Third party liability refers to the legal obligation of health care sources (third party sources) to pay for all, or part, of a medical claim of a Medicaid beneficiary before Medicaid pays the claim. By law, the Medicaid program is the payer of last resort; that is, all other legally-obligated third-party sources must pay a claim before the Medicaid program pays for the care of an eligible individual. BCARS performs its TPL function in two ways: by avoiding making Medicaid payments when other commercial or public health insurance carriers should pay for a service; and by recovering Medicaid payments already made when a legally-obligated third-party source is later identified.
Preventing Medicaid payment when other health insurance coverage exists. Medicaid providers may use the ODM 06614, Health Insurance Fact Form, to inform the Cost Avoidance Unit of changes in third party insurance coverage. Forms may be faxed to: 614-728-0757.
Recovering from a liable third party for medical expenses paid by Medicaid.
Processing a claim when Medicaid is the secondary payer.
The Buy-In Unit processes Medicare Buy-In eligibility requests not updated by the county department of job and family services eligibility system. The Unit also ensures that Medicare premiums are paid for certain groups of consumers. In addition, the Unit updates, corrects and backdates Medicaid eligibility spans in the state's claims payment system (the Medicaid Management Information System or MMIS) when a county identifies an eligibility interface issue. A provider should work with the county department of job and family services when it feels an eligibility issue exists in MMIS.
Ohio's Cost Avoidance Efforts and Contractor