Wyo. Code R. 048-0037-4
Medicaid
Chapter 4: Third Party Liability
Effective Date: 04/05/1989 to 06/28/1995
Rule Type: Superceded Rules & Regulations
Reference Number: 048.0037.4.04051989
health/medicaid/04_Third_Party_Liability Agency HEALTH Health, Dept. of Program MEDICAID Medicaid Chapter Name Third Party Liability
Chapter No.4
Date Filed 04/05/89 Expr Date
Supr Date
These rules are promulgated by the Department of Health and Social Services pursuant to the Medical Assistance and Services Act of 1967, as amended (W. S. 42-4-101 et seq) and the Wyoming Administrative Procedures Act, as amended (W. S. 16-3-101 et seq.).
This chapter shall apply to and govern all issues of third party liability involving the Medicaid program.
(a) 'Applicant.' A person who has submitted a written application for Medicaid, either directly or through a representative acting on his or her behalf, which has not received final action.
(b) 'Application.' An applicant's written request for Medicaid.
(c) 'Assignment of benefits.' The transfer from an applicant or recipient to the Department of the applicant's or recipient's rights to medical support or payments for services from any third party payer.
(d) 'Claim.' A request by a provider for Medicaid payment for services provided to a recipient.
(e) 'Department.' The Wyoming Department of Health and Social Services.
(f) 'Local agency.' The county office of the Division of Public Assistance and Social Services of the Department.
(g) 'Medicaid.' Medical assistance and services provided pursuant to Title XIX of the Social Security Act, as amended, and the Wyoming Medical Assistance and Services Act, as amended.
(h) 'medicare.' The health insurance program for the aged and disabled established pursuant to Title XVIII of the Social Security Act.
(i) 'Medicare crossover claim.' A claim for services provided to a recipient who is eligible for Medicare and Medicaid.
(j) 'Provider.' A person or entity that has signed a provider agreement with the Department.
(k) 'Provider agreement.' A written contract or agreement between a provider and the Department in which the provider agrees to comply with the provisions of the contract or agreement and applicable state and federal statutes and rules as conditions of participation in Medicaid.
(l) 'Recipient.' A person who has been determined eligible for Medicaid or a person formerly eligible for Medicaid on whose behalf the Medicaid program has made or is obligated to make payments of Medicaid funds.
(m) 'Right of Action.' The right or potential right of a recipient to recover from a third party payer for the costs of services provided to a recipient.
(n) 'Services.' Goods or services authorized for Medicaid payments under W. S. 42-4-103 and the rules of the Department.
(o) 'Structured settlement.' A payment scheme under which a recipient receives or will receive more than one payment of money as settlement of a right of action arising, in whole or in part, from an illness, injury or disability which has required services for which the Department has made or is obligated to make Medicaid payments. Structured settlement includes all payment schemes with more than one payment, regardless of the number of payments, the amount of the payments, the periodicity of the payments or the reason for the payments.
(p) 'Subrogation.' The succession of the Department to the rights of a recipient with respect to third party payers.
(q) 'Third party liability.' The right of a recipient to recover from a third party payer the costs of services.
(r) 'Third party payer.' A person, entity, agency or government program that may be liable to pay all or part of the costs of services provided to a recipient, including, but not limited to, Medicare, insurance companies, workers' compensation, defendants in legal actions involving recipients, and a spouse or parent who is obligated by law or court order to pay all or part of such costs.
(i) Automatic assignment of benefits. By signing an application, an applicant makes an assignment to the Department of benefits on the applicant's behalf and on behalf of any relative for whom application is made.
(ii) Effective dates of assignment of benefits. The assignment of benefits is effective upon a determination of eligibility and remains in effect with respect to services provided during the period of eligibility for Medicaid, including any period of retroactive eligibility.
(b) Payer of last resort. Medicaid will pay for services only after all sources of third party liability have been exhausted, except as provided by 42 U.S.C. 1396d(b) and Title V of the Social Security Act.
