Ohio Administrative Code|Rule 5160-26-09.1 | Managed health care programs: third party liability and recovery.

                                                
(A) Tort.
(1) Pursuant to sections 5160.37 and
			 5160.38 of the Revised Code, the Ohio department of medicaid (ODM) maintains
			 all rights of recovery (tort) against the liability of any third party payer
			 (TPP) for the cost of medical services.
(2) Managed care plans
			 (MCPs) are prohibited from accepting any settlement, compromise, judgment,
			 award, or recovery of any action or claim by the member.
(3)  MCPs must notify ODM and/or its
			 designated entity within fourteen calendar days of all requests for the release
			 of financial and medical records to a member or the member's
			 representative pursuant to the filing of a tort action. Notification must be
			 made via the "Notification of Third Party (tort) Request For Release"
			 form (ODM 03245, rev. 7/2014) or a method determined by the ODM designated
			 entity, provided ODM approved the designated entity's method and notified
			 MCPs.
(4) MCPs must submit a summary of
			 financial information to ODM and/or its designated entity within thirty
			 calendar days of receiving an original authorization to release a financial
			 claim statement letter from ODM pursuant to a tort action. MCPs must use the
			 "Tort Summary Statement" form (ODM 03246, rev. 7/2014) or a method
			 determined by the ODM designated entity, provided ODM has approved the
			 designated entity's method and notified MCPs. Upon request, the MCPs must
			 provide ODM and/or its designated entity with true copies of medical
			 claims.
(B) Fraud, waste, and abuse recovery. ODM assigns to MCPs its
		  rights of recovery against any TPP for costs due to provider fraud, waste, or
		  abuse as defined in rule 5160-26-01 of the Administrative Code related to each
		  member during periods of enrollment in the MCP. In instances when an MCP fails
		  to properly report suspected fraud, waste, or abuse, before the suspected
		  fraud, waste, or abuse is identified by the state of Ohio, any portion of the
		  fraud, waste, or abuse recovered by the state shall be retained by the
		  state.
(C) Coordination of benefits.
(1) ODM assigns its right to third party
			 resources (coordination of benefits) to MCPs for services rendered to each
			 member during periods of enrollment. ODM reserves the right to identify,
			 pursue, and retain any recovery of third party resources assigned to an MCP but
			 not collected by the MCP after one year from date of claim
			 payment.
(2) MCPs must act to provide coordination
			 of benefits if a member has third party resources available for the payment of
			 medical expenses for medically necessary medicaid-covered services. Such
			 expenses will be paid in accordance with this rule and sections 5160.37 and
			 5160.38 of the Revised Code.
(3) The MCP is the payer of last resort
			 when a member has third party resources available for payment of medical
			 expenses for medicaid-covered services, except: 
(a) The MCP pays after
				any TPP including medicare but before:
(i) Resources provided through the children with medical
				  handicaps program under sections 3701.021 to 3701.0210 of the Revised
				  Code.
(ii) Resources that are exempt from primary payer status
				  under federal medicaid law, 42 U.S.C. 1396 (as in effect July 1,
				  2018).
(iii) Resources provided through the state sponsored program
				  awarding reparations to victims of crime, as set forth in sections 2743.51 to
				  2743.72 of the Revised Code.
(b) The MCP pays first for preventive pediatric services
				before seeking reimbursement from any liable third party.
(4) MCPs will take reasonable measures to
			 ascertain and verify any third party resources available to a member. When an
			 MCP denies a claim due to third party liability (TPL), the MCP must timely
			 share, on the explanation of payment sent to providers, available information
			 regarding the third party resources for the purposes of coordination of
			 benefits, including:
(a) Insurance company name;
(b) Insurance company billing address for claims;
(c) Member's group number;
(d) Member's policy number; and
(e) Policy holder name.
