Medicaid Enterprise Systems - Third Party Liability

Medicaid Management Information System (also known as "MMIS"). Suppliers awarded a contract will support one or more of the five services listed below:

1. TPL Recovery Service

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2. TPL Commercial Billing Recoupment Service

3. TPL Hospital/Physician Service

4. TPL Care Management Organization Come Behind Service

5. TPL System Module

TPL Recovery Services

The Recovery services include both the recovery process (recovery efforts) programs and the cost saving programs. The Supplier will be responsible for recovery efforts from the Casualty/Tort Subrogation program, Trust programs, Estate Recovery Program, and STABLE/ABLE program as outlined in the requirements. Additionally, the Recovery Supplier will be responsible for managing the State's HIPP and CHIPRA cost saving programs. The recovery efforts will include recovery of Medicaid expenditures from verified third parties who are liable to pay for medical expenses incurred due to trauma or accident related injuries. It will also include the recovery efforts upon the death of a Medicaid member with a trust agreement and members subject to estate recovery.

The goal of the HIPP and CHIPRA cost saving programs is to enhance cost avoidance funds for the agency, by providing health insurance premium assistance to eligible Medicaid members.

TPL Commercial Recoupment Services

The Commercial Recoupment procurement will result in a supplier that will be responsible for recouping reimbursements from other responsible health insurers or payors, where Medicaid payments have been made. Commercial billing/post-payment recoupments are considered primarily a back-up process to cost avoidance, a secondary method of recoupment. The recoupments are for claims where it is later determined that a third-party resource is responsible for the payment. Recoupments are identified by the utilization of data matching, other claims and TPL data.

One of the agency's functions is to capture the third-party insurance information from the Medicaid member during the eligibility determination and the eligibility re-determination process. The Supplier will be required to perform routine data matches with commercial carriers, other government agencies, and other alternative data resources. The Commercial recoupment core services include commercial billing, overpayment, Medicare recoupment, provider recoupment, health insurance carriers/payors recoupment and data matches/third party resources along with file maintenance

TPL Hospital Physician Services

The Supplier will be responsible for creating a weekly data match for third party resources and file maintenance. The focus of the service is to increase cost avoidance through leveraging hospital and physician data sources. The supplier will be responsible for providing data match information to the agency to ensure the agency has up-to-date information about Medicaid members. The supplier must take reasonable measures to determine the liability of the third-party payer.

CMO Come Behind Services

The Supplier will be responsible for establishing a new CMO Come Behind Services program to recoup reimbursements from responsible third-party health insurers or payers 365 days after the paid encounter claim date. Commercial recoupments, or post-payment recoupments, are considered a secondary method of recoupment to cost avoidance. Commercial recoupments are pursued for encounter claims initially paid by Medicaid and later determined to be the responsibility of a third-party resource. The Supplier must perform all come behind third-party resource identification, health insurance data matches, verification, updates, and recoupment services using information provided by the agency and additional data sources available to the supplier.

The CMO Come Behind Services program services include health insurance carrier/payer recoupment and data match/third party resources, along with file maintenance.

TPL System Module

The Third-Party Liability System Module will automate TPL functions and integrate with other Medicaid system modules, such as Claims and Eligibility. The module will provide the ability to manage cases where recovery from other liable parties takes place. Leads from various sources will be electronically captured, and the module will contain a dashboard with configurable functionality for claim and carrier bill details. The module will perform automated matching of Medicaid members coverages against external data sources to identify overlapping coverages with Medicaid. The module will automatically update third party coverage information, to ensure member information is up to date and accurate. Letters and correspondence with other liable parties, including insurance carriers, will be electronically generated, and stored.

Based on business rules, the module will generate blanket denial or TPL exemptions for provider requests. If necessary, the module will automatically send inquiries to the member or provider using the preferred method of communication. The module will automatically generate and transmit electronic bills to liable carriers. It will track carrier payments and calculate interest on unpaid carrier bills. The module will identify outstanding credit balances and automatically issue a payment demand letter to the provider of service. Funds recovered from other liable parties will be captured and transmitted to Financial modules. The module will provide access to review and update members' coverages. Additional coverage for members will be electronically captured and transmitted to the Claims module and Eligibility system to improve processing of coordination of benefits. Automated reporting will provide a view of compliance with business objectives for timely resolution of leads.