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Third Party Liability and Recoveries

The Office of Recovery performs third party functions in two ways: by avoiding Medicaid payments when other commercial or public health insurance carriers should pay for a service; and by recovering Medicaid payments made prior to the identification of  a legally-obligated third-party source.  Third party liability (TPL) refers to the legal obligation of health care sources (third party sources) to pay for all, or part, of a medical claim of a Medicaid beneficiary. This may include health insurance, casualty coverage resulting from an accidental injury, or payments received directly from an individual who has either voluntarily accepted or been assigned legal responsibility for the healthcare of a Medicaid recipient.  By law, Medicaid is the payer of last resort.

Cost Avoidance

A method of avoiding payment of Medicaid claims when other insurance resources are available to the Medicaid recipient.  Providers may use the Report Third Party Insurance Form to notify the Office of Recovery of changes in third party insurance coverage.

Pay and Chase

A method used where Medicaid pays the recipient’s medical bills and then attempts to recover from liable third parties.

Coordination of Benefits

The processing of claims when Medicaid is the secondary payer.

Casualty/Subrogation

Identifying, managing, and recovering all Medicaid’s payments as a result of claims for services with trauma diagnosis.  Currently, this function is handled by our TPL vendor.

Estate Recovery

Recovering payments from estates of deceased beneficiaries for various services. Additional information can be found at on our Estate Recovery Fact Sheet.

Medicare Buy-In

Monitoring the Buy-In files, Medicare Part A & B, for CMS billing.

Beneficiary Recoupment

Recovering payments from beneficiaries who received benefits during an ineligible period.

Medicare Part C

Resolving provider Medicare Part C issues for compliance with state and federal regulations.

Resources

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