Adult Medicaid Manual MA-2400 THIRD PARTY RECOVERY

VII. third party insurance for nchc and bccm

DMA contracts with a vendor for data matches with multiple insurance databases to search for comprehensive, pharmacy, and other types of insurance for NCHC and BCCM. Reports are generated based on third party resource information that is keyed into EIS by the vendor, TPR, and county workers on the TA Screens and TU Screens. The county must review the report to ensure that appropriate action is taken on the third party resource information.

A. County Responsibility for the NCXPTR Report

The title of the weekly report is DHREHC NCHC/BCCM TPR COUNTY REP and is based on the third party resource information that is keyed into TPR Screens.

ISSUED 01/01/11-CHANGE 25-10

(VII.A.)

1. Review the County Report. The report is sorted by county, EIS District number, and by who keyed the insurance. If the county keyed the insurance, no further review of that entry is necessary. Entries keyed by HMS will indicate HMS. Entries keyed by TPR have their own code.

2. The county must determine if the entries on the report are valid or invalid/non-applicable third party resources.

a. If the insurance reported is valid, the county must evaluate for all other Medicaid categories. If ineligible, start the process to terminate the BCCM or NCHC case. See MA-3250, Breast and Cervical Cancer Medicaid or MA-3255 NC Health Choice.

b. If the insurance reported is verified invalid/non-applicable:

(1) Terminate the insurance on the TA Screen/TU Screen.

(a) If the insurance has ended, put the end date on TPR.

(b) If the recipient never had the insurance, terminate the insurance in TPR.

(2) For all invalid/non-applicable insurance complete the DMA-5055 entering information on the program affected, the recipient, the insurance, the reason not valid or non-applicable, and the county/worker. Fax the form, with attached verification, to Third Party Recovery Attn: Program Integrity Contract Administrator at (919) 715-4725. This information is needed by TPR to block further transmission of invalid insurance information.

B. NCXPTR State Report

The title of the report for state use is DHREHC NCHC/BCCM TPR STATE REP. MPRs will have access to this report and must assure that counties are working the County report, DHREHC NCHC/BCCM TPR COUNTY REP on a regular basis. This report is run the last working day of the month. It has a lag time of two months. The report at the end of March will have data from January.