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December 2016 Texas Medicaid Provider Procedures Manual

Section 8: Third Party Liability (TPL)

Section 8: Third Party Liability (TPL)
Table of Contents
8.1 Third Party Liability (TPL) 3
8.2 Verifying a Client’s TPR 3
8.3 TPR Sources 4
8.3.1 Exceptions 5
8.3.1.1 Adoption Cases 6
8.4 Non-TPR Sources 6
8.5 TPL for Hospitals 6
8.6 TPL for Managed Care 6
8.7 Tort 7
8.7.1 Accident-Related Claims 7
8.7.1.1 Accident Resources, Refunds 8
8.7.1.2 Workers’ Compensation 8
8.7.2 Providers Filing Liens for Third Party Reimbursement 9
8.7.3 Informational Claims 9
8.7.4 Submission of Informational Claims 9
8.7.5 Informational Claim Converting to Claims for Payment 10
8.8 Other Insurance Claims Filing 10
8.8.1 Unbundled Services That Are Prior Authorized and Manually Priced Procedure Codes 11
8.8.2 Other Insurance Credits 11
8.8.2.1 Deductibles 12
8.8.2.2 HMO Copayments 12
8.8.2.3 PPO Discounts 13
8.8.2.4 Verbal Denial 13
8.8.2.5 110-Day Rule 13
8.8.2.6 Filing Deadlines 13
8.8.3 Claims Forwarded to Other Insurance Carriers 14
8.9 Other Insurance Appeals 15
8.10 Refunds Resulting from Other Insurance Payments 15
8.11 Contact Information 16
8.12 Forms 16
 

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