Ohio Admin. Code 5160-26-09.1 - Managed health care programs: third party liability and recovery
(A) Tort.
(1) Pursuant to sections
5160.37 and
5160.38 of the Revised Code, the
Ohio department of medicaid (ODM) maintains all rights of recovery (tort)
against the liability of any third party payer (TPP) for the cost of medical
services.
arising out
of any accident/incident related to an injury of a member.
(2) Managed care plans (MCPs) are prohibited
from accepting any settlement, compromise, judgment, award, or recovery of any
action or claim by the member.
(3)
MCPs must notify ODM and/or its designated entity within fourteen calendar days
of all requests for the release of financial and medical records to a member or
the member's representative pursuant to the filing of a tort action.
Notification must be made via the "Notification of Third Party (tort) Request
For Release" form (ODM 03245, rev. 7/2014) or a method determined by the ODM
designated entity, provided ODM approved the designated entity's method and
notified MCPs.
(4) MCPs must submit
a summary of financial information to ODM and/or its designated entity within
thirty calendar days of receiving an original authorization to release a
financial claim statement letter from ODM pursuant to a tort action. MCPs must
use the "Tort Summary Statement" form (ODM 03246, rev. 7/2014) or a method
determined by the ODM designated entity, provided ODM has approved the
designated entity's method and notified MCPs. Upon request, the MCPs must
provide ODM and/or its designated entity with true copies of medical
claims.
(B) Fraud, waste, and abuse recovery. ODM assigns to MCPs its
rights of recovery against any TPP for the
costs arising out of
due to provider fraud,
waste, or abuse as defined by
in rule
5160-26-01
of the Administrative Code related to each member during periods of enrollment
in the MCP. In instances when an MCP fails to properly report
a case of suspected fraud, waste, or abuse, before the suspected fraud, waste, or abuse is identified by the state of Ohio,
any portion of the fraud, waste, or abuse
recovered by the state shall be retained by the state.
(C) Coordination of benefits
(COB).
(1) ODM assigns its right to third party
resources (coordination of benefits) to contracted MCPs for services rendered to each
member during periods of enrollment. ODM reserves the right to identify,
pursue, and retain any recovery of third party resources assigned to an MCP but
not collected by the MCP after one year from date of claim payment.
of the paid claim.
(2) MCPs must act to provide coordination of
benefits if a member has third party resources available for the payment of
medical expenses for medically necessary medicaid-covered services. Such
expenses will be paid in accordance with this rule and sections
5160.37 and
5160.38 of the Revised
Code.
(3) The MCP is the payer of
last resort when a member has third party resources available for payment of
medical expenses for medicaid-covered services, except:
for the following
resources in which the MCP is the primary payer.
(d)
(b)
The MCP pays first
Resources available for
prenatal care for pregnant women, or
preventive pediatric services before seeking
reimbursement from any liable third party.
pursuant to 42 C.F.R. 433.139 (October 1,
2016).
(a)
The MCP pays
after any TPP including medicare but before:
(a)
(i) Resources provided through the children with
medical handicaps program under sections
3701.021 to
3701.0210 of the Revised
Code.
, as specified in
rule
5160-1-03
of the Administrative Code.
(b)
(ii) Resources
that are exempt from primary payer status under federal medicaid law,
42 U.S.C.
1396 (as in effect July 1,
2017
2018 ).
(c)
(iii) Resources
provided through the state sponsored program awarding reparations to victims of
crime, as set forth in sections
2743.51 to
2743.72 of the Revised
Code.
(4) MCPs
will take reasonable measures to ascertain and verify any third party resources
that are available to
the
a member.
When an MCP denies a claim due to third party liability (TPL), the MCP must
timely share, on the explanation of payment sent to
providers,
appropriate and available
information regarding the third party resources to
the provider for the purposes of coordination of benefits,
including, but not limited to, the following
information:
(a) Insurance company
name;
(b) Insurance company billing
address for claims;
(c) Member's
group number;
(d) Member's policy
number; and
(e) Policy holder
name.
(5) MCPs must
require providers who are submitting TPL claims to the MCPs to request
information regarding third party benefit(s)
benefits
from the member or his/her authorized representative. If the member or the
member's authorized representative specifies that the member has no third party
benefit(s)
benefits , or the provider is unable to determine that
the member has third party benefit(s)
benefits , the MCP must permit the provider to submit a
claim to the MCP. If, as a result of requesting the information, the provider
determines that third party liability exists, the MCP must allow the provider
to submit a claim for reimbursement if he/she first takes reasonable measures
to obtain third party payment(s)
payment as set forth in paragraph (C)(6) of this
rule.
