Third-Party Liability

IDAHO ADMINISTRATIVE CODE IDAPA 16.03.26 Department of Health & Welfare Medicaid Plan Benefits Section 026 Page 25 01. Determining Liability. The Department will take reasonable measures to determine liability of third parties for services rendered to a participant. (7-1-26) 02. Current Resource. The Department will treat any third-party liability as a current resource when payment by the third-party has been made or will be made within a reasonable time. (7-1-26) 03. Withholding Payment. The Department will not withhold payment because of the liability of a third party when liability cannot be currently established or available to pay the participant's medical expense. (7-1-26) 04. Seeking Third-Party Reimbursement. The Department will seek reimbursement from a third party when liability existed, but was not treated as a current resource, with the exceptions provided under this rule. The Department will seek reimbursement from a participant in any situation in which the participant has received direct payment from any third-party and not forwarded the money to the Department for services received. (7-1-26) 05. Billing Third Parties First. Medicaid providers must bill all other sources of direct third-party payment, with the following exceptions: (7-1-26) a. When the resource is a court-ordered absent parent and there are no other viable resources available, the claims will be reimbursed, and the resources billed by the Department; (7-1-26) b. Preventive pediatric care including early and periodic screening, diagnostic, and treatment services which includes: (7-1-26) i. Well Child examinations for children under age twenty-one (21) years when provided according to guidance in the Idaho Medicaid Provider Handbook; (7-1-26) ii. Diagnosis services to identify the nature of an illness or other problem by examination of the symptoms. (7-1-26) c. When PA has been approved under these rules, treatment services to control, correct, or ameliorate health problems found through diagnosis and screenings; (7-1-26) d. If the claim is for preventative pediatric care under this rule, the Department will make payment for the service provided in its fee schedule and will seek reimbursement from the third party under 42 U.S.C. 1396a(a)(25)(E). (7-1-26) 06. Accident Determination. When the participant's Medicaid card indicates private insurance or when the diagnosis indicates an accident for which private insurance is often carried, the claim will be suspended or denied until third party liability determination can occur. (7-1-26) 07. Third-Party Payments. The Department will pay the provider the lowest amount of the following: (7-1-26) a. The provider’s actual charge for the service; (7-1-26) b. The maximum allowable charge for the service as established by the Department in its pricing file; or (7-1-26) c. The third-party allowed amount minus the third-party payment, or the patient liability as indicated by the third-party. (7-1-26) 08. Subrogation of Third-Party Liability. In all cases where the Department will be required to pay for a participant who is entitled to recover any medical expenses from any third party, the Department will be subrogated to the rights of the participant to the extent of the amount of Medicaid benefits paid by the Department. (7-1-26) IDAHO ADMINISTRATIVE CODE IDAPA 16.03.26 Department of Health & Welfare Medicaid Plan Benefits Section 030 Page 26 a. If litigation or a settlement in such a claim is pursued by the Medicaid participant, the participant must notify the Department. (7-1-26) b. If the participant recovers funds from a third party, the participant must repay the amount of benefits paid by the Department. (7-1-26) 09. Subrogation of Legal Fees. (7-1-26) a. If a participant incurs the obligation to pay attorney fees and court costs for the purpose of enforcing a monetary claim to which the Department is subrogated, the amount which the Department is entitled to recover, or any lesser amount which the Department may agree to accept, will be reduced by the total amount of attorney fees and court costs paid by the participant. (7-1-26) b. If a settlement or judgment is received by the participant that does not specify which portion is for payment of medical expenses, it will be presumed that the settlement or judgment applies first to the medical expenses in an amount equal to that paid by the Department. (7-1-26) 027. – 029. (RESERVED)