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Effective: December 1, 2006 |
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15.15ar1 - Third-Party Liability (TPL) (Archive) |
Archived: October 1, 2008 |
In some situations people may have coverage for all or part of their medical expenses related to an accident or injury through a third party payor. It does not have to be health insurance. This is third party liability (TPL).
The Benefit Recovery Section (BRS) of DHS assists in the coordination of TPL benefits and MA or GAMC.
Types of Third Party Liability.
Types of Third Party Liability
Examples of third party liability include but are not limited to:
l Workers' Compensation may be liable for the cost of medical care and/or subsistence related to on-the-job injuries.
l Auto insurance policies may cover medical costs related to auto accidents within certain limits.
l Homeowners or business liability policies may cover medical costs related to accidents on the home or business owner's property.
l Tort claims and lawsuits may result in court-ordered awards for recovery of medical expenses caused by another party's negligence or malpractice including but not limited to:
n Product liability.
n Medical malpractice.
n Pedestrian injuries.
Notify the Benefit Recovery Section (BRS) in the following situations:
l An applicant or enrollee currently has access to third party liability payments.
Note: BRS will coordinate payments for which the third party is liable with payments made by the health care programs.
l An applicant or enrollee has a claim, settlement, or lawsuit pending within the last six years that could result in payment of medical expenses.
Note: BRS may be able to file a claim or intervention to allow DHS to be reimbursed for medical care and/or subsistence paid by DHS while the claim, settlement or lawsuit was pending.
Do not require a Household Insurance Information Form (HIIF) for current or potential third party liability payments reported on an application.
Use the following mailing address when mailing BRS information:
DHS Benefit Recovery.
P.O. Box 64994.
St. Paul, MN 55164-0994.
Do not consider actual or potential third party liability payments to be other health insurance. TPL is not an insurance barrier to MinnesotaCare eligibility.
If someone indicates at application, renewal or between renewals that a household member has been injured on the job or in an accident follow these steps:
1. Follow up with the client to determine if there are current or potential third party liability payments.
2. Send the Accident/Injury Follow-Up Request for Information (DHS-4870) to the client if the application does not contain enough information.
Note: Do not pend an application or renewal for receipt of this information.
3. Notify BRS by sending a MAXIS email using email code BRSS. Include the following in the email:
l The enrollee’s name and Person Master Index (PMI) number.
l The date of injury.
l The type of potential TPL (auto insurance, workers’ compensation, homeowner’s insurance, etc.).
l Whether a claim or settlement is pending.
l The name and address of the parties involved including the name of any of the following as applicable:
n Attorney.
n Insurance Company
n Liable party.
Do not consider actual or potential third party liability payments to be other health insurance or a barrier to MA/GAMC eligibility.
If a client reports accidents or injuries with possible third party liability at application, renewal or between renewals follow these steps:
1. Follow up with the client to determine if there are current or potential third party liability payments.
Note: Do not pend an application or renewal for receipt of this information.
2. Enter the information on the MAXIS STAT/ACCI screen if any of the following situations are met:
l The applicant or enrollee is pursuing legal action on an old or recent injury.
l Insurance is currently paying for medical costs related to the injury.
l Potential insurance payments are available for costs associated with the injury.
l The client has an active or pending Workers' Compensation claim.
Note: BRS will generate a Work Injury Report if they receive notice of possible Workers' Compensation eligibility through an interface with the Department of Labor and Industry.
3. MAXIS will interface the information to MMIS.
l MMIS will generate and send a Medical Services Questionnaire (MSQ) (DHS-2337) to the client to be returned to BRS.
l BRS will monitor the return of the MSQ. If the client:
n Does not respond to the first MSQ, BRS will generate a second notice and send it to the worker. Go to Step 4.
n Does respond to the steps are complete.
4. Send the second MSQ request to the enrollee allowing 10 days for its return.
l If the MSQ is returned, go to Step 5.
l If the MSQ is not returned, go to Step 6.
5. Update the information in STAT/ACCI and forward the MSQ to BRS. The steps are complete.
6. Deny or close with 10-day notice if the applicant or enrollee fails to respond to the second MSQ request.
7. Notify BRS of a denial or closure due to non-response to MSQ.
l Do not deny or close benefits for children under age 18.
l Clients closed for non-cooperation with the MSQ or BRS and who then cooperate with BRS are eligible as of the first of the month of cooperation.
Example:
Mark applies for GAMC. He reports he was injured in a fall at a grocery store two years ago. He has not received any payments as a result of this injury but has retained an attorney and plans to file suit.
Action:
1. Complete the STAT/ACCI screen in MAXIS.
2. MAXIS sends an interface with the information to MMIS which generates an MSQ to the client.
Mark sends MSQ back to BRS but it has not been completed. BRS generates a second MSQ and sends it to the worker.
Action:
3. The worker sends the MSQ to the client requesting it be returned completed within 10 days.
Mark returns the completed MSQ.
Action:
4. Update the information in STAT/ACCI and forward the completed MSQ to BRS.
Example:
Jean applies for MA. She reports she was injured in an auto accident two months ago. Her auto insurance carrier is covering the costs of ongoing medical treatment related to the accident.
Action:
1. Complete the STAT/ACCI screen.
2. MAXIS sends an interface the information to MMIS which sends out the MSQ to Jean.
Jean must provide information on the auto insurance claim to BRS.
Example:
Jolene applies for MA for herself and her children. She reports that her son was treated at the emergency room for cuts and bruises sustained in a sledding accident two months ago. There are no insurance claims active or pending. Jolene does not plan to file a suit.
Action:
Do not complete the STAT/ACCI screen because there is not any potential TPL.
Example:
Bob applies for MA for himself and his family. He was injured on the job six months ago and has been unable to return to work. He receives weekly payments from Workers’ Compensation as well as coverage for medical costs related to the injury.
Action:
1. Complete the STAT/ACCI screen.
2. MAXIS sends an interface to MMIS which sends out the initial MSQ.
Bob must provide information about the injury and the Workers Compensation. The income he receives will be counted as unearned income.