Section 610. Third party liability

A. The Medicaid agency meets all requirements of:

1. 42 CFR 433.138 and 433.139

2. 42 CFR 433.145 through 433.148

3. 42 CFR 433.151 through 433.154

4. Sections 1902(a)(25)(H) and (I) of the Act.

B. 12VAC30-20-190, governing the identification of liable resources with respect to third party liability:

1. Specifies 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;

2. Describes the methods the agency uses for meeting the follow-up requirements contained in §§ 433.138(g)(1)(i) and (g)(2)(i);

3. Describes the methods the agency uses for following up on information obtained through the State motor vehicle accident report file data exchange required under § 433.138(d)(4)(ii) and specifies the time frames 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; and

4. Describes the methods the agency uses for following up on paid claims identified under § 433.13(a) (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 specifies the time frames 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.

C. Providers are not 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 Title IV-D agency

D. 12VAC30-20-200, governing the payment of claims with respect to third party liability, specifies:

1. The method used in determining a provider's compliance with the third party billing requirements at § 433.139(b) (3) (ii) (C).

2. The threshold amount or other guideline used in determining whether to seek recovery or reimbursement from a liable third party, or the process by which the agency determines that seeking recovery of reimbursement would not be cost effective.

3. The dollar amount or time period the State uses to accumulate billings from a particular liable third party in making the decision to seek recovery of reimbursement.

E. 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.

F. The Medicaid agency has written cooperative agreements for the enforcement of rights to and collection of third party benefits assigned to the State as a condition of eligibility for remedial assistance with the State Title IV-D agency. The requirements of 42 CFR 433.152(b) are met.

G. The Medicaid agency assures that the State has in effect the laws relating to medical child support under § 1908 of the Act.

H. The Medicaid agency specifies the guidelines used in determining the cost effectiveness of an employer-based group health plan; the State provides methods for determining cost effectiveness in 12VAC30-20-210.

Historical Notes

Subsections A and B derived from VR460-01-69, eff. July 1, 1994; subsections C, D, and E derived from VR460-01-69.1, eff. July 1, 1994; subsections F, G and H derived from VR460-01-70, eff. July 1, 1994.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.