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5.2.9 Accident-Related Claims
TMHP monitors all accident claims to determine whether another resource may be liable for the medical expenses of the CSHCN Services Program clients. Providers are required to ask clients whether the medical services are necessary because of accident-related injuries. If the claim is the result of an accident, providers must indicate this information in Block 10 of the CMS-1500 claim form, or Blocks 31 through 34 on the UB-04 CMS-1450 claim form.
If payment is available from a known third party, such as personal injury protection automobile insurance, that responsible party must be billed before the CSHCN Services Program. If the third-party payment is substantially delayed due to contested liability or unresolved legal action, a claim may be submitted to TMHP for consideration of payment. TMHP processes the liability-related claim and pursues reimbursement directly from the potentially liable party on a postpayment basis.
The following information must be included on these claims:
• Name and address of the TPR
•Description of the accident including location, date, time, and alleged cause
•Reason for delayed payment by the TPR
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