing the Department’s rights to third party recovery, except as otherwise set forth herein.

2. The Contractor must develop and implement systems and procedures to identify potential third parties who may be liable for payment of all or part of the costs for providing Covered Services under this Contract. Potential third parties must include any of the sources identified in 42 C.F.R. 433.138 relating to identifying third parties. The Contractor must coordinate with the Department to obtain information from other state and federal agencies and the Contractor must cooperate with the Department in obtaining information from commercial third party resources.

3. The Contractor must actively pursue and collect from third party resources which have been identified except when the cost of pursuing recovery reasonably exceeds the amount which may be recovered by the Contractor…

5. The Contractor may retain as income all amounts recovered from third party resources as long as recoveries are obtained in compliance with this Contract and state and federal laws.

6. The Contractor shall not restrict access to Covered Services due to the existence of possible or actual third party liability...

9. The Contractor shall have the same rights as the Department has pursuant to § 26-4-403, C.R.S. Notwithstanding any other provision of this Contract, the Contractor shall not have the rights provided to the Department pursuant to § 26-4-403(4) and § 26-4-403(5), C.R.S...

11. In any case where the Department has recovery rights against a third party pursuant to § 26-4-403(3) and/or (4), C.R.S. and the Contractor has recovery rights against the same third party, it is acknowledged that the Department’s rights take precedence over the rights of the Contractor.

12. Benefits for Members will be coordinated with minimum coverages required under the Colorado Auto Accident Reparations Act (No Fault) 10-4-706(l) (b) to (1) (c), Colorado Revised Statutes, as amended. If a 'No Fault' Policy provides coverage in excess of the minimum required by the State law, the Contractor shall coordinate benefits with those coverages in effect. " Colorado Contract, pages 23-25.

"3.41 Third Party Coverage...
Pursuant to this requirement, the MCO is required to comply with federal and state statutes and regulations regarding third party liability and the MCO shall be responsible for making every reasonable effort to determine the legal liability of third parties to pay for services rendered to Members under this contract. The MCO shall pursue, collect, and retain any monies from third party payers for services to the MCO's Members under this contract, subject to the following terms and conditions:

a. The DEPARTMENT hereby assigns to the MCO all rights to third party recoveries from Medicare, health insurance, casualty insurance, workers' compensation, tortfeasors, or any other third parties who may be responsible for payment of medical costs for the MCO's members...
When the MCO seeks recovery from a third party for care provided to a member following an accident, the MCO may recover only its cost of care…" Connecticut Contract, pages 51-52.

"Appendix L: Bulletins, Memos and Policy Transmittals...
Third Party Coverage...
Managed Care Health Plans are responsible for collecting third party payments for services rendered to enrollees and for maintaining records of third party collections (TPL) and submitting reports…" Connecticut Contract, Appendix L, page 7.

"7.2.7 Third Party Liability
Under Section 1902 (a)(25) of the Social Security Act, the State is required to take all reasonable measures to identify legally liable third parties and treat third party liability as a resource of the Medicaid recipient.

As part of this requirement, the state has determined that the pursuit of third party payment for services covered in the DSHP benefit package is the responsibility of the MCO. As such, the MCO should utilize and require its subcontractors to utilize or pursue, when available, covered medical and hospital services or payments for DSHP members available from other public or private sources. This responsibility includes pursuit of a third party for medical services provided by the MCO that may be related to an accidental injury, medical malpractice or any other cause for legal action. This responsibility includes accident and trauma cases that occur while a member is enrolled in the MCO. MCOs will retain all funds collected as part of this activity. Service information must be reviewed by the MCO to determine that all third party payment sources are identified and payment is pursued.

All available TPL information must be submitted-to the State via electronic format on a monthly basis. The State will also supply monthly updates and on-line information related to TPL. Encounter data should include information on all TPL collections...

Recovery of TPL by the MCOs will be initiated within 60 days of the date the third party coverage becomes known to the MCO. Follow-up will be conducted at 60 day intervals after the original reimbursement request was sent to the third party insurance, and until the claim is resolved. If the MCOs do not initiate original recovery within 60 days of the date of discovery, the State reserves the right to initiate recovery action with out subsequent reimbursement to the MCOs." Delaware RFP, pages II.50-II.51.

"K. THIRD PARTY LIABILITY
1. Provider shall be responsible for identification and collection of third party liability as defined in federal statutes and regulations.

2. Provider shall comply with the Health Care Assistance Reimbursement Act of 1984, effective June 14, 1984 (D.C. Law 5-86: D.C. Code Section 3-501 et seq.)" District of Columbia Contract, page 33.

"10. Third Party Resources. The plan shall be responsible for making every reasonable effort to determine the legal liability of third parties to pay for services rendered to members under this contract. The plan has the same rights to recovery of the full value of services as the agency, including those provided for in Section 409.910, F.S. The following standards govern recovery.

a. If the plan has determined that third party liability exists for part or all of the services provided directly by the plan to member, the plan shall make reasonable efforts to recover from third party liable sources the value of services rendered.

b. If the plan has determined that third party liability exists for part or all of the services provided to a member by a subcontractor or referral provider, and the third party is reasonably expected to make payment within 90 days, the plan may pay the subcontractor or referral provider only the amount, if any, by which the subcontractor's allowable claim exceeds the amount of the anticipated third party payment; or, the plan may assume full responsibility for third party collections for service provided through the subcontractor or referral provider.

c. The plan may not withhold payment for services provided to a member if third party liability or the amount of liability cannot be determined or if payment shall not be available within a reasonable term, not to exceed 90 days.

d. When both the agency and the plan have liens against the proceeds of a third party resource, the agency shall prorate the amount due to Medicaid to satisfy such liens under Section 409.910, F.S., between the agency and the plan. This prorated amount shall satisfy both liens in full.

e. The agency may...offer to provide third party recovery services to the plan...

f. All funds recovered from third parties shall be treated as income for the plan…" Florida Contract pages 59-60.

FLMH

"4.23 Third Party Resources
The contractor shall be responsible for making every reasonable effort to determine the legal liability of third parties to pay for services rendered to enrollees under this contract. The following standards will govern recovery:

A. If the contractor determines that third party liability exists for part or all of the services provided directly by the contractor to a member, the contractor shall make reasonable efforts to recover from third party liable sources the value of the services rendered.
B. If the contractor determines that third party liability exists for part or all of the services provided to a member by a subcontractor, and the third party will make payment within a reasonable time, the contractor shall pay the subcontractor only the amount, if any, by which the subcontractor's allowable claim exceeds the amount of the third party liability; or, the contractor shall assume full responsibility for third party collections for service provided through a subcontract or referral provider...
D. All funds recovered from third parties will be treated as income for the contractor." Florida Mental Health RFP, page 65.

"43.000 Third Party Liabilities
43.010 Definition...
The application of TPLs is based on Section 1902(a)(25) of the Social Security Act which requires that state Medicaid agencies take all reasonable measures to identify legally liable third parties and treat verified TPL as a resource of the Medicaid applicant or recipient.

43.020 Reimbursement from Third Parties
DHS shall be responsible for coordination and recovery of accident and workers' compensation subrogation benefits involving QUEST recipients. The health plan shall seek reimbursement from all other liable third parties to the limit of legal liability for the health services rendered. The health plan shall retain all health insurance benefits collected, including cost avoidances.

Reimbursement from the third party shall be sought unless the health plan determines that recovery would not be cost effective...

43.030 Responsibilities of DHS and the Health Plan
DHS shall:
* Collect and provide recipient TPL information to the health plan.
* Be responsible for coordination and recovery of accident and workers' compensation subrogation benefits.

The health plan shall coordinate health care benefits with other coverages, both public and private, which are or may be available to pay medical expenses on behalf of any recipients including:
* Continuing cost avoidance of the health insurance plans accident and workers' compensation benefits.
* Reporting all accident cases incurring medical and dental expenses in excess of $500 to DHS.
* Providing a list of medical and dental expenses, in the format request by DHS, for recovery purposes.
* Recovering medical expenses incurred by recipients from all other TPL resources.
* Informing DHS of TPL information uncovered during the course of normal business operations.
* Providing DHS with monthly reports of the total cost avoidance and amounts collected from TPLs within 30 working days of the end of the month.
* Developing procedures for determining when to pursue TPL recovery." Hawaii RFP, pages 57-58.