(c) Recovery of payments. If the Department pays or is or becomes obligated to pay Medicaid funds to or on behalf of a recipient because of an injury, illness or disability for which a third party payer is or becomes liable, the Department may recover the full amount of such Medicaid funds from the third party payer to the extent of such payer's liability to the recipient.
(a) Notice to applicants of assignment of benefits. At the time of application, the Department shall provide written notice to applicants of the automatic assignment of benefits pursuant to W. S. 42-4-106(b).
(b) Notice to provider of responsibilities.
(i) At the time a provider becomes enrolled in Medicaid, the Department shall give written notice to the provider of the procedures to follow in submitting claims which involve or may involve third party payers.
(ii) Within a reasonable time after the submission of a claim for which there may be a third party payer, the Department shall provide written notice to such provider, stating:
(A) The Department's right to recover any payments which have been made or which will be made in the future;
(B) The Department's right to reject any claims because of the probable existence of a third party payer; and
(C) The procedures the provider shall follow in submitting claims involving third party payers.
(a) Notification of third party payer. An applicant or recipient shall notify the local agency or the Social Security Administration or the Department of the possibility of third party liability at the time of application, at the time of an eligibility redetermination, and within ten days after any change in potential third party payers.
(b) Notice to providers. A recipient shall present his or her eligibility card to a provider at the time the recipient requests services. A recipient shall also inform a provider of the existence or possible existence of a third party payer at the time the recipient requests services from the provider and upon request from the provider.
(c) Cooperation in establishing paternity and obtaining medical support. An applicant or recipient must cooperate with the Department and local agency in establishing paternity of a child eligible for Medicaid or applying for Medicaid, and to identify and collect from any third party payer. Cooperation includes:
(i) Appearing at the Department or local agency office to provide information or evidence, under penalty of perjury, regarding paternity;
(ii) Appearing as witness at a court or other proceeding to testify regarding paternity;
(iii) Pay to the Department any support or medical care funds received that are covered by the assignment of benefits; and
(iv) Upon request from the Department or local agency, take any other reasonable steps to assist in establishing paternity, determining third party liability and securing payment from third party payers.
(d) The refusal to cooperate in establishing paternity as set forth above, or the refusal to cooperate in locating third party payers or recovering payments from such payers, shall render such person ineligible for Medicaid, except as provided in 42 C.F.R. 433.148(c) and (d).
(a) Verify and obtain information. At the time a recipient requests services from a provider, the provider shall review the recipient's eligibility card for information regarding third party payers. The provider shall ask the recipient if the information on the card is current and whether there are or may be additional third party payers. If the provider learns of a potential third party payer that is not listed on the eligibility card, the provider shall notify the Department or the local agency of that information.
(b) Notify Department of requests for information. The provider shall notify the Department or local agency of any requests for medical records or information regarding a recipient by the recipient, an attorney or any other person or entity acting on behalf of the recipient or a third party.
(i) Third party payer. When a provider is informed by a recipient, the Department or any other source that the recipient has or may have coverage by a third party payer, the provider shall seek payment from the third party payer before submitting a claim. When the amount of third party liability is less than the allowable Medicaid payment, the provider may submit a claim for the difference between the allowable Medicaid payment and the amount of third party liability. Such claim must be accompanied by documentation of the amount of third party liability.
(ii) Rejection by third party payer. The provider may submit a claim to the Department after receiving a written notice from the third party payer that a request for payment for services has been rejected. The provider must attach a copy of the notice of rejection to the claim. The Department shall allow the claim subject to its normal procedures and standards.
(iii) Failure to respond by third party payer. A provider that has not received payment or a rejection notice from a third party payer within ninety days after submitting a request for payment, may submit a claim. The provider shall submit with the claim a copy of the request for payment to the third party payer, documentation of an additional attempt to contact the third party payer, and any written communication the provider has received from the third party payer. The Department shall allow the claim subject to its normal procedures and standards.
(iv) Submission of claims after payment by third party payer. A provider that has received payment from a third party payer may submit a claim. The provider shall submit with the claim copies of the request for payment to the third party payer and documentation of the payment received. The Department shall allow such claim only to the extent the allowable Medicaid reimbursement exceeds the payment received from the third party payer and subject to the Department's normal procedures and standards.
