when is a hospital required to report third party liability to medicare coordination of benefits

Implementing regulations of the Centers for Medicare & Medicaid Services (CMS), formerly the Health Care Financing Administration, establish that "promptly" means 120 days from (1) the date a claim is filed with an insurer or a lien is filed against a potential liability settlement or (2) the date the service was furnished or the date of a hospital discharge.

Full Answer

What is third party liability under Medicaid?

Third party liability. Medicaid is generally the payer of last resort: by law, all other sources of coverage must pay claims under their policies before Medicaid will pay for the care of an eligible individual.

Where can I find information on third party liability and coordination?

CMS maintains a web page on Medicaid third party liability and coordination of benefits, with links to a list of frequently asked questions and a guide to effective state agency practices ( CMS 2015 ).

Does HIPAA apply to 3rd party liability information?

3 Sharing of third party liability information between the state, its contractor, and providers or potentially liable third parties is permitted under the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) but must comply with the HIPAA business associate requirements, where applicable.

What is the Medicare coordination of benefits program?

The Medicare program uses Coordination of Benefits (COB) processes to identify payers primary to Medicare and Medicare Secondary Payer (MSP) recovery processes to recover mistaken primary payments and conditional payments.

Who is responsible for coordination of benefits?

Who is responsible for coordination of benefits? The health insurance plans handle the COB. The health plans use a framework to figure out which plan pays first — and that they don't pay more than 100% of the medical bill combined. The plan type guides a COB.

How is Medicare considered in determining coordination of benefits?

Coordination of benefits (COB) allows plans that provide health and/or prescription coverage for a person with Medicare to determine their respective payment responsibilities (i.e., determine which insurance plan has the primary payment responsibility and the extent to which the other plans will contribute when an ...

What is Mandatory insurer Reporting?

The Mandatory Insurer Reporting Law (Section 111 of Public Law 110–173) requires all insurers to report the Social Security and Medicare health insurance claims numbers of its members who meet certain reporting criteria to the Centers for Medicare and Medicaid Services (CMS).

Can you bill Medicare for persons covered by a third party payer?

However, the MSP provisions allow Medicare to pay conditionally for a beneficiary's covered medical expenses when the third party payer does not pay promptly. If conditional payments are made, Medicare has the right to recover those payments.

How is the coordination of benefits process best described?

Sometimes two insurance plans work together to pay claims for the same person. That process is called coordination of benefits. Insurance companies coordinate benefits to: Avoid duplicate payments by making sure the two plans don't pay more than the total amount of the claim.

Do you have to coordinate benefits?

It is common for employees to be covered by more than one group insurance plan. This is typically achieved through a spouse or common-law partner's plan. When an individual is covered by more than one plan, coordination of benefits becomes a requirement to ensure everything runs smoothly between the two plans.

What is Medicare Secondary Payer reporting?

As background, the MSP reporting requirements are intended to help the Centers for Medicare and Medicaid Services (CMS) determine whether a plan is primary to Medicare—that is, whether a plan pays first, and Medicare is a secondary payer.

What is the reporting process of CMS?

Reporting is accomplished by either the submission of an electronic file of liability, no-fault, and workers' compensation claim information, where the injured party is a Medicare beneficiary, or by entry of this claim information directly into a secure Web portal, depending on the volume of data to be submitted.

What is the Medicare Secondary Payer Act?

In 1980, Congress passed legislation that made Medicare the secondary payer to certain primary plans in an effort to shift costs from Medicare to the appropriate private sources of payment.

What information is required to file a third party claim medical?

Third-party insurance claim procedureThe other driver's name and phone number.Their license and registration information.Their vehicle information.Their auto insurance information (from their ID card)Photos of the accident scene and vehicle damage.Witness statements.Police report.

Which is the assumption of an obligation for which another party is primarily liable?

Define subrogation. Is the assumption of an obligation for which another party is primarily liable. Subrogation refers to the contractual right of a third-party payer to recover health care expenses from a liable party.

What are the five major categories of third party payers?

Third-party payers are those insurance carriers, including public, private, managed care, and preferred provider networks that reimburse fully or partially the cost of healthcare provider services.

