Third Party Resource Requirements Clause Samples

Third Party Resource Requirements. For the purposes of this Agreement, the Payor and the Provider shall abide by the requirements of the related sections of the MDHHS/PIHP Contract. Medicaid is a payer of last resort. PIHPs are required to identify and seek recovery from all other liable third parties in order to make themselves whole. Third party liability (TPL) refers to any other health insurance plan or carrier (e.g., individual, group, employer-related, self-insured or self-funded plan or commercial carrier, automobile insurance and workers compensation) or program (e.g., Medicare) that has liability for all, or part of a recipients covered benefit.

Third Party Resource Requirements. Medicaid is a payer of last resort. PIHPs are required to identify and seek recovery from all other liable third parties in order to make themselves whole. Third party liability (TPL) refers to any other health insurance plan or carrier (e.g., individual, group, employer-related, self-insured or self-funded plan or commercial carrier, automobile insurance and worker's compensation) or program (e.g., Medicare) that has liability for all or part of a recipient’s covered benefit. The PIHP shall collect any payments available from other health insurers including Medicare and private health insurance for services provided to its individuals in accordance with Section 1902(a)(25) of the Social Security Act and 42 CFR 433 Subpart D, and the Michigan Mental Health Code and Public Health Code as applicable. The PIHP shall be responsible for identifying and collecting third party liability information and may retain third party collections, as provided for in section 226a of the Michigan Mental Health Code. The PIHP must report third-party collections as required by MDCH. When a Medicaid beneficiary is also enrolled in Medicare, Medicare will be the primary payer ahead of any PIHP, if the service provided is a covered benefit under Medicare. The PIHP must make the Medicaid beneficiary whole by paying or otherwise covering all Medicare cost-sharing amounts incurred by the Medicaid beneficiary such as coinsurance, co-pays, and deductibles. In relation to Medicare-covered services, this applies whether the PIHP authorized the service or not.

Third Party Resource Requirements. For the purposes of this Agreement, the Payor and the Provider shall abide by the requirements of the related Subsections of the MDHHS/PIHP Contract. Medicaid is a payer of last resort. PIHPs are required to identify and seek recovery from all other liable third parties in order to make themselves whole. Third party liability (TPL) refers to any other health insurance plan or carrier (e.g. individual, group, employer-related, self-insured or self-funded plan or commercial carrier, automobile insurance and workers compensation) or program (e.g., Medicare) that has liability for all or part of a recipients covered benefit. Therefore, under this Agreement, the Provider, shall ensure that it and/or its subcontractors pursue, recover and apply reimbursements from all liable third party resources, as applicable, for determining the net cost per fiscal year of Medicaid specialty services required of the Provider hereunder and rendered to Medicaid eligibles, in accordance with Section 1902(a)(25) of the Social Security Act and 42 CFR 433 Subpart D, and the Michigan Mental Health Code, Public Health Code and Administrative Rules, as applicable. The Provider shall not apply Medicaid subcapitation funds to cover costs of specialty supports/services rendered to Medicaid eligibles per fiscal year under this Agreement in any instance(s) in which the Provider receives or establishes an accounts receivable in anticipation of receiving monies directly for them from a third party resource that provides for, reimburses, offsets, or otherwise covers payment retroactively, currently, or subsequently for said costs of supports/services. When a Medicaid eligible is enrolled in Medicare also, Medicare will be the primary payer ahead of Medicaid subcapitated funding payments, if the service provided under this Agreement is a covered benefit under Medicare. For Medicaid eligible recipients who have Medicare coverage, the Provider, shall be responsible for applicable Medicare co-insurance, co-pays, and deductible payments, using Medicaid subcapitated funds under the requirements of this Section, for services that the Provider is responsible for pursuant to this Agreement and for Medicare-covered services where the authorizations of such Medicare-covered services are not the responsibility of the PIHP, pursuant to the requirements of Subsection 7.8.2.4 of the MDHHS/PIHP Contract.

Third Party Resource Requirements. 55 6.6.3.5 Vouchers 55 6.7 Quality Assessment and Performance Improvement Program Standards 57 6.7.1 Quality Assessment and Performance Improvement Program 57 6.7.2 External Quality Review 57 6.7.3 Annual Effectiveness Review 57

Third Party Resource Requirements. Medicaid is a payer of last resort. PIHPs and their providers/contractors are required to identify and seek recovery from all other liable third parties in order to make themselves whole. Third party liability (TPL) refers to any other health insurance plan or carrier (e.g., individual, group, employer-related, self-insured or self-funded plan or commercial carrier, automobile insurance and worker's compensation) or program (e.g., Medicare) that has liability for all or part of a recipient’s covered benefit. The PIHP shall collect any payments available from other health insurers including Medicare and private health insurance for services provided to its individuals in accordance with Section 1902(a)(25) of the Social Security Act and 42 CFR 433 Subpart D, and the Michigan Mental Health Code and Public Health Code as applicable. The PIHP shall be responsible for identifying and collecting third party liability information and may retain third party collections, as provided for in section 226a of the Michigan Mental Health Code as applicable. The PIHP must report third-party collections as required by MDHHS. When a Medicaid beneficiary is also enrolled in Medicare, Medicare will be the primary payer ahead of any PIHP, if the service provided is a covered benefit under Medicare. The PIHP must make the Medicaid beneficiary whole by paying or otherwise covering all Medicare cost-sharing amounts incurred by the Medicaid beneficiary such as coinsurance, co-pays, and deductibles in accordance with coordination of benefit rules. In relation to Medicare-covered services, this applies whether the PIHP authorized the service or not. If the MDHHS enters into a Coordination of Benefits Agreement (CBA) with Medicare for FFS, and if the PIHP contract includes responsibility for coordination of benefits for individuals dually eligible for Medicaid and Medicare, the MDHHS requires the PIHP to enter into a CBA with Medicare and participate in the automated claims crossover process.

Third Party Resource Requirements. ABW is a payer of last resort. PIHPs are required to identify and seek recovery from all other liable third parties in order to make themselves whole. Third party liability (TPL) refers to any other health insurance plan or carrier (e.g., individual, group, employer-related, self-insured or self-funded plan or commercial carrier, automobile insurance and worker's compensation) or program (e.g., Medicare) that has liability for all or part of a recipient’s covered benefit. The PIHP shall collect any payments available from other health insurers including Medicare and private health insurance for services provided to its individuals in accordance with Section 1902(a)(25) of the Social Security Act and 42 CFR 433 Subpart D, and the Michigan Mental Health Code and Public Health Code as applicable.