HIBH

43.020 Reimbursement from Third Parties
DHS shall be responsible for coordination and recovery of accident and workers' compensation subrogation benefits involving QUEST members. The BHMC plan shall seek reimbursement from all other liable third parties to the limit of legal liability for the behavioral health services rendered. The BHMC plan shall retain all health insurance benefits collected, including cost avoidances.

Reimbursement from the third party shall be sought unless the BHMC plan determines that recovery would not be cost effective...

43.030 Responsibilities of DHS and the BHMC Plan...
The BHMC plan shall coordinate behavioral healthcare benefits with other coverages. both public and private, which are or may be available to pay medical expenses on behalf of any members including:
• Continuing cost avoidance of the behavioral health insurance plans accident and workers' compensation benefits.
• Reporting all accident cases incurring behavioral health expenses in excess of $500 to DHS.
• Providing a list of behavioral health expenses, in the format requested by DHS. for recovery purposes.
• Recovering behavioral health expenses incurred by members from all other TPL resources." Hawaii Behavioral Health RFP, pages 44-45.

"(l) Coordination of Benefits for Beneficiaries who are Clients
(1)The Department is responsible for the identification of Beneficiaries who are Clients with health insurance coverage provided by a third party and ascertaining whether third parties are liable for medical services provided to such Beneficiaries. Money which the Department receives as a result of these collection activities shall belong to the Department to the extent the Department has incurred any expense or paid any claim and thereafter any excess receipts shall belong to the Contractor, to the extent the Contractor has incurred any expense or paid any claim, to the extent permitted by law.

(2) The Contractor will conduct a data match for the Department to identify Illinois Medicaid recipients with active private health insurance through the Contractor. The Department will assume the reasonable and customary costs of these semi-annual matches. The discovery of a third party liability match will prevent the Department from paying premiums for recipients already covered by the Contractor. The Contractor will further make available to the Department a contact person from whom the Department can request to make third party liability inquiries for the purpose of maintaining accurate eligibility information for these recipients.

(3) Upon the Department's verification that a Beneficiary who is a Client has third party coverage for major medical benefits, the Department shall disenroll such Beneficiary from the Contractor's Plan. Such disenrollment shall be effective the first day of the calendar month no later than three (3) months from the date the disenrollment is entered into the Department's computer system. The monthly Capitation payments shall be adjusted accordingly on the first day of the month the disenrollment is effective. The Contractor shall be notified of the disenrollment on the Pre-listing.

(4) The Contractor shall report with the reported Encounter Data any and all third party liability collections it receives so the Department can offset the next month's Capitation payment accordingly.

(5) The Contractor shall report to the Department any health insurance coverage for Beneficiaries it discovers at any time." Illinois HMO Contract, pages 75-76.

"4.6.10.4 Third Party Liability Reporting
Federal regulations require that OMPP's contract with risk-based managed care entities specify any activities to be performed by the MCO relating to third party liability (TPL) requirements in 42 CFR 433, Subpart D. MCOs will be responsible for identifying and collecting third party liability information, and may retain third party liability collections...

4.6.10.4.1 MCO TPL Responsibilities - Cost Avoidance
When the MCO is aware of health or casualty insurance coverage prior to paying for a health care service for an enrollee, it shall avoid payment by rejecting a provider's claim and direct that the claim be submitted first to the appropriate third party.

If insurance coverage is not available, or if one of the exceptions to the cost avoidance rule discussed in Section 4.6.10.4.2 applies, then payment must be made and a claim made against the third party, if it is determined that the third party is or may be liable.

The MCO must ensure that its cost avoidance efforts do not prevent an enrollee from receiving medically necessary services in a timely manner.

4.6.10.4.2 Cost Avoidance Exceptions
In the following situations, the MCO must first pay the provider and then coordinate with the liable third party:
* The coverage is derived from a parent whose obligation to pay support is being enforced by the State Title IV-D Agency and the provider of service has not received payment from the third party within 30 days after the date of service.
* The claim is for prenatal care for a pregnant woman or for preventive pediatric services (including EPSDT) that are covered by the Medicaid program.
* The claim is for labor, delivery and post-partum care, and does not involve hospital costs associated with the inpatient hospital stay.

If any other third party payor fails to respond within 90 days of the date of the provider's attempt to bill, the MCO must pay the claim upon submission by the provider of the claim and documentation supporting the billing provider's persistent attempts to obtain payment...

If the MCO was not aware of third party coverage at the time services were rendered or paid for, the MCO shall pursue reimbursement from potentially liable third parties, if it is cost-effective to do so.

The OMPP has a cost avoidance waiver for pharmacy claims...

4.6.10.4.3 Coordination of Benefits
If a Medicaid recipient enrolled with the MCO is also enrolled or covered by a health or casualty insurer, the MCO is fully responsible for coordinating benefits so as to maximize the utilization of third party coverage. The MCO shall be responsible for payment of the enrollee's coinsurance, deductibles, copayments, and other cost-sharing expenses, but the MCO's total liability shall not exceed what the MCO would have paid in the absence of TPL, after subtracting the amount paid by the primary payor...

The MCO shall coordinate benefits and payments with the health or casualty insurer for services authorized by the MCO, but provided outside the MCO's plan. Such authorization may occur prior to provision of service but any authorization requirements imposed on the enrollee or provider of service by the MCO must not prevent or unduly delay an enrollee from receiving medically necessary services...

If the Medicaid enrollee's primary insurer is a commercial HMO and the MCO cannot efficiently coordinate benefits because of conflicts between the primary HMO's rules and the MCO's rules, the MCO may submit a written request for disenrollment to the enrollment broker...

4.6.10.4.4 Casualty cases
The MCO may exercise any independent subrogation rights it may have under Indiana law in pursuit or collection of payments it has made when a legal cause of action for damages is instituted by the enrollee or on behalf of the enrollee. Any recoveries made may be retained by the MCO, but must be reported to the OMPP. " Indiana RFP, pages 4-44 - 4-47.

"6.5 Subrogation
The Department hereby assigns the HMO all rights to pursue and recover, at the HMO's discretion and expense, payments from third party payors for Covered Services. Monies collected shall be retained by the HMO. The HMO shall maintain records of all third-party collections. Reports in the format set forth in Addendum II shall be provided to the Department within 30 days of the end of each Contract quarter...

The HMO shall instruct Providers regarding the billing of third party payers identified on the Enrollment Information tape prior to billing the HMO for services, except for services identified by the Department as payable prior to pursuit of third party payments." Iowa Contract, page 43.

IABH

"53.5 UTILIZATION OF OTHER INSURANCE COVERAGE FOR SUBSTANCE ABUSE TREATMENT
In providing substance abuse treatment to DPH participants in the Iowa Plan, state appropriations and block grant funds should be payment of last resort. Persons with other insurance may participate in the Iowa Plan and have coverage for substance abuse treatment. This would depend on insurance co-payment and the relationship to the sliding fee scale. Third party recoveries are retained by the provider. The Contractor is required to report annually on collections from other insurers on a form provided by DPH." Iowa Behavioral Health Contract, page 39.

"REQUIREMENTS FOR SUBSTANCE ABUSE SERVICES
I. MAINTENANCE OF LOCAL FUNDING FOR SUBSTANCE ABUSE SREVICES (DPH Participants only)

The Contractor shall assist treatment program networks in developing others sources of financial support for program activities, including the following activities:

1. Recover, to the maximum extent feasible, third-party revenues to which the treatment program is entitled as a result of services provided...

III.. PAYMENT OF LAST REPORT-DPH funds only
DPH funds, as provided by this contract are to be used as 'payment of last resort' (i.e. all other available funds used prior to billing funds available through this contract)." Iowa Behavioral Health Contract, pages 96-97.

"E. COORDINATION OF BENEFITS AND POST-PAY RECOVERY (THIRD PARTY LIABILITY)… Under Section 1902(a)(25) of the Social Security Act, the state is required to take all reasonable measures to identify legally liable third parties and treat verified TPL as a resource of the Medicaid consumer.

The HMO must agree to take responsibility for identifying and pursuing TPL for its Medicaid members. The HMO must make best efforts to identify and coordinate with all third parties against whom members may have a claim for payment or reimbursement for services. These third parties may include Medicare, any other group insurance, trustee, union, welfare, or employer organization, employee benefit organization including preferred provider organizations or similar type organizations, any coverage under governmental programs, and any coverage required to be provided for by state law...

