SECTION 340:75-13-77. Potential payment from third party sources

  Section 447.20 of Title 42 of the Code of Federal Regulations requires that the Oklahoma Department of Human Services take all reasonable measures to ascertain liability of a third party, for example, private insurance, to pay for care and services.

(1)   Third party liability is treated as a resource if payment by a third party has been made on behalf of the recipient.

(A)   In instances where such liability is found to exist after medical assistance has been made available, the Oklahoma Health Care Authority (OHCA) seeks reimbursement to the extent of such legal liability.

(B)   If the applicant or recipient has already received payments from a third party, Form 08AD050E, Third Party Liability Resource, is completed and submitted to the OHCA Third Party Liability Unit.

(2)   The Child Welfare worker is responsible for identifying and providing all insurance information for each child. Private insurance information is provided to the custody specialist and the custody specialist is kept current on any changes in the private insurance. OHCA accesses private insurance for payment of medical claims before Medicaid pays on the claims.

340-75-13-78. Third party liability, accident, or injury

When medical services are provided to a recipient of Medicaid as the result of an accident or injury, the Child Welfare (CW) worker determines if there has been or may be monetary settlements that affect eligibility. The Oklahoma Health Care Authority (OHCA), Third Party Liability Unit checks all paid claims for potential accident or trauma related diagnosis codes and follows up on those directly with the recipient.

(1)   If the recipient fails to cooperate or does not respond to requests from OHCA, OHCA may request the local office to submit Form 08AD050E, Third Party Liability Resource.

(2)   If a recipient continues to not respond to requests for information or fails to cooperate with the CW worker, the worker suspends further benefits until the recipient has supplied the necessary information to OHCA.

[Source: Amended at 10 Ok Reg 3987, eff 7-13-93 (emergency); Amended at 11 Ok Reg 1733, eff 5-12-94; Amended at 16 Ok Reg 102, eff 10-13-98 (preemptive); Amended at 19 Ok Reg 2265, eff 6-27-02; Amended at 24 Ok Reg 1323, eff 6-1-07]