DEH rev4 22 Base Plan TPL p69,69a,70

Revision: Page 69

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State: __________________

THIRD PARTY LIABILITY

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Citation(s)

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4.22 Third Party Liability

A. The Medicaid Agency meets all requirements of:

42 CFR 433.137

(1) 42 CFR 433.138 and 433.139;

(2) 42 CFR 433.145 through 433.148;

(3) 42 CFR 433.151 through 433.154;

1902(a)(25)(G), (H) and (I) (4) Sections 1902(a)(25)(G), (H) and (I); and

of the Act

1902(a)(60) & (5) Section 1902(a)(60) of the Act.

1908A of the Act

B. Identification of Liable Resources. The State uses the following methods to identify liable resources:

42 CFR 433.138(f) (1) Specify the frequency with which the data exchanges required in §433.138(d)(1), (d)(3) and (d)(4) and the diagnosis and trauma code edits required in §433.138(e) are conducted:

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TN: ______ Approval Date ___ Effective Date ______

Supersedes TN:_____

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STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State: __________________

THIRD PARTY LIABILITY

______________________________________________________________________________

Citation(s)

______________________________________________________________________________

B. Identification of Liable Resources (continued)

42 CFR 433.138(g)(1)(ii) (2) Describe the methods the agency uses for meeting

and (2)(ii) the following requirements contained in

§433.138(g)(1)(i) and (g)(2)(i):

42 CFR 433.138(g)(3)(i) (3) Describe the methods the agency uses for

and (iii) following up on information obtained through the State motor vehicle accident report file data exchange required under §433.138(d)(4)(ii) and specify the timeframes for incorporation into the eligibility case file and into its third party data base and third party recovery unit of all information obtained through the follow-up that identifies legally liable third party resources:

TN: ______ Approval Date ___ Effective Date ______

Supersedes TN:_____

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STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State: __________________

THIRD PARTY LIABILITY

_____________________________________________________________________________

Citation(s)

______________________________________________________________________________

B. Identification of Liable Resources (continued)

42 CFR 433.138(g)(4)(i) (4) Describe the methods the agency uses for

through (iii) following up on paid claims identified under §433.138(e) (methods include a procedure for periodically identifying those trauma codes that yield the highest third party collections and giving priority to following up on those codes) and specify the timeframes for incorporation into the eligibility case file and into its third party data base and third party recovery unit of all information obtained through the follow-up that identifies legally liable third party resources:

3. Payment of Claims. The State uses the following methods in the payment of claims:

42 CFR 433.139(b)(3)(ii)(C) (1) Describe the method used in determining a provider’s compliance with the third party billing requirements at §433.139(b)(3)(ii)(C):

TN: ______ Approval Date ___ Effective Date ______

Supersedes TN:_____

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STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State: __________________

THIRD PARTY LIABILITY

_____________________________________________________________________________

Citation(s)

______________________________________________________________________________

C. Payment of Claims (continued)

42 CFR 433.139(f)(2) (2) Specify the threshold amount or other guideline used in determining whether to seek recovery of reimbursement from a liable third party, or the process by which the agency determines that seeking recovery of reimbursement would not be cost effective:

42 CFR 433.139(f)(3) (3) Specify the dollar amount or time period the State uses to accumulate billings with respect to a particular third party in making the decision whether or not to seek recovery of reimbursement:

42 CFR 433.139(b)(3)(ii)(A) (4) Specify whether or not providers are required to bill liable third parties when services covered under the plan are furnished to an individual on whose behalf child support enforcement is being carried out by the State IV-D agency:

TN: ______ Approval Date ___ Effective Date ______

Supersedes TN:_____

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STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

State: __________________

THIRD PARTY LIABILITY

______________________________________________________________________________

Citation(s)

______________________________________________________________________________

42 CFR 447.20 D. The Medicaid agency ensures that the provider furnishing a service for which a third party is liable follows the restrictions specified in 42 CFR 447.20.

42 CFR 433.151(a) E. The Medicaid agency has elected written cooperative agreements for the enforcement of rights to collection of third party benefits assigned to the State as a condition of eligibility for medical assistance with the following entities: (Check as appropriate.)

___ State title IV-D agency. The requirements of 42 CFR 433.152(b) are met.

___ Other State agency(ies) (specify):

___ Other agency(ies) of another State (specify):

___ Courts and law enforcement officials.

42 CFR 433.153 F. The Medicaid agency makes incentive payments in accordance with 42 CFR 433.153.

42 CFR 433.154 G. The Medicaid agency distributes collections in accordance with 42 CFR 433.154.

TN: ______ Approval Date ___ Effective Date ______

Supersedes TN:_____