SRS will retain responsibility for collecting medical subrogation for HMO premiums. SRS will coordinate these activities with the HMO. The HMO is required to comply with any information requests regarding medical subrogation." Kansas Contract, page 66.

"C. Third-Party Resources
If a member has resources available for payment of expenses associated with the provision of Covered Services, other than those which are exempt under Title XIX of the Act, such resources are primary to the coverage provided by the Department and must be exhausted prior to payment by the Department. The Capitation Rate set forth in this Contract has been adjusted to account for the primary liability of third parties to pay such expenses. The Contractor shall be responsible for making every reasonable effort to determine the legal liability of third parties to pay for services rendered to Members pursuant to this Contract. All funds recovered by the Contractor from Third-Party Resources shall be treated as income to the Contractor.

The Contractor shall submit a report to the Department within sixty (60) days following the end of each calendar quarter listing all Third-Party Resources known to the Contractor or any subcontractor and not reflected on Member Medicaid cards. This report shall include each Member's name, Medicaid number and the name of the Third-Party Resource." Kentucky Contract, pages 35-36.

"7.3.3 Third Party Resources
By law, Medicaid is the payer of last resort and as a result shall be used as a source of payment for covered services only after all other sources of payment have been exhausted… The Partnership shall be responsible for making every reasonable effort to determine the legal liability of third parties to pay for services rendered to Members pursuant to this Contract. All funds recovered by The Partnership from third-party resources shall be treated as income to The Partnership." Kentucky RFA, page 25.

"Third Party Payments/Coordination of Benefits
In order to ensure that federal third party liability requirements are met and to maximize savings from available third party resources, identification and recovery of third party resources must be a joint effort between the Department for Medicaid Services (DMS) and the Partnership...

42 CFR 433.138 requires the partnership be responsible for actively seeking and identifying third party resource, i.e. health or casualty insurance, liability insurance and attorneys retained for tort action, through contact with the Partnership Members, participating providers, and the Medicaid Agency.

42 CFR 433.139 requires the Partnership be responsible to assure that the Medicaid Program is the payor of last resort when other third party resources are available to cover the costs of medical services provided to Medicaid Eligibles. When the Partnership is aware of other redirecting the provider to bill the other third party resource as a primary payor. If the Partnership does not become aware of another third party resource until after the payment for service, the Partnership is responsible to seek recovery from the third party resource on a post payment basis.

To meet the requirements of 42 CFR 433.138 through 433.139, the Partnership shall be responsible for:
   A. Maintaining an MIS that includes:
    1. Third Party Liability Resource File...
    2. Third Party Liability Billing File...
      a) Commercial Insurance/Medicare Part B Billing...
      b) Medicare Part A...
      c) Manual Research/System Billing...
    3. Questionnaire File

     B. Coordination of Third Party Information
     1. Division of Child Support Enforcement (DCSE)...
     2. Casualty Recoveries...

     C. Claims
     1. Processing...
     2. Encounter Data." Kentucky RFA, Attachment IV, pages 38-41.

"D. THIRD PARTY LIABILITY (TPL)
1. General Rule. Except as expressly described below, the Department shall be responsible for, and have the exclusive right to, third party liability (‘TPL’) recoveries for Medicaid managed care clients. The capitation rate ranges set for the Managed Care Initiative are consistent with this policy. In cases where the Department is responsible for collecting TPL, the historical data used to determine capitation rates were not adjusted for TPL recoveries. In cases where the Contractor is responsible for TPL recoveries, the data were adjusted downward to reflect TPL recoveries.

2. Comprehensive Insurance Coverage. The Department shall disenroll Enrollees who have comprehensive insurance coverage. The Department will recover and retain TPL for services provided under the Plan to the Enrollees while the third party coverage was in effect.

3. Non-Comprehensive Insurance Coverage. Medicaid clients with non-comprehensive health insurance coverage will be enrolled and will remain enrolled assuming they meet all other enrollment criteria. The Contractor shall retain and be responsible for all TPL recoveries for this group.

4. Casualty. The Department will retain responsibility for identifying and recovering casualty settlements. These recoveries will not be shared with the Contractor." Maine Contract, page 50.

"THE MCO AGREES: …
K. To accept as payment in full the amounts paid by the Department … provided, however, that nothing in this Agreement shall prevent the MCO from seeking coordination of benefits or subrogation recoveries in accordance with applicable rules and regulations." Maryland Contract, pages 1-3.

"10.09.65.18...
.18 Third-Party Liability.
A. An MCO is responsible for the identification of, and collection of, moneys owning from responsible third parties liable for the cost of medical care furnished by the MCO to enrollees...

G. When both the Department and an MCO have a right of subrogation, they shall coordinate settlement negotiation, ensuring that the funds available are prorated to allow sufficient compensation to settle each party's claim amount.

H. For insurance coverage identified by an MCO with a retroactive effective date, an MCO shall ensure that procedures are in place to allow for the collection of funds from either the provider or the insurance carrier for claims paid by the MCO during the coverage period, for up to 2 year from the date of treatment." Maryland COMAR 10.09.65.18.

"SECTION 2. CONTRACTOR RESPONSIBILITIES...
Section 2.2 Administration and Contract Management...
H. Benefit Coordination
The Contractor shall:
1. Designate a Third Party Liability (TPL) Benefit Coordinator who shall serve as a contact person for Benefit Coordination issues related to this Contract.
2. Establish and implement a Benefit Coordination plan, in collaboration with the Division designed to ensure that in accordance with state and federal law, MassHealth is the payer of the last resort…" Massachusetts Contract, pages 16-23.

MABH

"5.2 Reimbursement Methodology for DMH Acute Care Consumers...
B. Reimbursement Rules for Designated Emergency Programs (DEPs)/Emergency Screening Programs (ESPs)
1. In accordance with Section 5.2 A of Appendix A to this Contract, the Contractor shall utilize DMH Service Compensation Payments to pay ESPs/DEPS, whichever is applicable, for Covered Services rendered to DMH Acute Care Consumers who are not Recipients or Excluded Recipients subject to the following limitations and requirements:
a. The Contractor shall require ESPs/DEPs to identify and bill all available sources of Third Party Liability (TPL) for DMH Acute Care Consumers who are not Recipients or Excluded Recipients...

C. Reimbursement Rules for DMH Covered Services for DMH Acute Care Consumers
1. In accordance with Section 5.2.A of this Appendix A to the Contract, the Contractor shall utilize DMH Service Compensation Rate Payments to reimburse Network Providers and non-Network providers for DMH Covered Services as described in Appendix C to this Contract for DMH Acute Care Consumers who are not Recipients or Excluded Recipients subject to the following limitations and requirements:
a. For DMH Covered Services rendered to DMH Acute Care Consumers who are not Recipients, the Contractor shall require Network Providers and non-Network providers to bill TPL, the Free Care Pool in accordance with applicable law..." Massachusetts MH/SAP Contract, Appendix A, pages 56-61.

"l0.0 BENEFIT COORDINATION - RECIPIENTS
The Contractor shall:
10.01.01 Develop a plan to be submitted to the Division for prior review and approval, no later than the end of the sixth month of the first Contract Year, which shall address systems and resources required to perform Benefit Coordination for Recipients (‘Recipient Benefit Coordination Plan'). The Recipient Benefit Coordination Plan shall address and propose resolution to the following two major Benefit Coordination situations that arise when Recipients receiving a service(s) are:
a. subsequently granted retroactive eligibility for TPL; and
b. determined to have TPL by the Contractor or Provider at the time the service(s) were delivered.

10.01.02 Ensure that the Recipient Benefit Coordination Plan, at a minimum, addresses the process for identifying and recovering inappropriately paid funds, describes the tracking and reporting mechanisms, and the processes and procedures to inform the Division of TPL.

10.01.03 Develop a plan to be submitted to the Division for prior review and approval no later than the sixth month of the first Contract Year which shall outline the policies and procedures to be implemented by the Contractor to notify the Division when the Contractor has identified a Recipient with TPL.

