Current through Register Vol. 41, No. 3, September 23, 2024
1. Definitions
"IEVS" - the Income and Eligibility Verification
System.
"Third Party" - any individual, entity or program that is
or may be liable to pay all or part of the expenditures for medical assistance
furnished under a State Plan.
"Title IV-A agency" - the organizational unit in the State,
the Department of Social Service, that has the responsibility for determining
eligibility for all groups covered by Medicaid.
"Title IV-D agency" - the organizational unit in the State,
the Department of Social Services, that has the responsibility for
administering or supervising the administration of a State plan for child
support enforcement under Title IV-D of the Act.
"Title XIX agency" - the organizational unit in the State
responsible for administering the implementation of programs created by the
nineteenth amending title to the Social Security Act.
"TPQY" - Third Party Information Query system administered
by the Social Security Administration.
"VEC" - the Virginia Employment Commission (the state SWICA
agency) which is the state organizational unit responsible for providing a work
ready labor force, temporary income protection to workers involuntarily
unemployed, and labor market and economic information.
2. Determining liability of third
parties.
2.1. The agency takes all
reasonable measures to determine the legal liability of third parties to pay
for care and services furnished under the Plan. The Commonwealth is a "209b"
state and all eligibility is determined by the Department of Social Services
(DSS). At a minimum, such measures include the requirements specified
below.
2.2. Health insurance
information.
A. Health insurance information
is obtained by the Title IV-A agency (DSS) during the initial application and
redetermination processes for Medicaid eligibility.
B. The information is coded on the
recipient's eligibility card and in the computer system.
C. Health insurance information may include,
but is not limited to, the policy holder's name, the relationship to the
applicant or recipient, the policy holder's social security number (SSN) and
policy number, and the name and address of the insurance company.
D. The Title XIX agency has an agreement with
the IV-A agency to collect and to transmit from the applicant or recipient
during the initial application and each redetermination process such health
insurance information as is useful in identifying legally liable third party
resources so that the Medicaid agency may process claims under the third party
liability payment procedures specified in
42 CFR
433.139 b-f. Health insurance information may
include, but is not limited to, those elements described in item C
above.
E. The Title IV-A agency
incorporates into the eligibility case file the names and SSNs of absent or
custodial parents of Medicaid recipients to the extent such information is
available.
F. Payment of health
insurance premiums when identified as cost effective.
2.3. Exchange of data.
The Title XIX agency obtains and uses information for the
purpose of determining the legal liability of third parties so that the agency
may process under the third party liability payment procedures specified in
§ 433.139 b-f, and the agency utilizes information from these
sources:
1. The Title XIX agency does
not have an agreement with SWICA or SSA wage and earning files data since the
eligibility information is obtained from the IV-A agency. The IV-A agency is
responsible for obtaining all necessary eligibility information for applicants
and uses IEVS, TPQY and VEC files.
2. The IV-A agency utilizes all wage and
earnings information appropriate to the determination of eligibility. The DSS
obtains its information through IEVS (the alternate information source allowed
by 42 CFR
433.138(d)(2)) which
obtains information from Department of Motor Vehicles (DMV), Internal Revenue
Service (IRS) and VEC. The Title IV-A agency updates the Title XIX agency's
eligibility file which is then used for claims processing.
3. The Industrial Commission of Virginia
(Workers' Compensation agency) has denied the Title XIX agency's request to
provide data matches. Documentation of such denial has been provided to the
HCFA Regional Office. The Title XIX agency will continue its efforts to obtain
data matches with this agency.
4.
Agreements to obtain data matches from the DMV (State motor vehicle accident
report files) are presently in progress.
2.4. Diagnosis and trauma code edits.
1. The Title XIX agency takes action to
identify those paid claims for Medicaid recipients that contain diagnosis codes
800-999 (ICDCM) International Classification of Disease, Ninth Revision
Clinical Modification Volume I (as updated annually), inclusive, for the
purpose of determining the legal liability of third parties so that the agency
may process claims under the third party liability payment procedures specified
in 42 CFR
433.139 b-f.
2. These system edits are used
daily.
2.5. Follow-up procedures
for identifying legally liable third party resources.
1. The Title XIX agency follows up on
information within 30 days in order to identify legally liable third party
resources for casualty cases.
a. Information
is obtained from providers, Title XIX program representatives, third party
monthly alert letters, insurance companies, attorneys, probation officers,
social service agencies, recipients, newspaper articles, and clerks of
court.
b. Information is retained
in third party case files.
c.
Within 30 days, the Title XIX agency determines the amount of monies paid for
health services rendered to injured recipients. The responsible third party is
identified and within 30 days is notified that the Commonwealth has a lien for
monies expended by the agency for the injured recipient.
d. The agency issues several lien status
letters which have 90 day reply due dates depending on the age of the accident
date, the lien amount and the agency's historical experience with the third
party or the third party's attorney.
e. After no response is received to several
lien status letters, the case is referred to the Office of the Attorney General
for investigation and/or collection.
2. The agency uses the following procedures
for trauma code edits.
a. The system produces
monthly third party alert letters from the edits' applications. In third party
alert letters, the affected recipients are requested to advise the Title XIX
agency about the necessity for their treatment and if attorneys, insurance
companies or other third parties are involved in their case. This information
is utilized within 30 days of receipt to open cases for recovery of funds where
applicable. This information is not entered into the eligibility case file
where the agency enters only the individual's health insurance coverage, but is
retained in the third party case files.
b. New information as obtained is added to
third party case files on a daily basis.
3. The Title XIX agency follows up on health
insurance information within 60 days in order to identify legally liable third
party resources and incorporates this information into the eligibility case
file so that the agency may process claims under the third party liability
payment procedures specified under § 433.139 b-f.
The health insurance information which might not be
obtained during the eligibility process can appear during invoice processing
and this information is researched and investigated and added to the recipient
eligibility file.
4. Once
an agreement with the state motor vehicle agency has been obtained, the Title
XIX agency will incorporate the procedures identifying the methods used by the
agency to identify legally liable third party resources.
2.6. Information and data exchanges.
The Title XIX agency complies with
42 CFR
433.138(h)(1) and (2) and at
the present time has a written agreement with the Title IV-D agency. No
reimbursement has been requested by the IV-D agency for reasonable costs
incurred in furnishing information to the Title XIX agency.
2.7. Reports.
The Title XIX agency will produce such reports as the
Secretary prescribes for the purpose of determining compliance under §
433.138 of the CFR and evaluating the effectiveness of the third party
liability identification system.
Statutory Authority
Social Security Act Title XIX; 42 CFR 430 to end; all
other applicable Statutory and regulatory sections.