Third Party Liability in Health Insurance

In the United States there are many sources of health coverage, including indemnity health insurers, group health plans, managed care organizations...

Coordination of Benefits: Special Situations

There are two situations in which state Medicaid agencies follow different rules for avoiding and recovering Medicaid expenditures: (1) when the st...

Federal Role in Medicaid TPL

Although Medicaid is jointly funded by states and the federal government, states are responsible for administering eligibility and claims processin...

What is TPL in Medicaid?

It is possible for Medicaid beneficiaries to have one or more additional sources of coverage for health care services. Third Party Liability (TPL) refers to the legal obligation of third parties (for example, certain individuals, entities, insurers, or programs) to pay part or all of the expenditures for medical assistance furnished ...

Can a third party request Medicaid?

Third parties should treat a request from the contractor as a request from the state Medicaid agency. Third parties may request verification from the State Medicaid agency that the contractor is working on behalf of the agency and the scope of the delegated work.

Can Medicaid be contracted with MCO?

State Medicaid programs may contract with MCOs to provide health care to Medicaid beneficiaries, and may delegate responsibility and authority to the MCOs to perform third party discovery and recovery activities. The Medicaid program may authorize the MCO to use a contractor to complete these activities.

Can Medicaid use a contractor?

The Medicaid program may authorize the MCO to use a contractor to complete these activities. Third parties may request verification from the state Medicaid agency that the MCO or its contractor is working on behalf of the agency and the scope of the delegated work.

What are the two sources of information on whether there may be a liable third party for a particular claim?

States have two main sources of information on whether there may be a liable third party for a particular claim: (1) Medicaid enrollees themselves and (2) data matches with other insurers or data clearinghouses.

How does Medicaid coordinate benefits?

Insurers routinely coordinate benefits by determining whether a third party is liable for payment of a particular service provided to a covered member and then denying payment up front or collecting reimbursement from the third party. Medicaid coordinates benefits with other insurers as a secondary payer to all other payers.

How many people were on medicaid in 2012?

The Government Accountability Office (GAO) estimates that out of the 56 million people enrolled in the Medicaid program in 2012, 7.6 million had private coverage and 10.6 million Medicaid enrollees had access to other public coverage, including Medicare and veterans’ and military health programs ( GAO 2015 ).

What is TPL in Medicaid?

Federal regulation refers to this requirement as third party liability (TPL), meaning payment is the responsibility of a third party other than the individual or Medicaid. To implement the Medicaid TPL requirements, federal rules require states to take reasonable measures to identify potentially liable third parties and process claims accordingly.

What information is needed for Medicaid renewal?

Such information may include the name of the policyholder, his or her relationship to the applicant or enrollee, Social Security Number (SSN), and the name and address of the insurance company and policy number. For child applicants, the state must collect and include in the case file the names and SSNs of absent or custodial parents, to the extent such information is available. 2 In addition, state child support agencies are required to notify the Medicaid agency whenever a parent has acquired health coverage for a child as a result of a court order.

When does Medicaid avoid recovery?

There are two situations in which state Medicaid agencies follow different rules for avoiding and recovering Medicaid expenditures: (1) when the state contracts with managed care plans to administer comprehensive benefits, and (2) when the state covers individuals eligible for both Medicare and Medicaid.

Who is responsible for making payment to medicaid?

This means that if an insurer and Medicaid both provide coverage of a given benefit, the other payer is first responsible for making payment and Medicaid is responsible only for any balance covered under Medicaid payment rules.

What is Medicare investigation?

The investigation determines whether Medicare or the other insurance has primary responsibility for meeting the beneficiary's health care costs. Collecting information on Employer Group Health Plans and non-group health plans (liability insurance ...

What is BCRC in Medicare?

Benefits Coordination & Recovery Center (BCRC) - The BCRC consolidates the activities that support the collection, management, and reporting of other insurance coverage for beneficiaries. The BCRC takes actions to identify the health benefits available to a beneficiary and coordinates the payment process to prevent mistaken payment of Medicare benefits. The BCRC does not process claims, nor does it handle any GHP related mistaken payment recoveries or claims specific inquiries. The Medicare Administrative Contractors (MACs), Intermediaries and Carriers are responsible for processing claims submitted for primary or secondary payment.