11.0 BENEFIT COORDINATION - DMH ACUTE CARE CONSUMERS
The Contractor shall:

11.01.01 Establish and implement a Benefit Coordination plan for DMH Acute Care Consumers ('DMH Benefit Coordination Plan') which shall be effective on the Full Service Start Date; be reviewed and approved by the Division; and address systems and resources required to perform the following activities: ...
b. provide training and ongoing support to the ESPs or, in the alternative, the DEPs, whichever is applicable, to maximize TPL available to cover DMH Acute Care Consumers (Medicaid, Medicare, or other health insurance)..." Massachusetts MH/SAP Contract, Appendix B, pages 72-73.

"II-R THIRD PARTY RESOURCE REQUIREMENTS
The Contractor will collect any payments available from other health insurers including Medicare and private health insurance for services provided to its members in accordance with Section 1902(a)(25) of the Social Security Act and 42 CFR 433 subpart D. The contractor will be responsible for identifying and collecting third party liability information and may retain third party collections…" Michigan Contract, page 46.

"Article 12. Third Party Liability and Coordination of Benefits.
Section 12.1. Agent of the STATE. Pursuant to 42 C.F.R. 433… the STATE hereby authorizes the HEALTH PLAN as its agent to obtain third party reimbursement by any lawful means including asserting subrogation interest and filing liens, and to coordinate benefits, for HEALTH PLAN Enrollees whose premiums have been paid in whole or part by the STATE.

Section 12.2. Third Party Recoveries. The HEALTH PLAN must take reasonable measures to determine the legal liability of third parties to pay for services furnished to HEALTH PLAN Enrollees. To the extent permitted by state and federal law, the HEALTH PLAN shall use Cost Avoidance and/or Post Payment Recovery Processes, as defined in Article 2 of this Contract, to ensure that primary payments from the liable third party are utilized to offset medical expenses...

Section 12.3. Coordination of Benefits.
Section 12.3.1. Coordination of Benefits. For Enrollees who have private health care coverage, the HEALTH PLAN must coordinate benefits in accordance with Minnesota Rules… Coordination of benefits includes paying any applicable copayments or deductibles on behalf of an Enrollee, except for MinnesotaCare copays pursuant to Section 4.3.3.

Section 12.3.2. Cost Avoidance.
A. General. The HEALTH PLAN shall cost avoid all claims or services that are subject to third-party payment, and may deny a service to an Enrollee if the HEALTH PLAN is assured that a third party (i.e., other insurer) will provide the service. The HEALTH PLAN must determine whether it is more cost-effective to provide the service or pay the copays, coinsurance and deductibles to a Non-Participating Provider. If the HEALTH PLAN refers an Enrollee to a third-party insurer for a service which the HEALTH PLAN covers, and the third-party insurer requires payment in advance of all copayments, coinsurance and deductibles, the HEALTH PLAN shall make such payments in advance or at the time such payments are required...

Section 12.3.3. Post Payment Recoveries. The HEALTH PLAN shall recover funds post payment in cases where the HEALTH PLAN was not aware of third-party coverage at the time services were rendered or paid for, or the HEALTH PLAN was not able to cost avoid (payment was not available at the time the claim was filed). The HEALTH PLAN shall identify all potentially liable third parties and pursue reimbursement from them. Potentially liable third parties include, but are not limited to, Medicare, Uninsured/Underinsured motorist insurance, First and third party liability insurance, Tortfeasors, Workers' Compensation, Medical payments insurance for accidents (otherwise known as ‘med pay’ provisions or benefits of policy), and Indemnity/accident insurance. The HEALTH PLAN-shall develop procedures to identify trauma diagnoses and investigate potential liability. The HEALTH PLAN shall not pursue reimbursement under estate recovery or Medical Support recovery provisions (recovery of medical expenses paid for an Enrollee out of an Enrollee's estate or from an absent parent)." Minnesota Contract, pages 92-94.

"Third Party Liability: ...
Under Section 1902(a)(25) of the Social Security Act, the State is required to take all reasonable measures to identify legally liable third parties and treat third party liability as a resource of the Medicaid beneficiary.

Coordination of Benefits: By law, Medicaid is the payer of last resort. This means that the health plan shall be used as a source of payment for covered services only after all other sources of payment have been exhausted. The health plan is an agent of the State agency for purpose of coordination of benefits.

The health plan may retain up to 100 per cent of its third-party collections if all of the following conditions exist:
1) Total collections received do not exceed the total amount of the health plan's financial liability for the member.
2) There are no payments made by the state agency related fee-for-service.
3) Such recovery is not prohibited by State or federal law…" Missouri RFP, pages 86-87.

"E. Third Party Considerations:
1) Except as otherwise noted, the CONTRACTOR shall actively pursue, collect and retain any moneys from third-party payers for services to ENROLLEES covered under this contract except where the amount of reimbursement the CONTRACTOR can reasonably expect to receive is less than the estimated cost of recovery...

2) Collection from third-party payers is the responsibility of the CONTRACTOR or its SUBCONTRACTORS. The CONTRACTOR and SUBCONTRACTORS shall pursue collection from the third-party payer prior to any collection efforts directed toward the ENROLLEE i.e., cases in which the ENROLLEE has already received payment from the third-party payer...

Except for third-party recoveries as defined in this section, the DEPARTMENT continues to be responsible for all third-party requirements as described in 42 CFR 433 Subpart D. The DEPARTMENT will continue to pursue casualty and estate recovery collections. The CONTRACTOR may not pursue casualty and estate recovery collections." Montana Contract, pages 4-5.

"13.43 Third Party Liability (TPL) Requirements: The plan shall utilize a cost avoidance methodology whenever there is a verified third party resource (TPR) within the following parameters:
(a) The plan, its subcontractors or providers, shall actively pursue, collect, and retain any monies from third party payers for the usual and customary charges on covered services to clients covered under the plan’s Contract with the Department for NHC except when the amount of reimbursement the plan can reasonably expect to receive is less than the estimated cost of recovery; and

(b) The plan, its subcontractors or providers, may, at their sole discretion, compromise a claim against a third party payer, or may elect not to pursue the claim if they determine it is not cost effective to do so. The Department shall provide whatever assistance or assignments, as are necessary, to aid in the plan’s collection efforts. Any recoveries by the plan shall not affect continued payment of capitation for that client as long as the client remains enrolled in NHC.

(c) The Department has assigned to the plan, or its subcontractors or providers, all rights to recover payments from third parties as provided by state law, in its contract with the plan...Under federal law, the Department is required to identify legally liable third parties and treat verified TPR as a resource of the client. The plan, its subcontractors or its providers shall not pursue collection from the client but directly from the liable third party payers, except as allowed in 468 NAC, 469 NAC, and 477 NAC.

(d) TPR includes, but is not limited to:
(1) Private health insurance:
(2) Casualty insurance;
(3) Employment-related group health insurance;
(4) Group health plans defined under section 607(1) of ERISA;
(5) Workers’ Compensation; and
(6) Other federal program unless excluded by statute, such as Indian Health Service programs and Migrant Health programs.
(e) The plan shall:
(1) Take responsibility for pursuing TPR for clients in the above categories;
(2) Make reasonable attempts to identify TPR within its existing resources...The Department shall retain the responsibility for collecting the TPR of Medicare Part A and/or Part B, medical support from absent parents, and first party probate estate recoveries;
(3) Provide available information to, and cooperate with, the Department in its effort to collect those resources;
(4) To track its TPR recoveries for its enrolled clients and to report these recoveries to the Department using the guidelines listed below...
(5) Maintain records of all third party recoveries and report this recovery activity to the Department on a monthly basis in a form and manner agreeable to both parties…" Nebraska Contract, pages 91-92.

NEBH

"11.51 Third Party Liability (TPL) Requirements: The PHP shall utilize a cost avoidance methodology whenever there is a verified third party resource (TPR). The following parameters apply:

(a) The PHP, its subcontractors or providers, shall actively pursue, collect, and retain any monies from third party payers for the usual and customary charges on covered services to clients except when the amount of reimbursement the PHP can reasonably expect to receive is less than the estimated cost of recovery; and

(b) The PHP, its subcontractors or providers, may, at their sole discretion, compromise a claim against a third party payer, or may elect not to pursue the claim if they determine it is not cost effective to do so. The Department shall provide whatever assistance or assignments, as are necessary, to aid in the plan’s collection efforts. Any recoveries by the PHP shall not affect continued payment of capitation for that client as long as the client remains enrolled in the NHC.

