Current through March 20, 2024
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 12-13-7-3; IC 12-15
Sec. 15.
(a) The
following definitions are intended to apply only to this section:
(1) "Certification" means a statement
authenticated by the seal of the office.
(2) "Coordination of benefits" means all
activities by which an insurer notifies or is notified by other insurers or
Medicaid, or both, that a claim has been received, for the purpose of
establishing primary liability, if previous payment has been made on all or
part of the claim.
(3) "Final
settlement" means payment of money from a third party liable for the injury,
illness, or disease of a member whether by compromise, judgment, court order,
or restitution, which payment is intended as the total compensation for the
injury, illness, or disease caused by the liable third party.
(4) "Notice" means a written statement of the
office's claim bearing:
(A) a certification
that the person named in the notice is a member of Medicaid; and
(B) the signature of an authorized Medicaid
employee.
(5) "Office's
claim" means a statement of Medicaid payments made by the office for any
Medicaid member that has been certified by an authorized Medicaid
employee.
(b) The office
has a lien upon any money or fund payable by any third party who is or may be
liable for the medical expenses of a Medicaid member when the office provides
Medicaid. Circumstances under which the office may assert its lien include, but
are not limited to, cases where Medicaid has made payment because:
(1) payment from a third party was not
immediately available;
(2) there
are disputes and delays in the coordination of benefits;
(3) the third party was not
identified;
(4) the office
erroneously made payment before the third party or all other parties had made
payment;
(5) a court order has been
issued; or
(6) the member asserts a
claim against a third party who is or may be liable for the injury, illness, or
disease of a Medicaid applicant or member.
(c) The office, acting in behalf of the
Medicaid member, may initiate an action against a third party that is or may be
liable for the injury, illness, or disease of a Medicaid member because:
(1) the member has not done so; and
(2) the time remaining under the statute of
limitations for the action is six (6) months or less.
(d) In perfecting its lien, the office shall
take the following action before the third party makes final settlement to the
Medicaid member as total compensation for the member's injury, illness, or
disease:
(1) Serve notice:
(A) to third parties in the manner described
in subsection (e); or
(B) to
insurers in the manner described in either subsection (e)(3)(C) or (f) as
deemed appropriate by the office.
(2) File a claim that:
(A) shows the amount of payment made at the
time notice is served;
(B) is
updated at not less than yearly intervals and shows the total of all identified
expenditures and average daily cost of the individual's care;
(C) is prepared by the office's staff or is a
hard copy of computer generated claims payment records; and
(D) is certified by an authorized Medicaid
employee.
(e)
The office may perfect its lien by serving notice to third parties in the
following manner:
(1) Filing a written notice
in the Marion County Court stating the following:
(A) The name and address of the
member.
(B) That the individual is
eligible for Medicaid.
(C) The name
of the person or third party alleged to be liable to the injured, ill, or
diseased member.
(2)
Sending a copy of the notice filed in the Marion County Court by certified mail
to the third party.
(3) Sending a
copy of the notice to the following persons or entities if the appropriate
names and addresses are determined:
(A) The
member.
(B) The member's
attorney.
(C) The insurer or other
third parties.
(f) The office may serve notice to insurers
or initiate the coordination of benefits by mailing a notice to the insurer
that:
(1) is on state letterhead;
(2) is sent by certified mail; and
(3) includes, if reasonably available to the
office, the following information pertaining to the Medicaid member:
(A) Name of employer.
(B) Name of policyholder.
(C) Employee identification number.
(D) Claim certificate number.
(g) When an insurer has
received the notice specified in subsection (e)(3)(C) or (f) prior to making
payment on a claim, and the insurer is liable for part or all of a Medicaid
member's medical expenses, the insurer shall coordinate the benefits with the
office and:
(1) pay the provider of service
for bills submitted by the provider unless the office certifies that it has
already paid the bill;
(2)
reimburse the office for claims submitted by the office; or
(3) reimburse the office if the provider and
the office submit claims for the same services.
(h) An insurer that is put on notice of a
claim by the office under either subsection (g)(1), (g)(2), or (g)(3) and
proceeds to pay the claim to a person or entity other than the office is not
discharged from payment of the office's claim.
(i) Once Medicaid has been reimbursed for the
office's claim by the insurer, the insurer has discharged its responsibility
for that claim. Neither the insurer nor the member shall be held liable for any
remaining balance. For any provider seeking adjustments in payment, recourse is
limited to an administrative appeal as provided by
405 IAC 1-1.4.
(j) The rules set forth in subsection (g)
shall also apply when the member notifies the insurer that the member has
received Medicaid from the office. In this case, the insurer is required to
initiate coordination of benefits with the office.
(k) Any clause in any insurance contract that
excludes payment when the contract beneficiary is eligible for Medicaid is void
and the insurer shall make payments described in subsection (g).
(l) The office may waive its lien, at its
discretion.
Transferred from the Division of Family and Children
(470 IAC 5-1-13) to the Office of
the Secretary of Family and Social Services (405 IAC
1-1-15) by
P.L.
9-1991,
SECTION
131, effective January 1,
1992.