What is a COB plan?

Coordination of benefits (COB) allows plans that provide health and/or prescription coverage for a person with Medicare to determine their respective payment responsibilities (i.e., determine which insurance plan has the primary payment responsibility and the extent to which the other plans will contribute when an individual is covered by more than one plan).

Does BCRC cross over insurance?

Note: An agreement must be in place between the Benefits Coordination & Recovery Center (BCRC) and private insurance companies for the BCRC to automatically cross over claims. In the absence of an agreement, the person with Medicare is required to coordinate secondary or supplemental payment of benefits with any other insurers he ...

Does Medicare pay a claim as a primary payer?

Where CMS systems indicate that other insurance is primary to Medicare, Medicare will not pay the claim as a primary payer and will return it to the provider of service with instructions to bill the proper party.

Does BCRC process claims?

The BCRC does not process claims, nor does it handle any GHP related mistaken payment recoveries or claims specific inquiries. The Medicare Administrative Contractors (MACs), Intermediaries and Carriers are responsible for processing claims submitted for primary or secondary payment.

Who must report under Section 111?

Who Must Report. An organization that must report under Section 111 is referred to as a responsible reporting entity (RRE). In general terms, NGHP RREs include liability insurers, no-fault insurers, and workers’ compensation plans and insurers. RREs may also be organizations that are self-insured with respect to liability insurance, ...

What is NGHP reporting?

Mandatory Insurer Reporting for Non-Group Health Plans (NGHP) Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) added mandatory reporting requirements with respect to Medicare beneficiaries who have coverage under group health plan (GHP) arrangements as well as for Medicare beneficiaries who receive settlements, ...

What is an applicable plan?

Include penalties for noncompliance. Define who must report, a responsible reporting entity (RRE), as “an applicable plan”: "... [T]he term 'applicable plan' means the following laws, plans, or other arrangements, including the fiduciary or administrator for such law, plan, or arrangement: (i) Liability insurance (including self-insurance).

Who must report a claim to Medicare?

Reporting a Case. Medicare beneficiaries, through their attorney or otherwise, must notify Medicare when a claim is made against an alleged tortfeasor with liability insurance (including self-insurance), no-fault insurance or against Workers’ Compensation (WC). This obligation is fulfilled by reporting the case in the Medicare Secondary Payor ...

When does Medicare focus on the date of last exposure?

When a case involves continued exposure to an environmental hazard, or continued ingestion of a particular substance, Medicare focuses on the date of last exposure or ingestion to determine whether the exposure or ingestion occurred on or after 12/5/1980.

How to get BCRC contact information?

Contact information for the BCRC may be obtained by clicking the Contacts link. When reporting a case in the MSPRP or contacting the BCRC, the following information is needed: Beneficiary Information: Once all information has been obtained, the BCRC will apply it to Medicare’s record.

What is a BCRC letter?

If Medicare is pursuing recovery directly from the beneficiary, the BCRC will issue a Rights and Responsibilities letter and brochure. The Rights and Responsibilities letter is mailed to all parties associated with the case.

What is a rights and responsibilities letter?

The Rights and Responsibilities letter is mailed to all parties associated with the case. The Rights and Responsibilities letter explains: What happens when the beneficiary has Medicare and files an insurance or workers’ compensation claim; What information is needed from the beneficiary;

Does Medicare cover non-ruptured implants?

For non-ruptured implanted medical devices, Medicare focuses on the date the implant was removed. (Note: The term “exposure” refers to the claimant’s actual physical exposure to the alleged environmental toxin, not the defendant’s legal exposure to liability.)

Does Medicare cover MSP?

Medicare has consistently applied the Medicare Secondary Payer (MSP) provision for liability insurance (including self-insurance) effective 12/5/1980. As a matter of policy, Medicare does not claim a MSP liability insurance based recovery claim against settlements, judgments, awards, or other payments, where the date of incident (DOI) ...

What happens if a third party is not liable for Medicaid?

