Sec. 7 AAC 160.200 - Third-party resources

ยง 7 AAC 160.200. Third-party resources

(a) The department will pay for a service, prescription drug, or supply only to the extent it is a covered service under AS 47.07.030 and 7 AAC 105 - 7 AAC 160 and only after the recipient has made full use of any other third-party resources available to pay for that service, prescription drug, or supply. A third-party resource includes

(1) workers' compensation under a law or plan of the United States or a particular jurisdiction;

(2) private, employer-based, or public health insurance;

(3) a prepaid health plan;

(4) a program or health plan of the federal government, including

(A) Veterans Administration benefits,

(B) the TRICARE military health plan under 10 U.S.C. 1071 - 1110 for active duty military personnel, reservists, dependents, and retirees, or other military health plan; and

(C) Medicare;

(5) the fishermen's fund (AS 23.35.060);

(6) automobile insurance, including uninsured or underinsured motorist insurance;

(7) an indemnity policy; and

(8) another jurisdiction's Medicaid or other medical assistance program.

(b) If a provider treats a recipient for an injury that the provider has reason to believe may have been caused by another individual, institution, corporation, business, or public or private agency, the provider shall notify the department of that belief at the time of billing. The department will evaluate this information to determine if there is potential for legal action, recovery from a settlement, or payment from a third-party resource. The department will not delay payment to the provider pending an evaluation.

(c) If a third-party resource makes a demand for the refund of a claim previously paid by the third-party resource and the billing deadline in 7 AAC 145.005(c) has expired, the provider has 60 days after the date of demand to bill Medicaid or adjust the original claim. The provider shall include a copy of the third-party resource's demand letter and proof of the refund that the provider made to the third-party resource with the claim.

(d) For purposes of this section, a tribal health program is not a third-party resource.

(e) In this section, "has made full use of" means the recipient has applied for, reasonably cooperated with, and to the extent possible has maintained eligibility for, a third party that will pay for a service, prescription drug, or supply otherwise covered under AS 47.07.030 and 7 AAC 105 - 7 AAC 160.

(Eff. 2/1/2010, Register 193)

Authority:AS 47.05.010

AS 47.07.030

AS 47.07.040

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