Reporting of Third Party Liability Recoveries and Costs Avoided
The managed care organization (MCO) must report third party recoveries no later than 60 days following the end of each calendar quarter, except for the fourth quarter report, which the MCO must submit no later than April 1 of the subsequent year. For example, third party recoveries and costs avoided for claims adjudicated from January 1, 2019, to March 31, 2019, are due May 30, 2019. The report must include all third party recoveries as follows:
- Four major program groups (Families and Children – Medical Assistance, MinnesotaCare, Minnesota Senior Health Options [MSHO] or Minnesota Senior Care Plus [MSC+] and Special Needs Basic Care [SNBC])
- By type of payer:
- Private health insurance
- Workers’ compensation
Note: there should be no “other” reporting without full explanation why it does not fit into one of these payer types.
- Cost avoidance or coordination of benefits
- For Medicare and private health insurance: Includes any amount the provider indicates was collected from the third party payer at the time of claims submission. We will review these amounts against reported encounter data TPL amounts.
- There should be no tort, automobile or workers’ compensation recoveries in this field without full explanation. Only rarely are there identified carriers which the provider can bill directly.
- Pay and chase or recoveries
- For Medicare and private health insurance: Includes amounts the MCO collects from a third party after the claim has been paid to the provider. This usually occurs when the MCO learns of the insurance after the claim is paid. We will review these amounts against reported encounter data TPL amounts.
- For workers’ compensation, auto or tort claim: Applies when the recipient pursues a third party or insurance company for compensation. In these instances, the MCO paid for services and intervened to recover their interest.
The MCO must certify the quarterly report pursuant to §9.10
Contract References: F&C §10.4.; MSHO/MSC+ §10.4.; SNBC §10.4.