May 4, 2007 Third Party Liability Recovery

TPL Commercial Recovery Talking Points

On May 4, 2007 the Department of Public Welfare's Division of Third Party Liability (TPL) issued a commercial insurance recovery (that encompasses some Medicare covered services as well) related to claims originally paid by Medical Assistance.

• TPL is seeking assistance from medical providers in recovering funds from third party payers who had insurance coverage obligations for Medical Assistance recipients at the time the service was delivered. The Department was not aware of the third party at the time of service delivery.
• TPL is continually identifying resources via eligibility data exchanges with carriers and Medicare. These are often identified after a claim is paid. It is a federal requirement that TPL is required to recover payments when a third party is identified. Medical Assistance (Medicaid) is to be the payer of last resort.
• It is also sometimes to the providers' advantage to bill these resources since additional reimbursement may be received from the private payer.
• The claims in this current recovery cover dates of service Oct. 1, 2003 through April 8, 2007.
• The recovery letter to providers related to this recovery includes the following: a listing of the claims and resources to bill, instructions for responding to the recovery, the deadline of July 9th, and a TPL contact name and number should the provider have questions or require an extension.
• The letters also explain our expectation that the provider attempt to bill the third party resource identified for them. Subsequently TPL will recover the money electronically. Providers are not asked to submit checks or payments as a result of any payments they receive from a third party on the claims in this recovery.
• The Public Welfare Code under §1413(b)(c)(1)(2) states insurers must honor Medical Assistance related claims presented for payment within five years of the date of service. (This will shrink to three years effective July 1, 2007.). It is recommended that providers use the letter referencing this statute when submitting the claims in this recovery to the third party payers.
• If co-insurance and deductible amounts are due, the providers can re-bill for these payments through TPL by including a new invoice with their recovery response. These claims will be processed upon completion of the recovery.
• Claims where Medicare is the only resource and the date of service is prior to Oct. 1, 2005, were inadvertently left in the recovery. These claims will not be recovered and the providers do not need to respond to these claims.
• If access to claims data may cause a delay in responding, providers are encouraged to contact TPL for an extension.
• The recovery of these funds will not occur until early September.
• If providers are encountering problems in their attempts to reach the contact designated on their recovery letter, please instruct them to send an email to thirdpartyliability@state.pa.us.