D. THIRD PARTY LIABILITY CLAIMS

 

Regulation

Medi-Cal beneficiaries are required to reimburse the Medi-Cal program for costs of health care services when the beneficiary receives payment for care from a third party such as an insurance company or from a lawsuit.  This section provides policies and procedures regarding collection and processing of third party liability information.

 

 

Third Party State Notification

The Human Services Specialist (HSS) is required to notify the California Department of Health Services (CDHS) when: 

 

·       Information on the Statement of Facts or from other sources indicate potential third party liability; and

 

·       The beneficiary is eligible to Medi-Cal; and

 

·       The beneficiary intends to use Medi-Cal to pay for injury-related services; or

 

·       The beneficiary or his/her representative has initiated an insurance claim; HSS’s compensation claim; or wrongful death, malpractice, or similar civil suit against a potentially liable third party.

 

 

Transmitting Third Party Notification

Form CWC 6041 is used to transmit third party liability information to the CDHS.  The HSS will:

 

·        Provide Form CWC 6041 to the client; and

 

·        Review the form for completeness.  To be complete, Form CWC 6041 must have the following information:

 

o       Medi-Cal beneficiary’s name. If a minor, the parent/guardian’s name should also be given.

 

o       Current address and telephone number.

 

o       14-digit Medi-Cal identification number.

 

o       Social Security Number.

 

o       Date of injury.

 

o       Name, address and telephone number of third party recovery   source(s) (i.e., attorney, insurance company, etc.) [If available]

 

o       Name of person responsible for accident/injury.

 

o       Name, address, and telephone number of providers of health care and dates of service (if available).

 

o       For HSS’s compensation claims, the name, address, and phone number of the employer and the HSS’s compensation case number.  Note: The HSS must obtain as much information as possible.

     

·       File a copy of the Form CWC 6041 in the case; and

 

·       Send the original to clerical to batch and mail.

 

If additional information becomes available, send a copy of the original Form CWC 6041 with the additional information to the CDHS.

 

 

Third Party Sources

Information from any of the following sources will require evaluation of third part liability status by the HSS:

 

Statement of Facts

 

·    Is the illness/injury the responsibility of a third party?

 

·    Does the Disability Insurance Benefits (DIB) or HSSs’ compensation require HSS follow-up for third party liability?

 

·    Has the applicant received money from insurance or court settlements?

 

Forms QR7

 

Any mention of a beneficiary’s involvement in an accident or illness requires that the HSS ask about the possible third part liability. 

 

Client Information

·    Beneficiaries are to be advised of their responsibility to notify their HSS if they are involved in an accident where a third party may be liable.

 

·    The HSS should also explain that the Medi-Cal program pays costs for medical care.  When a settlement is reached through Court action or from any insurance source, Medi-Cal is to be reimbursed from the settlement.

 

 

Direct Reimburse to Beneficiary by Liable Third Party

When a beneficiary advises a HSS that he/she has received a check made out to him/her by a liable third party for services paid for by Medi-Cal, the beneficiary/client should be informed:

 

·       To not cash the check;

 

·       To endorse the check as follows: “Pay only to the order of Health Card Deposit Fund;”

 

·       To include the following information on the back of the check:

 

o       Dates, place, and items of service for which the check has been issued;

 

o       Beneficiary’s full name;

 

o       The case number; and

 

o         Address of beneficiary

 

To mail the check to:

 

                                    California Department of Health Services

                                    Casualty Unit

                                    P.O. Box 2946

                                    Sacramento, CA 95811

 

 

 

CDHS Reports to the County

When the Casualty/HSS’s Compensation Section receives payment on an account, written notification is sent to the county where the beneficiary lives.  This alerts the county that a settlement was reached which may affect the eligibility of the individual.    

 

The State has no assurance that the named individual in fact has received monies. The HSS will use this information to review, contact the client for clarification and, if necessary, recompute eligibility.