(c) The Department has assigned to the PHP, or its subcontractors or providers, all rights to recover payments from third parties as provided by state law, in its contract with the PHP...The PHP, its subcontractors or its providers shall not pursue collection from the client but directly from the liable third party payers, except as allowed in 468 NAC, 469 NAC, and 477 and 480 NAC.

(d) TPL includes, but is not limited to:
   (1) Health insurance (private or group, including ERISA);
   (2) Casualty insurance;
   (3) Medicare;
   (4) Workers’ Compensation;
   (5) Other federal program unless excluded by statute, such as Indian Health Service programs and Migrant Health programs; and
   (6) Any other party legally obligated to pay medical expenses.

(e) The PHP shall agree to:
   (1) Take responsibility for pursuing TPR for clients in the above categories;
   (2) Make reasonable attempts to identify TPR within its existing resources, but the primary responsibility for identifying TPR and communicating that information to the plan is with the Department or its designee...
   (3) Provide available information to, and cooperate with, the Department in its effort to collect those resources;
   (4) To track its TPL recoveries for its enrolled clients and to report these recoveries to the Department using the guidelines listed below...
   (5)   Maintain records of all third party recoveries and report this recovery activity to the Department on a monthly basis in a form and manner agreeable to both parties...
   (6) On claims paid by the PHP, submit claims to health insurers within sixty days following notification of an available TPR;
   (7) In a liability situation, file a lien if lawfully permitted, within thirty (30) days following notification of the available liability resource; and
   (8) Notify the Department of clients who refuse to assist the PHP and the Department in enforcing TPR recovery." Nebraska Behavioral Health Contract, pages 62-63.

"C. Third Party Liability and Subrogation… Under Section 1902(a)(25) of the Social Security Act, DHCFP is required to take all reasonable measures to identify legally liable third parties and treat verified TPL as a resource of the Medicaid recipient.

The Contractor will act as DHCFP's agent in identification, collection and retention of TPL for Medicaid participants. This duty includes all collections, including legal actions. Contractors must meet current Medicaid requirements to investigate possible third party liability for specified diagnosis. The Contractor must also determine if casualty claims are filed and recover costs through subrogation. The contractor must determine the third party and seek payment. If the third party refuses to pay, all information on the third party and collection attempts are to be reported to DHCFP.

The Contractor must report TPL collections to DHCFP through encounter data and other DHCFP required reports. DHCFP will compare this information to DHCFP's projected level of collections based on historical experience. This amount will be built into future rates. If the Contractor does not meet or exceed projected collections, DHCFP will conduct a review to determine if there is a legitimate reason. If there is no legitimate reason, the projected collections will be deducted from the Contractor's costs before the data is used to set future rates. DHCFP will prospectively adjust capitation rates downward to account for expected TPL collections." Nevada Contract, page 42.

"Article IV
Payment to Contractor...

4.7 COORDINATION OF BENEFITS-----The State will initially identify for each Enrollee the existence of an, other health insurance and the Contractor will subsequently attempt to identify thereafter. The Contractor shall pursue all third party liability for services (per Sections 1902(a)(25) of the Act and 42 CFR 433.139) provided to Enrollees. Such third party payors include, but are not limited to, any other State or Federal medical care program, private group, or identification program. Such efforts shall include the following:

(1) Take reasonable measures to determine the legal liability of third parties to pay for services furnished to enrollees:
a. when trauma codes (ICD-9-CM diagnosis codes 800 through 999) apply to Enrollees; and
b. by researching leads and potential Third Party Liability (TPL) suspects.

(2) Inform the State Fiscal Agent of any other insurance discovered to exist for Enrollees;

(3) Maintain a system for Cost Avoidance criteria, and deny reimbursement for claims where other liability exists;

(4) Identify, initiate recovery, and track claims against liable third party carriers to recover the cost of benefits furnished to Enrollees when:
a. services were rendered within the Plan without a directly reimbursable fee; or, b. services were for:
(i) prenatal care;
(ii) preventative pediatric care;
(iii) children with coverage provided by an absent parent; or c. third party liability is discovered after services have been provided.

(5) Identify, initiate recovery, and track claims against liable third party carriers to recover the cost of benefits furnished for accident trauma cases involving Enrollees;

(6) Maintain case tracking for benefit recovery and accident trauma cases in order to:
a. identify appropriate costs of services to be recovered;
b. ascertain the current status of all claims;
c. support accounts receivable records; and

(7) Maintain accurate and complete accounts receivable records for amounts billed to recover costs of benefits furnished to Enrollees.

Such amounts avoided or billed shall be considered in establishing the payment rates under Exhibit B. of this Agreement.

4.8 SUBROGATION-----If an Enrollee receives treatment for injuries as a result of an accident which is the fault of another person or entity and Contractor provides benefits, the State assigns Contractor the right to recover to the extent that benefits and services have been provided by Contractor; such assignment permits recovery only with respect to those individuals who have been defined as 'Enrollees' and who have a claim or right of action against any person or party, pursuant to RSA 167:14-a." New Hampshire General Service Agreement, page 18.

"ARTICLE 3
COMPENSATION/CAPITATION...
3.5 The contractor shall make an effort to determine whether enrollees have third party health insurance and will attempt to use such coverage when applicable. The contractor will be permitted to retain 100 percent of amounts it collects from third party collections as an offset to services provided by the contractor…" New Jersey Contract, pages 30-31.

"ARTICLE 16
MONITORING AND EVALUATION...
16.11 The contractor and its subcontractors hereby agree to utilize, whenever available, covered medical and hospital services or other public or private sources of payment for services rendered to enrollees in the contractor's plan.
A. The Medicaid program shall be the payor of last resort when third party resources are available to cover the costs of medical services provided to Medicaid enrollees. When the contractor is aware of these resources prior to paying for a medical service, it shall avoid payment by either rejecting a provider's claim and re-directing the provider to bill the appropriate insurance carrier, or if the contractor does not become aware of the resource until sometime after payment for the service was rendered, by pursuing post payment recovery of the expenditure.

B. The contractor shall avoid payment of claims where third party resources are payable. When the Department has reliable information about third party resources available to recipients, it will make an effort to provide such information to the contractor.

   C...
   1. The contractor shall pursue and collect payments where health insurance coverage is available. Monies so collected shall be retained by the contractor, but shall be utilized to reduce the expenditure of Medicaid funds.
   a. The DMAHS shall have the right to pursue, collect, and retain payments from liable health insurers if the contractor has failed to initiate collection from the health insurer within twelve (12) months from the date of service...

D. The contractor shall assist the DMAHS in the identification, pursuit and collection of third party resources as follows:
1. The contractor will notify DMAHS within 30 days upon its identification of health or casualty insurance coverage available to an enrollee, or any change in an enrollee's health insurance coverage…" New Jersey Contract, pages 84-89.

"2.F.3 Third Party Liability
The CONTRACTOR is responsible for identification of the third party coverage of members and coordination of benefits with applicable third parties. The CONTRACTOR shall inform HSD of any member who has other health care coverage. The CONTRACTOR shall provide documentation to HSD to enable HSD to pursue its rights under state and Federal law." New Mexico Contract, pages 57-58.

"5.D.8 On a periodic basis, HSD shall provide the CONTRACTOR wit third-party liability information for enrolled members. The CONTRACTOR shall:
(ii) Attempt to recover any third-party resources available to Medicaid clients (42 C.F.R. 433 Subpart D) and shall make all records pertaining to TPL collections for members available to HSD for audit and review, with the exception of tort and estate recovery TPL activities required by federal or state laws. HSD shall perform tort and estate recovery activities itself, and HSD shall have the right to retain any TPL collections generated by these activities…" New Mexico Contract, page 75.

"3. Compensation...
3.7 Third Party Health Insurance Determination
The Contractor and the LDSS will make diligent efforts to determine whether Enrollees have third party health insurance (TPHI)... The Contractor shall make good faith efforts to coordinate benefits with and collect TPHI recoveries from other insurers, and must inform the LDSS of any known changes in status of TPHI insurance eligibility within thirty (30) days of learning of a change in TPHI... The Contractor will be permitted to retain 100 percent of any reimbursement for Benefit Package services obtained from TPHI. Capitation Rates are net of TPHI recoveries…" New York Contract, pages 3-1-3-4.