(5) MCPs must require providers who are
			 submitting TPL claims to the MCPs to request information regarding third party
			 benefits from the member or his/her authorized representative. If the member or
			 the member's authorized representative specifies that the member has no
			 third party benefits, or the provider is unable to determine that the member
			 has third party benefits, the MCP must permit the provider to submit a claim to
			 the MCP. If, as a result of requesting the information, the provider determines
			 that third party liability exists, the MCP must allow the provider to submit a
			 claim for reimbursement if he/she first takes reasonable measures to obtain
			 third party payment as set forth in paragraph (C)(6) of this rule.
(6) The MCP must require providers to
			 take reasonable measures to obtain all third party payments and file claims
			 with all TPPs prior to billing the MCP. The MCP must permit providers who have
			 taken reasonable measures to obtain all third party payments, but who have not
			 received payment from a TPP or received partial payment, to submit a claim to
			 the MCP requesting reimbursement for rendered services.
(a) MCPs must process claims when the provider has complied with
				one or more of the following reasonable measures:
(i) The provider first submits a claim to the TPP for the
				  rendered services and does not receive a remittance advice or other
				  communication from the TPP within ninety days after the submission date. MCPs
				  may require providers to document the claim and date of the claim submission to
				  the TPP.
(ii) The provider has retained and/or submitted one of the
				  following types of documentation indicating a valid reason for non-payment for
				  the services not related to provider error:
(a) Documentation from the TPP;
(b) Documentation from the TPP's automated eligibility and
					 claim verification system;
(c) Documentation from the TPP's member benefits reference
					 guide/manual; or
(d) Any other documentation from the TPP showing there is no
					 third party benefit coverage for the rendered services.
(iii) The provider submitted a claim to the TPP and received a
				  partial payment along with a remittance advice documenting the allocation of
				  the charges.
(b) Valid reasons for non-payment from a TPP to the provider for
				a third party benefit claim include, but are not limited to:
(i) The service is not covered under the member's third
				  party benefits.
(ii) The member does not have third party benefits through the TPP
				  for the date of service.
(iii) All of the provider's billed charges or the TPP's
				  approved rate was applied, in whole or in part, to the member's third
				  party benefit deductible amount, coinsurance and/or co-payment for the TPP. The
				  provider may then submit a secondary claim to the MCP showing the appropriate
				  amount received from the TPP.
(iv) The member has not
				  met any required waiting periods, or residency requirements for his/her third
				  party benefits, or was non-compliant with the TPP's requirements in order
				  to maintain coverage.
(v) The member is a dependent of the individual with third party
				  benefits, but the benefits do not cover the individual's
				  dependents.
(vi) The member has reached the lifetime benefit maximum for the
				  medical service or third party benefits being billed to the TPP.
(vii) The TPP is disputing or contesting its liability to pay the
				  claim or cover the service.
(7) If the provider receives payment from
			 the TPP after the MCP has made payment, the MCP must require the provider to
			 repay the MCP any amount overpaid by the MCP. The MCP must not allow the
			 provider to reimburse any overpaid amounts to the member.
(8) MCPs must make available to providers
			 information on how to submit a claim that will have a zero paid amount in the
			 third party field on the claim.
(9) MCP payment for third party claims
			 will not exceed the MCP allowed amount for the service, less all third party
			 payments for the service.
(10) An MCP's timely
			 filing limits for provider claims shall be at least ninety days from the date
			 of the remittance advice that indicates adjudication or adjustment of the third
			 party claim by the TPP.
(11) MCPs must ensure that providers do
			 not hold liable or bill members in the event that the MCP cannot or will not
			 pay for covered services unless all of the specifications set forth in rule
			 5160-26-05 and rule 5160-26-11 of the Administrative Code are met. The provider
			 may not collect and/or bill the member for any difference between the MCP
			 payment and the provider's charge or request the member to share in the
			 cost through a deductible, coinsurance, co-payment, or other similar charge,
			 other than MCP co-payments as permitted in rule 5160-26-12 of the
			 Administrative Code.
(D) The MCP is required to submit
		  information regarding members with third party coverage as directed by
		  ODM.