5101:3-26-09.1 Managed health care programs: third party recovery.

(A) Pursuant to sections 5101.58 and 5101.59 of the Revised Code, ODJFS 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.

(B) Managed care plans (MCPs) must notify ODJFS 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 (JFS 03245, rev. 03/06).

(C) MCPs must submit a summary of financial information to ODJFS and/or its designated entity within thirty calendar days of receiving an original authorization to release a financial claim statement letter from ODJFS pursuant to a tort action. MCPs must use the “Tort Summary Statement for ODJFS” form (JFS 03246, rev. 03/06). Upon request, the MCPs must provide ODJFS and/or its designated entity with true copies of medical claims.

(D) MCPs are prohibited from accepting any settlement, compromise, judgment, award, or recovery of any action or claim by the member.

(E) ODJFS assigns its right to third party (TP) resources (coordination of benefits) to contracted MCPs for services rendered to each member during periods of membership, except as stated in paragraph (A) of this rule.

(F) MCPs must act to provide coordination of benefits if a member has third party resources available for the payment of medical expenses for medicaid-covered services. Such expenses will be paid in accordance with this rule and sections 5101.58 and 5101.59 of the Revised Code.

(G) 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 those resources listed in paragraphs (G)(1) to (G)(3) of this rule. In these instances, the MCP is the primary payer.

(1) Resources provided through the children with medical handicaps program under Title V of the Social Security Act, as specified in rule 5101:3-1-03 of the Administrative Code.

(2) Resources that are exempt from primary payer status under Title XIX of the Social Security Act.

(3) 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.

(H) MCPs will take reasonable measures to ascertain and verify any third party resources that are available to the member. When an MCP denies a claim due to third party liability (TPL), the MCP must timely share appropriate and available information regarding the third party to the provider for the purposes of coordination of benefits, including, but not limited to, third party liability information received from ODJFS.

(I) MCPs must require providers who are submitting TPL claims to the MCPs to request information regarding third party benefit(s) from the member or his/her authorized representative. If the member or the member’s authorized representative specifies that the member has no TP benefit(s), or the provider is unable to determine that the member has third party benefit(s), 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 TP liability exists, the MCP must allow the provider to submit a claim for reimbursement if he/she first takes reasonable measures to obtain TP payment(s) as set forth in paragraph (J) of this rule.

(J) The MCP must be the last payer to receive and adjudicate the claim, except for those exemptions listed in paragraph (G) 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 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).

(1) MCPs must process claims when the provider has complied with one of the following requirements:

(a) The provider first submits a claim to the TPP and receives a remittance advice indicating that a valid reason for non-payment applies for the service as described in paragraph (J)(2) of this rule.

(b) The provider first submits a claim to the TPP for the rendered service(s) no fewer than three times within a ninety-day period and does not receive a remittance advice or other communication from the TPP within ninety days of the last submission to the TPP. MCPs may require providers to document each claim submission and the date of the submission.

(c) The provider did not send a claim to the TPP, but has retained and/or submitted at least one of the following types of documentation that indicates a valid reason for non-payment for the service(s) as set forth in paragraph (J)(2) of this rule:

(i) Documentation from the TPP;

(ii) Documentation from the TPP’s automated eligibility and claim verification system;

(iii) Documentation from the TPP’s member benefits reference guide/manual; or

(iv) Any other reliable information and/or documentation from the TPP that there is no third party benefit coverage for the rendered service(s).

(d) The provider first submits a claim to the TPP and receives a partial payment along with a remittance advice documenting the allocation of the billed charges.

(2) Valid reasons for non-payment from a third party payer to the provider for a third party benefit claim include, but are not limited to, the following:

(a) The service(s) is not covered under the member’s third party benefits.

(b) The medical expenses for the member were incurred prior to the TPP coverage dates.

(c) The medical expenses for the member were incurred after the TPP coverage was terminated.

(d) The member does not have third party benefits through the TPP for the date of service.

(e) All of the provider’s billed charges or the TPP’s approved rate was applied to the member’s third party benefit deductible amount.

(f) All of the provider’s billed charges or the TPP’s approved rate was applied in total across the member’s deductible, coinsurance, and/or co-payment for the third party benefit.

(g) The member has not met eligibility, out-of-pocket expenses, required waiting periods, or residency requirements for his/her third party benefits.

(h) The member is a dependent of the individual with third party benefits, but the benefits do not cover the individual’s dependents.

(i) The member has reached the lifetime benefit maximum for the medical service being billed to the third party payer.

(j) The member has reached the benefit maximum of his/her third party benefits.

(k) The TPP is disputing or contesting its liability to pay the claim or cover the service.

(K) MCPs must allow providers who have taken reasonable measures as described in paragraph (J) of this rule to obtain all third party payments, but who have not received payment from a TPP, or received a partial payment, to submit a claim to the MCP requesting reimbursement for the rendered service(s). 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.

(L) 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.

(M) MCP reimbursement for third party claims will not exceed the MCP allowed amount for the service, less all third party payments for the service. If the result is less than or equal to zero dollars, there will be no further payment for the service.

(N) The MCP will reject a TP claim when the TP claim indicates coverage by a TPP, and the submitted claim does not indicate collection of the third party payment or does not indicate compliance with paragraph (J) of this rule. MCPs may have providers complete their investigation of available third party benefits before submitting a TP claim to the MCP for payment. MCPs must require providers and/or trading partners to do the following:

(1) Retain and/or submit documentation to support all required information submitted on a TP claim.

(2) Include on a TP claim any required TP claim information issued to them by the TPP, by the member, or any other source.

(O) 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 paragraph (D)(9) of rule 5101:3-26-05 and paragraph (E) of rule 5101:3-26-11 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 5101:3-26-12 of the Administrative Code.

Replaces: 5101:3-26-09.1

Effective: 09/15/2008

R.C. 119.032 review dates: 09/01/2013

Promulgated Under: 119.03

Statutory Authority: 5111.02, 5111.16, 5111.17

Rule Amplifies: 5111.01, 5111.02, 5111.021, 5111.16, 5111.17

Prior Effective Dates: 11/1/94, 7/1/97 (Emer), 9/27/97, 7/1/01, 7/1/03, 6/1/06, 7/1/07