Alabama Administrative Code
Title 560 - ALABAMA MEDICAID AGENCY
Chapter 560-X-20 - THIRD PARTY
Section 560-X-20-.01 - Third Party Program
Universal Citation: AL Admin Code R 560-X-20-.01
Current through Register Vol. 43, No. 02, November 27, 2024
(1) General.
(a) The purpose of the Third Party
Division of Alabama Medicaid Agency is to fulfill the requirements pertaining
to third party liability and to ensure that Medicaid is the payer of last
resort.
(b) In general third party
resources are primary to Medicaid.
(c) Federal law requires that state Medicaid
agencies take all reasonable measures to identify third party resources which
may have legal/fiscal/contractual liability as a result of medical assistance
furnished to a Medicaid recipient.
(d) Where third party liability is known or
reasonably expected, the Medicaid Agency ensures that Providers collect third
party resources prior to filing Medicaid.
(e) Where Medicaid payment has not been
reduced by third party benefits, the Medicaid Agency is required to take
reasonable measures to obtain reimbursement from third parties for the cost of
medical assistance furnished to Medicaid recipients to the extent that the
third party may have legal/fiscal/contractual liability. This may be done
through post payment billing to the third party or through recoupment of
Medicaid payment from the provider who must then file with the primary
payor.
(f) Claims for services
which are filed with Medicaid and paid in full or in part by a third party will
be applied against program benefit limitations.
(2) Definitions
(a) Third Party - Any individual, entity or
program that is or may be liable (contractually or otherwise) to pay all or
part of the medical cost of any medical assistance furnished to a recipient
under a State plan. A third party benefit may be available at any time through
contract, court award, judgment, settlement, or agreement.
(b) Private insurer - a third party which may
be:
1. Any commercial insurance company
offering health or casualty insurance to individuals or groups, including both
experience-rated insurance contracts and indemnity contracts.
2. Any profit or nonprofit prepaid plan
offering either medical services or full or partial payment for the diagnosis
or treatment of an injury, disease, or disability.
3. Any organization administering health or
casualty insurance plans for professional associations, unions, fraternal
groups, employer-employee benefit plans, and any similar organization offering
these payments or services, including self-insured and self-funded
plans.
4. Any health insurer,
including group health plans, as defined in Section 607(1) of the Employee
Retirement Income Security Act of 1974, self-insured plans, service benefit
plans, managed care organizations, pharmacy benefit managers, or other parties
that are, by statute, contract, or agreement, legally responsible for payment
of a claim for a health care item or service.
Author: Wanda Wright, Administrator, Third Party Liability
Statutory Authority: Code of Ala. 1975, § 22-6-6, 42 CFR §§432, 433 and 447.20; Section 1902(a)(25), Social Security Act.
Disclaimer: These regulations may not be the most recent version. Alabama may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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