If there is no established liable third party, the SMA may pay claims to the maximum Medicaid payment amount established for the service in the state plan. If the SMA later establishes that a third party was liable for the claim, it must seek to recover the payment. This may occur when the Medicaid beneficiary requires medical services in casualty/tort, medical malpractice, Worker’s Compensation, or other cases where the third party’s liability is not determined before medical care is provided. It may also occur when the SMA learns of the existence of health insurance coverage after medical care is provided.

Who is liable for Medicaid?

Medicaid and Other Coverage: A Medicaid beneficiary may have a third party resource (health insurance, or another person or entity) that is liable to pay for the beneficiary’s health care.

What is a dually eligible beneficiary?

These beneficiaries are enrolled in Medicare Part A and/or Part B and qualify for help from Medicaid to pay some Medicare costs. Some dually eligible beneficiaries may also qualify for additional Medicaid benefits, depending on income and resources.

What information must an SMA incorporate into its information system?

Once an SMA has identified a liable third party, it must incorporate that information into its information system to streamline the COB process. Regulations specify that the SMAs must incorporate information related to liable third parties in the following systems:

What is a TAG in Medicaid?

The COB/TPL TAG is a forum for state Medicaid senior COB/TPL managers to discuss technical and operational issues and share best practices with CMS, relating to Medicaid policy issues. The purpose of the TAG is to inform and advise CMS as it prepares guidance, identifies and resolves issues, reviews operational policies, and carries out its responsibilities with respect to Medicaid COB/TPL requirements. The TAG also enables CMS to apprise members of current and planned initiatives in areas of interest. State members of the TAG include a Chairperson and 10 State Representatives, one for each of the 10 CMS regions. Each State Representative is responsible to solicit subjects for discussion from the states in his region and share TAG meeting summaries and other communications with the states. The COB/TPL team and Regional Office staff attend monthly conference calls, and other program and state staff attend the TAG meetings, as appropriate.

Can Medicaid be filed against a deceased person?

Medicaid estate recovery claims must be filed against the estate of a deceased Medicaid beneficiary in accordance with the state’s probate code specifications. The probate code may also establish the Medicaid agency’s standing in the priority order of payment to creditors of the estate.

Is Medicaid a payer of last resort?

There are a few exceptions to the general rule that Medicaid is the payer of last resort and these exceptions generally relate to federal-administered health programs. For a federal-administered program to be an exception to the Medicaid payer of last resort rule, the statute creating the program must expressly state that the other program pays only for claims not covered by Medicaid; or, is allowed, but not required, to pay for health care items or services.

What is a COB plan?

Coordination of Benefits (COB): Allows benefit plans that provide health and/or prescription coverage for a person with Medicare and/or other Commercial Coverage to determine their respective payment responsibilities (i.e., determine which insurance benefit plan has the primary payment responsibility and the extent to which the other benefit plans will contribute when an individual is covered by more than one benefit plan).

What is the purpose of a managed care policy?

The purpose of this policy is to provide guidelines that define the order of coverage where insurance and managed care companies coordinate coverage and payment of medical services for Members covered under more than one plan.

What is COB insurance?

Coordination of Benefits (COB) is a provision which establishes the order in which insurance plans pay claims when an individual has coverage under more than one plan. The insurance industry has developed a consistent and orderly way to determine which plan pays its full benefits and which plan pays a reduced amount (if any), which when added together equal more than a single plan's benefit, but not more than the total amount of the allowable charges incurred. It is intended that individuals do not profit when having coverage under more than one plan and that Members and/or providers receive the appropriate amount of reimbursement for medical services.

Mandatory Insurer Reporting For Non-Group Health Plans

Who Must Report

Reporting

• The purpose of Section 111 reporting is to enable CMS to pay appropriately for Medicare-covered items and services furnished to Medicare beneficiaries. Section 111 NGHP reporting of applicable liability insurance (including self-insurance), no-fault insurance, and workers’ compensation claim information helps CMS determine when other insurance cove...

See more on cms.gov

Reporting Requirements – Nghp User Guide and Alerts

Registration and The Section 111 COBSW

Reporting Assistance

Compliance