"10.7 Third Party Resources...
The Plan may delay payment to a subcontractor or Out-of-Plan provider for up to sixty (60) days following the date of service in the event that a third party resource is identified from which the subcontractor of Out-of-Plan Provider is obligated to collect payment. If payment is not made by the third party within such sixty (60) day period, the Plan must pay the subcontractor or Out-of-Plan Provider and obtain a refund of any subsequent payments made by the third party. The Plan may not withhold payment from a subcontractor or Out-of-Plan Provider for services provided to a Member due to the existence of third party resources, because the liability of a third party resource cannot be determined, or because payment will not be available within sixty (60) days…" North Carolina Contract, page 20.

"5 CONSIDERATION AND PAYMENTS...
E. Except as otherwise noted, the Contractor shall actively pursue, collect, and retain all moneys from third-party payers for services to enrollees covered under this contract except where the amount of payment the Contractor can reasonably expect to receive is less than the estimated cost of recovery...

Collection from third-party payers is the responsibility of the Contractor or its subcontractors. The Contractor and subcontractors shall pursue collection from the third-party payer prior to any collection efforts directed toward the enrolled recipient, i.e., cases in which the recipient has already received payment from the third-party payer… The Department will, upon request, assist the Contractor in obtaining recipient cooperation regarding third-party liability recovery. In order to obtain the benefit of N.D.C.C. §§ 50-24.1-02(2), 50-24.1-02.1, and 50-24.1-08, the Contractor is authorized to act as an agent of the Department in effecting collection from the third-party payer. Except for TPL recoveries as defined in this section, the Department continues to be responsible for all TPL requirements as described in 42 CFR 433, sub-part D. The Department will continue to pursue casualty and estate recovery collections. The Contractor may not pursue pharmacy major medical, casualty, and estate recovery collections. The Contractor and the Department will coordinate TPL recoveries made with respect to recipients who have received recoverable benefits provided both through the Contractor and directly by the Department." North Dakota Contract, pages 3-4.

"5101:3-26-091 MANAGED CARE PLAN: Third party recovery...
(B) ODHS assigns its right to third party resources (coordination of benefit) in accordance with rule 5101:1-39-56 of the Administrative Code to contracted MCPs for services rendered to each enrollee during periods of enrollment, except as stated in paragraph (A) of this rule. If an enrollee has resources available for payment of medical expenses, other than those which are exempt under Title XX of the Social Security Act, then such resources have the primary responsibility to pay for such expenses in accordance with rule 5101:3-1-08 of the Administrative Code.
(C) MCPs will take reasonable measures to ascertain any third party resources which are available to the enrollee.
(D) MCPs must act to provide coordination of benefits if an enrollee has resources available for the payment of medical expenses, other than those which are exempt under the Medicaid program. Such expenses will be paid in accordance with rule 5101:3-1-08 of the Administrative Code." Ohio RFP, Appendix E, OAC 5101:3-26-091, page 1.

"2.19.3 Third Party Liability
Health Plan is responsible for identifying and pursuing collection of third party liability (TPL) for its enrolled members…" Oklahoma RFP, page 62.

ORMH

"X. Third Party Resources
A. Notice to Health Insurance Group
Contractor shall notify the Health Insurance Group, Third Party Recovery Unit, Adult and Family Services Division(ASDF) within thirty(30) calendar days from the time that Contractor learns that an OMAP Member might have other health insurance...

B. Secondary Payor Status and Retroactive Disenrollment
Contractor is secondary payor when the OMAP Member is covered by another health insurance policy...

C. Collection of Third Party Resources
Contractor may require OMAP Members to cooperate in securing payment from the Third Party Resources (TPR), including liability insurance, but may not require OMAP Members to file a claim other than for personal injury protection coverage. To the extent permitted by law, Contractor shall make a reasonable effort to identify and pursue such TPR without regard to any Capitation Payments received by Contractor under this Agreement. Contractor shall have a system for obtaining timely assignment of the rights to Recovery or the assignment of lien rights from the OMAP Member and/or provider as necessary to effectively pursue TPR claims. If Contractor is unable to gain cooperation from the OMAP Member in pursuing the TPR, Contractor shall notify the AFSD's Third Party Recovery Unit of the OMAP Member's refusal to cooperate...

E. Claims Processing
Contractor may not refuse payment on Valid Claims based solely Contractor's belief that there may be potential TPR, absent documentation of potential TPR. If a Provider cannot obtain recovery from the TPR, Contractor shall not delay payment to the provider.

F. Accounting For Third Party Collections
Contractor shall be responsible for maintaining records in such a manner so as to ensure that all monies collected from TPR on behalf of OMAP Members may be identified and reported to Division in accordance with Exhibit C, Solvency Plan and Financial Reporting. Contractor shall also keep records third party recovery efforts that are not successful. Contractor shall make these records available for audit and review consistent with the provisions of this Agreement.

G. Third Party Recoveries
Contractor shall pursue third party recovery during this Agreement period pursuant to the requirements of this Agreement, federal and state law, rules and regulations. The Capitation rate(s) in this Agreement are based, in part, on projected third party recoveries. Contractor's failure to submit third party recovery data and/or pursue recoverable third party recovery obligation during this Agreement may create a claim for reimbursement to the extent required by federal law." Oregon Mental Health Contract, pages 44-46.

"SOLVENCY PLAN AND FINANCIAL REPORTING...
4 ...Contractor shall make reasonable efforts to identify and pursue such Third Party Resource without regard to any capitation payments. Contractor shall keep records of such efforts, successful or unsuccessful, to ensure accuracy of such reports and make reports and make records available for audit and review upon request." Oregon Mental Health Contract, page C2.

"P. PAYMENTS TO AND FROM HMOS
4. Third Party Liability (TPL)...
Under Section 1902(a)(25) of the Social Security Act, the Department is required to take all responsible measures to identify legally liable third parties and treat verified TPL as a resource of the MA recipient. The Department's TPL Section, or its contractor, is responsible to ensure that the Commonwealth is the payor of last resort when third party resources are available to cover the costs of medical services provided to MA recipients...

a. TPL Activity Under HealthChoices
Under the HealthChoices Program, TPL activities will be shared between the Department's TPL Section and the HMOs as follows:

1) The HMO will have responsibility for the cost avoidance through the coordination of benefits (COB) relative to federal and private health insurance-type resources including, but not limited to Medicare, private health insurance, ERISA plans, and workers' compensation...

2) The Department's TPL section retains the sole and exclusive right to pursue, collect, and retain recoveries of all health insurance cases…" Pennsylvania RFP, pages 90-94.

PABH

"j. Claims Payment and Processing (Part IV, Section G.3)
6) Provide the policy for recovery of third party liability. Include a flow chart and a written description of how the system will support a cost avoidance/recovery methodology for third party liability (TPL)." Pennsylvania Behavioral Health RFP, page 26.

"b. Third Party Liability (TPL)...
Under Section 1902(a) (25) of the Social Security Act, the Department is required to take all reasonable measures to identify legally liable third parties and treat verified TPL as a resource of the MA recipient. The Department's TPL Section, its contractor, is responsible to ensure that the Commonwealth is the payor of last resort when third party resources are available to cover the costs of medical services provided to MA recipients…When the Department, or its contractor, becomes aware of these resources prior to paying for medical services, they will generally avoid payment by rejecting a provider's claim and directing the provider to bill the appropriate insurance carrier. When the Department becomes aware of payments made on behalf of recipients who have valid third party resources, the Department will pursue post-payments recovery from liable parties.

1) TPL Activity Under HealthChoices Behavioral Health Services
Under the HealthChoices Behavioral Health Program, TPL activities will be shared between the Department's TPL Section and the MCOs as follows:
a) The MCO will have primary responsibility for cost avoidance through the coordination of benefits (COB) relative to federal and private health insurance-type resources including, but not limited to Medicare, private health insurance, ERISA plans, and workers' compensation. The MCO will attempt to avoid initial payment of claims, whenever possible, where federal or private health insurance-type resources are applicable. All cost avoided funds must be reported to the Commonwealth via encounter data submissions...

b) The Department's TPL Section retains the sole and exclusive right to pursue, collect and retain recoveries of all health insurance cases which are outstanding after the earlier of nine months from the data of service or six months after the date of payment...

c) The Department's TPL Section also retains the sole and exclusive responsibility to pursue, collect, and retain all non-health insurance-type resources such as casualty insurance, liability insurance and all persona injury damage claims whether or not subject to litigation…" Pennsylvania Behavioral Health RFP, pages 74-75.

