Adult Medicaid Manual MA-2400 THIRD PARTY RECOVERY

II. PROCEDURES

A. Determining the Availability of Third Party Resources

1. At application, redetermination, or change in situation, ask if the a/r has medical insurance coverage. If he does, request from the a/r the names of insurance companies, policy holders, names of individuals covered, policy numbers, group names/numbers and coverage begin dates for anyone requesting assistance. See II.B, for instructions on reporting.

a. If an applicant/recipient states that he has insurance but can not provide information regarding the company, coverage, and policy number(s), request the needed information by means of DMA-5097/DMA-5097S,

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(II.A.1.a.)

Request for Information. Follow procedures in MA-2303, Verification Requirements for Applications.

b. Accept the a/r’s statement when:

(1) Third party coverage is provided by the non-custodial parent (NCP) but the a/r is unable to get information regarding the name of the insurance company and the policy number from the non-custodial parent (NCP) or his employer.

(2) Third party coverage is provided by the NCP’s spouse, but the a/r is unable to get the information regarding the name of the insurance company and the policy number from the NCP’s spouse or the spouse’s employer.

(3) Third party coverage is provided by the a/r’s spouse, but the a/r is unable to get information regarding the name of the insurance company and the policy number from the spouse or the spouse’s employer.

c. Deny or terminate Medicaid eligibility for individuals who fail to meet the assignment provisions including assignment of rights to medical support or other third party resources.

d. Make a referral to IV-D, if appropriate. See MA-2375, Procedures For Child Support Enforcement.

e. Do not pend the application. Process according to procedures in MA-2304, Processing the Application, and report any third party resource information using the TA Screen/TU Screen as soon as it is known.

2. At each application or re-enrollment perform a TPR Individual Data (TI) inquiry. Use each a/r’s individual ID to ensure correct data displays in EIS. Refer to EIS 1055 for instructions. If the TI inquiry displays insurance, ask if the a/r is still covered by the insurance. If he states he is no longer covered by the policy, ask when the coverage ended. Verify terminated coverage through a third party source such as an insurance company or an employer. If coverage is terminated, enter a termination date in the system. If unable to verify coverage is terminated or if coverage is still in effect, leave insurance information unchanged in system.

The TI inquiry is necessary also to determine if there is comprehensive major medical insurance listed in EIS for North Carolina Health Choice (NCHC) and Breast and Cervical Cancer Medicaid (BCCM) cases. If comprehensive major medical insurance is in force, the a/r is ineligible for NCHC and BCCM. Refer to MA-3255, North Carolina Health Choice for Children and MA-3250, Breast and Cervical Cancer Medicaid for exceptions.

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(II.A.2.)

If a child is covered by a policy with no local providers, do not enter the third party coverage in EIS. This applies to Medicaid children using the same

criteria as outlined in MA-3255, North Carolina Health Choice for Children with no creditable coverage.

NOTE: View EACH screen of the TI inquiry information. A message is displayed at the bottom of the screen when there is more than one screen of data.

B.

Reporting Third Party Resources

1. Key the TA Screen/TU Screen, as soon as a third party resource is known. This may include school or dental insurance or any other third party resource. Refer to EIS-3350, for detailed instructions on keying the TA Screen/TU Screen.

a. To ensure the TA Screen/TU Screen is completed accurately, view the insurance policy, insurance pocket identification card, or contact the employer or insurance agent. It is preferable to use the insurance policy.

b. Enter each insurance policy in EIS when the applicant/recipient (a/r) or a budget unit member has more than one health and/or accident insurance policy.

2. When approving an application, use the information from the TPR inquiry results in II.A.2 to make corrections/additions/changes to TPR data in EIS. The Medicaid claims contractor uses the TPR Individual Data (TI) inquiry in EIS to ensure Medicaid claims are paid correctly. Key changes to data on the TPR Individual Update Screen or the TPR Policy Update Screen.

3. If TPR coverage has terminated, enter an individual end date indicating the date the insurance ended. If an entry is invalid, key a termination for data in TPR. See VII.A.2., below. EIS does not allow approval or continuation of NCHC or BCCM if comprehensive major medical insurance is open in EIS.

4. When Medicaid providers report the existence or termination of TPR coverage to the TPR section at DMA, TPR staff verifies the new information before updating EIS. When State TPR staff enter TPR data in EIS, the District Number is TPR. When the State has entered the TPR information, a county or the state may discover this information is incorrect. If either verifies the information is indeed incorrect, then either must update EIS with the corrected information.

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(II.B.)

5. Complete DMA-2043, Third Party Recovery “Accident” Information Report, to report tort liability third party coverage. See III.E., for procedures for handling tort liability.

6. Medicare information is generated by system exchanges with the Social Security Administration (SSA) through the Buy-In process and is entered into

EIS on the DSS-8125, or entered by the automated buy-in update. Refer to MA-2410, Medicare Enrollment & Buy-In, and EIS –Volume II.

7. Indemnity policies are defined as policies that pay the a/r a specific amount for certain illnesses, hospital stays, long term care and others. Code all indemnity policies other than LTC as 06 insurance type and enter into EIS. Code all LTC indemnity policies as 07 insurance type and enter into EIS. For an individual LTC indemnity policy, advise the a/r he may want to assign his rights and proceeds from the policy to the nursing facility.

C. Special Funds

When there is knowledge of the existence of a fund for payment of expenses related to traumatic/catastrophic illnesses, transplants, etc., inform the Third Party Recovery Section at Division of Medical Assistance. Do not report as a third party resource on TA Screen/TU Screen. Send a letter to the Division of Medical Assistance, providing as much information as possible.

Third Party Recovery can investigate the availability of such funds. Information in newspaper/other news media may provide leads. If possible, obtain a copy of any trust agreement or legal documentation as to how the fund is to be administered. Include the name of any person known to be associated with fund-raising events, trustee of a fund, etc. Send all information to:

Division of Medical Assistance

Third Party Recovery Section

2508 Mail Service Center

Raleigh, NC 27699-2508

Follow procedures in MA-2230, Financial Resources, to determine whether such funds are countable in reserve.