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4.10.7 Accident-Related Claims
TMHP monitors all accident claims to determine whether another resource may be liable for the medical expenses of clients with Medicaid coverage. Providers are requested to ask clients whether medical services are necessary because of accident-related injuries. If the claim is the result of an accident, providers enter the appropriate code and date in Block 10 of the CMS-1500 claim form, and Blocks 32ab to 35ab on the UB-04 CMS-1450 claim form.
If payment is immediately available from a known third party such as Workers' Compensation or PIP automobile insurance, that responsible party must be billed before Medicaid and the insurance disposition information must be filed with the Medicaid claim. If the third party payment is substantially delayed because of 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. Include the following information on these claims:
• Name and address of the TPR.
•Policy and claim number.
•Description of the accident including location, date, time, and alleged cause.
•Reason for delayed payment by the TPR.
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