(6)
The MCP must be the last payer to receive and
adjudicate the claim, except for those exemptions listed in paragraph (C)(3) of
this rule. The MCP must require providers to take reasonable measures
to obtain all third party payments and file claims with all TPPs prior to
billing the MCP. MCPs
The MCP must permit providers who have taken
reasonable measures to obtain all third party payments, but who have not
received payment from a TPP, or
have taken reasonable measures and received
partial payment, to submit a claim to the MCP requesting reimbursement for
the rendered service(s)
services .
(a) MCPs must process claims when the
provider has complied with one or more of the following reasonable measures:
(i) The provider first submits a claim to the
TPP for the rendered service(s)
services and does not receive a remittance advice or
other communication from the TPP within ninety days after the submission date.
MCPs may require providers to document the claim and date of the claim
submission to the TPP.
(ii) The
provider has retained and/or submitted at
least one of the following types of documentation
that indicates
indicating a valid reason for non-payment for the
service(s)
services
that is
not related to provider error:
(a)
Documentation from the TPP;
(b)
Documentation from the TPP's automated eligibility and claim verification
system;
(c) Documentation from the
TPP's member benefits reference guide/manual; or
(d) Any other information and/or documentation from the TPP
that
showing
there is no third party benefit coverage for the rendered
service(s)
services .
(iii) The provider submitted a claim to the
TPP and received a partial payment along with a remittance advice documenting
the allocation of the charges.
(b) Valid reasons for non-payment from a TPP
to the provider for a third party benefit claim include, but are not limited
to, the following:
(i) The service is not covered under the
member's third party benefits.
(ii)
The member does not have third party benefits through the TPP for the date of
service.
(iii) All of the
provider's billed charges or the TPP's approved rate was applied, in whole or
in part, to the member's third party benefit deductible amount, coinsurance
and/or co-payment for the TPP. The provider may then submit a secondary claim
to the MCP showing the appropriate amount received from the TPP.
(iv) The member has not met any required
waiting periods, or residency requirements for his/her third party benefits, or
was non-compliant with the TPP's requirements in order to maintain
coverage.
(v) The member is a
dependent of the individual with third party benefits, but the benefits do not
cover the individual's dependents.
(vi) The member has reached the lifetime
benefit maximum for the medical service or third party benefits being billed to
the third party payer
TPP .
(vii)
The TPP is disputing or contesting its liability to pay the claim or cover the
service.
(7)
If the provider receives payment from the TPP after the MCP has made payment,
the MCP must require the provider to repay the MCP any amount overpaid by the
MCP. The MCP must not allow the provider to reimburse any overpaid amounts to
the member.
(8) MCPs must make
available to providers information on how to submit a claim that will have a
zero paid amount in the third party field on the claim.
(9) MCP reimbursement
payment
for third party claims will not exceed the MCP allowed amount for the service,
less all third party payments for the service.
(10) An MCP's timely filing limits for
provider claims shall be at least ninety days from the date of the remittance
advice that indicates adjudication or adjustment of the third party claim by
the TPP.
(11) MCPs must ensure that
providers do not hold liable or bill members in the event that the MCP cannot
or will not pay for covered services unless all of the specifications set forth
in rule
5160-26-05
and rule
5160-26-11
of the Administrative Code are met. The provider may not collect and/or bill
the member for any difference between the MCP payment and the provider's charge
or request the member to share in the cost through a deductible, coinsurance,
co-payment, or other similar charge, other than MCP co-payments as permitted in
rule
5160-26-12
of the Administrative Code.
(D) The MCP is required to submit information
regarding members with third party coverage as directed by ODM.
Notes
Promulgated Under: 119.03
Statutory Authority: 5167.02
Rule Amplifies: 5167.02, 5167.03, 5167.10, 5167.32
Prior Effective Dates: 11/01/1994, 07/01/1997 (Emer.), 09/27/1997, 07/01/2001, 07/01/2003, 06/01/2006, 07/01/2007, 09/15/2008, 08/01/2011, 01/01/2014, 08/01/2016, 07/01/2017
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