(v) Time limit for submission of claims. A provider must submit claims to the Department within twelve months of the date of service, regardless of the potential involvement of a third party payer, except that Medicare crossover claims must be submitted within six months after the date of payment or rejection by Medicare. Claims submitted after the time limits specified in this paragraph shall be rejected.
(a) Probable existence of liability of third party payer established at time of claim. If the Department has established the probable existence of liability of a third party payer at the time a provider submits a claim, the Department shall reject the claim and return it to the provider for a determination of the amount of such liability.
(b) Probable existence of liability of third party payer not established at time of claim or unavailability of third party payments. If the Department has not established the probable existence of liability of a third party payer at the time a provider submits a claim, or if third party payments are not available at the time a provider submits a claim, the Department shall allow the claim, subject to the Department's normal procedures and standards.
(c) Establishing probable existence of liability of a third party payer. The probable existence of liability of a third party payer is established when the Department receives information, from any source, confirming the existence and extent of liability of a third party payer. When the amount of liability is established, the Department shall allow and pay claims involving third party liability only to the extent that the Medicaid payment allowed by the Department's normal procedures and standards exceeds the amount of the third party payer's liability.
(d) Third party payments are not available at the time of the submission of a claim if the existence and extent of third party payer liability is still disputed.
(a) Department subrogated to recipient' rights. In all cases where the Department has paid or is obligated to make Medicaid payments to a provider for services furnished to a recipient, the Department is subrogated to the rights of the recipient to recover from a third party payer to the extent of the amount of Medicaid payments made or to be made by the Department.
(i) Department's responsibility. Within a reasonable time after learning that a recipient is or intends to pursue a right of action, through an attorney or otherwise, the Department shall provide written notice to the recipient or the recipient's attorney of:
(A) The Department's right to recover any payments which have been made or which are made in the future;
(B) The Department's right to refuse claims because of the probable existence of a third party payer; and
(C) The requirements of this rule regarding any recovery, through litigation or otherwise, arising from a right of action involving a third party payer, conducting litigation involving a third party payer and reimbursing the Department from any such recovery.
(ii) Recipient's obligations. A recipient shall reimburse the Department for all Medicaid payments made or to be made by the Department on the recipient's behalf from any money the recipient receives from a third party payer, whether by a judgment arising out of litigation, settlement of a civil lawsuit or right of action, or in any other manner.
(b) Recovery through judgment in a civil lawsuit. If a recipient receives a judgment in a civil lawsuit arising, in whole or in part, from an illness, injury or disability which has required services for which the Department has made or is obligated to make Medicaid payments, the following standards and procedures shall apply:
(i) Notices and copies to Department. A recipient or the recipient's attorney shall provide the Department with copies of the following documents within ten days after the filing or entry of such documents with or by the court or within 10 days of the execution of such documents, if not filed with the court:
(A) The fee agreement, or, if there is no written agreement, a written memorialization of the oral agreement;
(B) All pleadings;
(C) All court orders;
(D) The verdict;
(E) The judgment;
(F) Notice of appeal; and
(G) Appellate opinions.
(ii) Allowance of attorney's fees and costs. The recipient may recover his or her attorney's fees, in an amount not to exceed one-third of the net recovery, and the necessary costs of the lawsuit incurred in obtaining the judgement. For purposes of this subsection, net recovery means the amount of the judgment minus the necessary costs of the lawsuit, excluding any attorney's fees. The recipient or the recipient's attorney shall submit an itemization of such costs at the time reimbursement is made to the Department.
(iii) Reimbursement of Department. From the money remaining after the payment of attorney's fees and costs, the recipient shall reimburse the Department for all Medicaid funds the Department has paid or is obligated to pay for services provided to the recipient arising out of such illness, injury or disability. The recipient shall reimburse the Department, regardless of how the judgment is denominated, before the payment of costs or expenses, except as provided by subsection (ii).
(iv) Payment of interest. If the recipient does not reimburse the Department within thirty days after the date the recipient receives money from the judgment, the recipient shall pay interest on the amount to which the Department is entitled at the rate of ten percent per annum, compounded quarterly, from the date the recipient received the money.