"2.15.04 Third Party Liability...
Contractor agrees to take responsibility for identifying TPL for its RIte Care membership and reporting such TPL source to the State within five (5) days of the source becoming known to Contractor." Rhode Island RFP, page 50.

"2.6 Third Party Liability, (TPL)
Medicaid payment is secondary to other sources of payment for covered health care. Under state law, the SCDHHS has an assignment of rights to any other insurance coverage for a Medicaid recipient and subrogation rights, both only to the extent that Medicaid has paid for a service… Under this Contract, the SCDHHS assigns its rights to such payments to the Contractor for any services covered by the Contractor which were received by a member during a month for which the Medicaid program paid the monthly payment to the Contractor." South Carolina Contract, page 6.

"4.7.3 Targeted Case Management Services...
Several targeted case management programs will remain fee-for-service as listed in Appendix C, Tab 2.

4.7.4 School-Based Services
School-based services will be one of the programs where the Medicaid provider will continue to be reimbursed fee-for-service for these services...

4.7.6 Institutional Long Term Care Facilities/Nursing Homes...
Medicaid HMO Program members admitted to a long term care facility/nursing home and requiring institutionalization for more than thirty days (30) will be disenrolled from the Medicaid HMO Program. After the first thirty days (30), payment for services will be billed fee-for-service by the appropriate Medicaid enrolled provider...

4.7.7 Mental Health and Alcohol and Other Drug Abuse Assessment Services
The Contractor is required to only provide mental health and alcohol and other drug assessment services as specified in Appendix C, tab 1. All other mental health and alcohol and other drug services will be reimbursed by SCDHHS on a fee-for-service basis.

4.7.8 Communicable Disease Services...
For members who elect to receive TB, STD, and HIV services outside the Contractor's provider network, the state public health agency will bill SCDHHS to be reimbursed by SCDHHS fee-for-service." South Carolina Contract, pages 19-21.

"8.3 Right of Conscience/Ethical Limitations
The Contractor has chosen to exercise its Right of Conscience and shall not be responsible for payment for Medicaid covered services set forth in Appendix C, Tab 4, Right of Conscience Services, except as indicated… The Contractor understands that it remains responsible to inform members that such services may be obtained through any provider who accepts Medicaid and will be reimbursed by Medicaid directly on a fee-for-service basis… If the Contractor's network providers render any of the services under its Right of Conscience provisions, the network provider shall bill SCDHHS directly in accordance with the Medicaid fee schedule." South Carolina Contract, page 44.

"2-10. Administration and Management
e. Fiscal Management...
6. Third Party Resources
The TennCare program shall be the payer of last resort for all medical services. The CONTRACTOR shall be entitled to, and shall exercise, full subrogation rights and shall be responsible for making every reasonable effort to determine the legal liability of third parties to pay for services rendered to enrollees under this Agreement and recover any such liability from the third party.
(a) If the CONTRACTOR has determined that third party liability exists for part or all of the services provided directly by the CONTRACTOR to an enrollee, the CONTRACTOR shall make reasonable efforts to recover from third party liable sources the value of services rendered...
(d) All funds recovered from third parties will be treated as offsets to claims expense for the CONTRACTOR." Tennessee Contract, pages 46-49.

"3-10. Payments to the Contractor...
b. Payment of the Capitation Rate...
The actual amount owed the CONTRACTOR for each enrollee shall be determined by dividing the appropriate monthly capitation rate category by the number of days in the month and then multiplying the quotient of this transaction by the actual number of days the enrollee was enrolled in the plan less ten percent (10%) to be withheld by TENNCARE...

The purpose of the withhold is to assure CONTRACTOR compliance with all TENNCARE requirements, including the requirements of Section 2-3. Benefits/Service Requirements and Limitations, Section 2-10.d. TennCare Quality Monitoring/Quality Improvement (QM/QI) Program and ATTACHMENT IV. Quality of Care Monitors of this Agreement, by establishing an agreed incentive for assuring CONTRACTOR compliance with the terms of this Agreement. If TENNCARE has not identified CONTRACTOR compliance deficiencies, TENNCARE will pay to the CONTRACTOR the withhold of the plan's payments withheld in the month subsequent to the withhold.
If TENNCARE determines that the CONTRACTOR has no deficiencies for six (6) consecutive months, the monthly withhold amount will be reduced to five percent (5%).

However, if TENNCARE determines that the CONTRACTOR has one (1) or more deficiencies in a given month, the amount of monthly withhold will be ten percent (10%) for each month that a deficiency exists and for six (6) consecutive months after the deficiency is corrected. After six (6) consecutive months with no deficiencies, the monthly withhold amount will again be reduced to five percent (5%) and continue at five percent (5%) as long as no deficiencies are identified… If TENNCARE has determined the CONTRACTOR is not in compliance in any given month, TENNCARE will provide written notice of such determination and TENNCARE will retain the amount withheld for the month prior to TENNCARE identifying the compliance deficiencies. Monthly retention of the withhold amount will continue for each subsequent month so long as the identified deficiencies have not been corrected...

However, any amounts withheld by TENNCARE for six (6) consecutive months for the same or similar compliance deficiency(s) shall be retained by TENNCARE on the anniversary of the sixth consecutive month and shall not be paid to the CONTRACTOR. If the same or similar specified deficiency(s) continues beyond six (6) consecutive months, TENNCARE may declare the plan ineligible for future distribution of the ten percent (10%) incentive withhold…" Tennessee Contract, pages 68-70.

"4.9 THIRD PARTY RECOVERY
4.9.1 Third Party Recovery… HMO is authorized to act as the State's agent in enforcing the State's rights to third party recovery under this contract.

4.9.2 Identification. HMO must develop and implement systems and procedures to identify potential third parties who may be liable for payment of all or part of the costs for providing medical services to Members under this contract. Potential third parties must include any of the source identified in 42 C.F.R. 433.138, relating to identifying third parties, except workers' compensation, uninsured and underinsured motorist insurance, first and third party liability insurance and tortfeasors. HMO must coordinate with TDH to obtain information from other state and federal agencies and HMO must cooperate with TDH in obtaining information from commercial third party resources. HMO must require all providers to comply with the provisions of 25 TAC §28, relating to Third Party Recovery in the Medicaid program.

4.9.3 Exchange of Identified Resources. HMO must forward identified resources of uninsured and underinsured motorist insurance, first and third party liability insurance and totfeasors ('excepted resources') to TDH for TDH to pursue collection and recovery from these resources… HMO must cooperate with TDH in obtaining and exchanging information from commercial third party resources.

4.9.4 Recovery. HMO must actively pursue and collect from third party resources which have been identified, except when the cost of pursuing recovery reasonable exceeds the amount which may be recovered by HMO...

4.9.4.1 HMO must provide third resource information to network providers to whom individual Members have been assigned or who provide services to Members. HOMO must require providers to seek recovery from potential third party resources prior to seeking payment from HMO...

4.9.4.2 HMO must prohibit network providers from interfering with or placing liens upon the State's right or HMO's right, acting as the State's agent, to recovery from third party resources...

4.9.5 Retention. HMO may retain as income all amounts recovered from third party sources as long as recoveries are obtained in compliance with the contract and state and federal laws.

4.9.6 Accountability. HMO must report all third party recovery efforts and amounts recovered as required in Article 12.1.12…" Texas Contract, pages 23-24.

"D. Third Party Liability (Coordination of Benefits)...
1. TPL Collections
The CONTRACTOR will be responsible to coordinate benefits and collect third party liability (TPL). The CONTRACTOR will keep TPL collections. The DEPARTMENT will set rates net of expected TPL collections excluding the lump sum rate set for deliveries… The CONTRACTOR must attempt to collect TPL before the DEPARTMENT will finalize reimburse the CONTRACTOR the delivery rate less TPL…" Utah Contract, Attachment B, page 38.

UTMH

"K. Third Party Collections...
The CONTRACTOR will be responsible to review each Medicaid Enrollee's Medical card or the DEPARTMENT's eligibility verification system to determine if the Enrollee also has TPL. Medicaid is the payer of last resort. Since rates will be established net of TPL based on Medicaid's past efforts, the CONTRACTOR will be responsible to collect monies from third-party payers for covered services to Enrollees except where the amount of reimbursement the CONTRACTOR can reasonably expect to receive is less than the estimated cost of recovery.

