County of San Diego Health and Human Services Agency HHSA MediCal Program Guide County Responsibilities for Third Party Liability Number Page 150301 1 of 3 Revision Date June 23 2017 Background MediCal is designed by law as the payer of last resort for health care servicesbenefits Any third party that is liable for services provided to a MediCal beneficiary must reimburse MediCal for any such serviced paid for by MediCal This section is revised to update instructions for on how to electronically notify the State of Third Party Liability claims Purpose To provide the policies and procedures for collection and processing of third party liability information Policy MediCal beneficiaries must reimburse the MediCal program for costs of health care services when the beneficiary receives payment for care from a third party such as an insurance company or from a lawsuit Procedure A Criteria for Notification to the State Notify the Department of Health Care Services DHCS when Information on the Statement of Facts or from other sources indicate potential third party liability The beneficiary is eligible to and receives MediCal The beneficiary intends to use MediCal to pay for injuryrelated services The beneficiary or hisher representative has initiated an insurance claim workers compensation claim or wrongful death malpractice or similar civil suit against a potentially liable third party B Notification to the State Transmit third party liability information to the State through the DHCS website at httpwwwdhcscagovservicesPagesTPLRDPIOnlineFormsaspx Select the appropriate option on this page PI Step 1 Personal Injury Notification New Case WC Step 1 Workers Compensation Notification New Case Provide the following information Fill out the page completely however if any information is unknown leave the field blank Beneficiarys first and last name Beneficiarys date of birth Beneficiarys MediCal number Date of injury Type of accident Final date of treatment related to the injury with a MediCal provider Beneficiarys attorney information if applicable Third Party Insurance Causers information Date of settlement County of San Diego Health and Human Services Agency HHSA MediCal Program Guide County Responsibilities for Third Party Liability Number Page 150301 2 of 3 After receiving the notification DHCS will review the form and verify eligibility Once eligibility is verified the beneficiary or hisher representative and the insurers will be notified that a case has been established No other action is required by the County C Sources of Information Information from any of the following sources will require evaluation of third party liability status Source ActionQuestions Statement of Facts Is the illnessinjury the responsibility of a third party Benefits from State Disability Insurance SDI or workers compensation require followup for third party liability Has the applicant received money from insurance or court settlements Beneficiary Information Advise beneficiaries of their responsibility to notify the County if they are involved in an accident where a third party may be liable Explain that costs for medical care are paid by the MediCal program When a settlement is reached through court action or from any insurance source MediCal is to be reimbursed from the settlement D Direct Reimbursement to Beneficiary When a beneficiary reports that heshe has received a check made out to himher by a liable third party for services paid for by MediCal inform himher to take the actions below Step Action 1 Do not cash check 2 Endorse the check as Pay only to the order of Health Care Deposit Fund 3 Include the following information on the back of the check Dates places and items of service for which the check has been issued Beneficiarys full name The case number Address of beneficiary 4 Mail the check to Department of Health Care Services Recovery Unit MS 4720 PO Box 997421 Sacramento CA 958997421 Program Impacts CalWORKs CalWORKs staff must also follow this process to report Third Party Liability information to DHCS References Title 22 Section 50771 MediCal Eligibility Procedures Manual MEPM 15B County of San Diego Health and Human Services Agency HHSA MediCal Program Guide County Responsibilities for Third Party Liability Number Page 150301 3 of 3 AllCounty Letter ACL 1225 MediCal Eligibility Division Information Letter MEDIL I 1706 Sunset Date This policy will be reviewed for continuance by 06302020 Approval for Release Rick Wanne Director Eligibility Operations County of San Diego Health and Human Services Agency HHSA MediCal Program Guide State Responsibilities for Third Party Liability Number Page 150302 1 of 1 Revision Date June 23 2017 Background MediCal is designed by law as the payer of last resort for health care servicesbenefits Any third party that is liable for services provided to a MediCal beneficiary must reimburse MediCal for any such serviced paid for by MediCal This section is revised to show the actions for which the State is responsible Purpose To provide the policies that the State follows for processing third party liability information Policy A Personal Injury The DHCS Recovery Unit is responsible for personal injury investigation and recovery actions B Workers Compensation Health Management Systems is responsible for Workers Compensation investigation and recovery actions Note County involvement ends once information has been transmitted to the State Procedure C DHCS Reports to County When Health Management Systems receives payment on an account written notification Form CWC 4000 is sent to the County where the beneficiary lives This alerts the County that a settlement was reached which may affect the eligibility of the individual The State has no assurance that monies have been received by the named individual Use this information to review contact the beneficiary for clarification and if necessary recompute eligibility Program Impacts None References MediCal Eligibility Procedures Manual MEPM 15B Sunset Date This policy will be reviewed for continuance by 06302020 Approval for Release Rick Wanne Director Eligibility Operations