(c) Recovery through settlement of a right of action. If a recipient receives money in settlement of a right of action arising, in whole or in part, from an illness, injury or disability which has required services for which the Department has made or is or becomes obligated to make Medicaid payments, regardless of whether a civil lawsuit is filed, the following standards and procedures shall apply:
(i) Copies to Department. A recipient or the recipient's attorney, must give the Department copies of the following within ten days of the filing or entry of the documents with or by the court or within ten days of the execution of such documents, if not filed with the court:
(A) The fee agreement, or, if there is no written agreement, a written memorialization of the oral agreement;
(B) All pleadings;
(D) Settlement agreements or Stipulations; and
(ii) Allowance of attorney's fees and costs. The recipient may recover his or her attorney's fees, in an amount not to exceed one-third of the net recovery, and the necessary costs incurred in obtaining the settlement. The recipient or the recipient's attorney shall submit an itemization of such costs at the time reimbursement is made to the Department. For purposes of this subsection, net recovery means the present value of the settlement or structured settlement, minus the necessary costs incurred in obtaining the settlement, excluding any attorney's fees.
(iii) Reimbursement of Department. From the money remaining after the payment of attorney's fees and costs, the recipient shall reimburse the Department for all Medicaid funds the Department has paid or is or becomes obligated to pay for services provided to the recipient arising out of such illness, injury or disability. The recipient shall reimburse the Department, regardless of how the settlement is denominated, before the payment of costs or expenses, except as provided by subsection (ii).
(iv) Structured settlements. If the recipient enters into a structured settlement under which the initial payment to the recipient is insufficient to reimburse the Department in full for all Medicaid payments made or to be made on behalf of the recipient for such illness, injury or disability, the recipient shall pay the Department all funds received in each installment, plus interest on the outstanding balance as specified in subsection (v), until the Department is paid in full, except as provided by subsection (ii).
(v) Payment of interest. If the recipient does not reimburse the Department in full within thirty days after the date the recipient receives money from the settlement, the recipient shall pay interest on the principal amount to which the Department is entitled at the rate of ten percent per annum, compounded quarterly, from the date the recipient received the money.
(d) Failure to comply with this section. The failure of a recipient or recipient's attorney to comply with this section shall not affect the Department's right to recover from the recipient to the extent of third party liability.
(e) The Department's right to recover payments.
(i) Right to recover.
(A) The Department shall have the right to recover directly from a third party payer to the extent of Medicaid funds paid or to be paid to a provider on behalf of a recipient when the existence and extent of liability of such payer is established.
(B) The Department shall have the right to recover directly from a recipient who has received money from a third party payer to the extent of Medicaid funds paid or to be paid on behalf of such recipient for which the third party payer is liable.
(C) The Department shall have the right to recover directly from a provider that has received Medicaid funds paid on behalf of a recipient to the extent the provider has received payments from a third party payer for the same services.
(ii) Methods of recovery. The Department may attempt to recover Medicaid funds from a third party payer, a provider or a recipient by:
(A) Initiating a civil lawsuit against the third party payer, provider or recipient;
(B) Reducing any future Medicaid payments to be made to the provider to the extent the provider has received payments from a third party payer for services for which Medicaid has also paid; or
(C) Any other method of collecting a debt or obligation permitted by law.
(a) Request for reconsideration. A provider may request that the Department reconsider a decision to deny, reduce or recover payments because of third party liability. Such request must be mailed to the Department by certified mail within thirty days of the date the Department sends notice to the provider of the decision to deny, reduce or recover payments.
(b) Reconsideration. The Department shall review the decision and send written notice to the facility of its final decision within thirty days after receipt of the request for reconsideration.
(c) Appeal. A facility may appeal the final decision pursuant to Chapter I of these rules by mailing by certified mail or personally delivering a request for hearing to the Department within thirty days of the date the notice of final decision is mailed to the facility.
(d) failure to request reconsideration. A facility which fails to request reconsideration pursuant to this section may not subsequently appeal the decision to deny, reduce or recover payments pursuant to Chapter I.