1. If the Medicaid Enrollee has coverage through Medicare, the CONTRACTOR must submit claims for mental health services to Medicare for payment. The payment of the Medicare coinsurance and deductible will be made by Medicaid according to DHCF policy for such claims.
2. If the Medicaid Enrollee has coverage through another health insurance carrier, the CONTRACTOR must attempt to collect any monies from the third party payer for covered services.
3. If the Medicaid Enrollee is a child where the absent parent has a duty to provide medical support, the CONTRACTOR should contact the Office of Recovery Services (ORS) and provide claims to that office so they may pursue collections from the absent parent." Utah Mental Health Contract, page 16.

"G. THIRD-PARTY LIABILITY (TPL)
1. Comprehensive Health Coverage...
Under section 1902 (a)(25) of the Social Security Act, (42 U.S.C. §1396a(a)(25) the State is required to take all reasonable measures to identify legally liable third parties and pursue verified resources. In cases in which the recipient was not identified for exclusion prior to enrollment in the HMO, the Contractor shall take responsibility for identifying and pursuing comprehensive health coverage. Any moneys recovered by third parties shall be retained by the Contractor and identified monthly to the Department. The Contractor shall notify DMAS on a weekly basis of any enrollees identified during the past week who were discovered to have comprehensive health coverage.

2. Workers' Compensation
If a member is injured at his or her place of employment and files a workers' compensation claim, the Contractor shall remain responsible for all services. The Contractor may seek recoveries from a claim covered by worker's compensation if the Contractor actually reimbursed providers and the claim is approved for the workers' compensation fund...

3. Estate Recoveries
The Contractor is prohibited from collecting estate recoveries. The Contractor shall notify DMAS on a weekly basis of any enrollees identified during that past week who have died, and are over the age of 55.

4. Other Coverage
The Department retains the responsibility to pursue, collect, and retain all non-health insurance resources, such as casualty, liability, estates, child support, and personal injury claims. The Contractor is not permitted to seek recovery of any non-health insurance funds." Virginia Contract, pages 93-94.

"3.8 Third Party Liability (TPL): The services and benefits available under this contract shall be secondary to any other medical coverage. The Contractor shall:
a. not refuse or reduce services provided under this agreement solely due to the existence of similar benefits provided under any other health care contracts (RCW 48.21.200), except in accordance with applicable coordination of benefits rules in Chapter 284-51 WAC.
b. attempt to recover any third-party resources available to members (42 CFR 433 Subpart D) and shall make all records pertaining to TPL collections for members available for audit and review.
c. pay claims for prenatal care and preventive pediatric care and then seek reimbursement from third parties (42 CFR 433.139(b)(3)).
d. pay claims for covered services when probable third party liability has not been established or the third party benefits are not available to pay a claim at the time it is filled (42 CFR 433.139(c)).
e. notify DSHS as set forth below when a member has TPL for medical care: ...
f. Communicate the requirements of this section to subcontractors that provide services under the terms of this agreement, and assure compliance with them.
g. On a calendar quarter basis, DSHS shall provide TPL information for members to the Contractor on computer tape.

3.9 Subrogation Rights of Third-Party Liability: ...

If a member requires medical services from the Contractor as a result of an alleged act or omission by a third-party giving rise to a claim of legal liability against the third-party, the Contractor shall have the right to obtain recovery of its cost of providing benefits to the injured person from the third-party. DSHS specifically assigns to the Contractor the DSHS's rights to all third party payments for medical care provided to a member on behalf of DSHS, which the member assigned to DSHS as provided in WAC 388-505-0540. DSHS also assigns to the Contractor its statutory lien under RCW 43.20B.070 with respect to medical benefits provided to members on behalf of DSHS under chapter 74.09 RCW.

While the injured person, or the injured person's representative should cooperate fully with the Contractor in effecting collection from persons causing the injury, the Contractor should obtain a signed agreement from the members in which the members agree to fully cooperate." Washington Contract, pages 12-14.

"3.27 Third Party Coverage...
The pursuit of third party payment for services covered in the Medicaid benefit package is the responsibility of the Managed Care Plan. The Managed Care Plan shall actively pursue, collect and retain any moneys from third-party payers for services to enrollees covered under this contract except where the amount of reimbursement the Managed Care Plan can reasonably expect to receive is less than the estimated cost of recovery. This responsibility includes accident and trauma cases that occur while a Medicaid recipient is enrolled in the Managed Care Plan. The Managed Care Plan will retain all funds collected as part of this activity. The Managed Care Plan must review service information to determine that all third party payment sources are identified and payment is pursued." West Virginia Contract, page 26.

"6.2.5 Third Party Liability
Under Section 1902(a)(25) of the Social Security Act, DHHR is required to take all reasonable measures to identify legally liable third parties and treat third party as a resource of the Medicaid recipient.

As part of this requirement, the State has determined that the pursuit of third party payment for services covered in the Medicaid benefit package is the responsibility of the MCP. MCP capitation payment rates are set accordingly. The MCP should utilize and require its subcontractors to utilize or pursue, when available, covered medical and hospital services or payments for Medicaid enrollees available from other public or private sources, including Medicare. This responsibility includes accident and trauma cases that occur while a Medicaid recipient is enrolled in the MCP. The MCP will retain all funds collected as part of this activity. The MCP must review service information to determine that all third party payment sources are identified and payment is pursued…" West Virginia RFA, page 44.

"H. COORDINATION OF BENEFITS (COB)-The HMO must actively pursue, collect and retain all monies from all available resources for services to enrollees covered under this Contract except where the amount of reimbursement the HMO can reasonably expect to receive is less than the estimated cost of recovery… COB recoveries will only be done by post-payment billing (pay and chase) for certain prenatal care and preventive pediatric services. Post-payment billing will also be done in situations where the third party, liability is derived from a parent whose obligation to pay is being enforced by the State Child Support Enforcement Agency and the provider has not received payment within 30 days after the date of service…

Other available resources may include, but are not limited to, all other State or Federal medical care programs which are primary to Medicaid, group or individual health insurance, ERISAs, service benefit plans, the insurance of absent parents who may have insurance to pay medical care for spouses or minor enrollees, and subrogation/workers compensation collections.

Subrogation collections are any recoverable amounts arising out of settlement of personal injury, medical malpractice, product liability, or Worker's Compensation. State subrogation rights have been extended to HMOs under s. 49.89(9), Act 31, Laws of 1989. After attorneys' fees and expenses have been paid, the HMO shall collect the full amount paid on behalf of the enrollee...

Where the HMO has entered a risk-sharing arrangement with the Department, the COB collection and distribution shall follow the procedures described in Addendum III of this Contract.

COB collections are the responsibility of the HMO or its subcontractors. Subcontractors must report COB information to the HMO. HMOs and subcontractors shall not pursue collection from the recipient but directly from the third party payer. Access to medical services will not be restricted due to COB collection.

The following requirement shall apply if the Contractor … is a health care insurer (including, but not limited to, a group health insurer and/or health maintenance organization) licensed by the Wisconsin Office of the Insurance Commissioner and/or a third-party administrator for a group or individual health insurer(s), health maintenance organization(s), and/or employer self-insurer health plan(s):

1. Throughout the Contract term, these insurers and third-party, administrators shall comply in full with the provision of Subsection 49.475 of the Wisconsin Statutes...

2. Throughout the Contract term, these insurers and third-party administrators shall also accept and properly process postpayment billings from the Department's fiscal agent for health care services and items received by Wisconsin Medicaid recipients.

If, at any time during the contract term, any of the insurers or third party administrators fail, in whole or in part, to adhere to the requirements of (1) or (2) above, the Department may take the remedial measures specified in Article IX.D.(3)(b) and Article X.B.(2)." Wisconsin Contract, pages 46-48.

"ADDENDUM III
RISK-SHARING FOR INPATIENT HOSPITAL SERVICES
The Department shall share risk with the HMO for inpatient hospital services provided by the HMO in the following manner: ...
7. The HMO is responsible for the collection of all coordination of benefits available on risk-sharing claims. No Departmental reimbursement under the risk-sharing agreement will be made on claims for which insurance is available unless an Explanation of (insurance) Benefits is provided indicating how much the insurance paid." Wisconsin Contract, Addendum III, pages 85-86.