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2012 Texas Medicaid Provider Procedures Manual

Medicaid Managed Care Handbook : 2. Overview of Medicaid Managed Care : 2.6 Reimbursement : 2.6.2 Third Party Liability (TPL) : 2.6.2.1 TPL Overview and Provider Responsibilities for Medicaid Managed Care Clients

2.6.2.1
The Third Party Liability program helps reduce Medicaid costs by shifting claims expenses to third party payers. Third party payers are entities or individuals that are legally responsible for paying the medical claims of Medicaid clients. As a condition of eligibility, Medicaid clients assign their rights (and the rights of any other eligible individuals on whose behalf he or she has legal authority under state law to assign such rights) to medical support and payment for medical care from any third party to Medicaid. Federal law and regulations require states to ensure Medicaid clients use all other resources available to them to pay for all or part of their medical care before turning to Medicaid. Medicaid pays only after the third party has met its legal obligation to pay (i.e., Medicaid is the payer of last resort). A third party is any individual, entity, or program that is, or may be, liable to pay for any medical assistance provided to a client under the approved state Medicaid plan. Third parties may include any of the following:
Refer to:
Form 4.4, Other Insurance Form (Vol. 1, General Information) to report a client’s changes to private health insurance.
Form 4.7, Tort Response Form (Vol. 1, General Information) to report a client’s accident or injury.
Note:
Adoption agencies or foster parents are no longer considered a TPR. Medicaid is primary in the STAR Health program (except when court-ordered to provide health insurance). This is an exception to the rule that Medicaid is payer of last resort. Providers must not bill other health insurance unless there is a court order that places this responsibility elsewhere. For THSteps or pharmacy TPL, providers must refer to the MCO, PBM, or dental plan that administers the client's managed care benefits for additional information.

Texas Medicaid & Healthcare Partnership
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