(a) Providers must make a good faith effort to determine,
at the time health care items or services are delivered or at any
time thereafter, whether the health care items or services being provided
to the recipient are a result of injuries caused by a person who is
or may be liable for payment for the health care items or services.
(b) Providers must submit information relating to the
existence or possible existence of third party liability obtained
from the recipient or legal representative of the recipient at the
time a claim is submitted to HHSC for payment, or at any time thereafter,
or when an informational claim is submitted under the provisions of §354.1003
of this chapter (relating to Time Limits for Submitted Claims).
(c) Providers are required to pursue recovery from
third party resources whose liability has been established or is undisputed,
before submitting a claim for payment to HHSC unless otherwise directed
by HHSC.
(d) Providers who identify a third party resource,
within 12 months from the date of service, and wish to submit a bill,
or other written demand for payment or collection of debt to a third
party resource after a claim for payment has been submitted and paid
by HHSC, must: refund any amounts paid by Medicaid prior to submitting
a bill or other written demand for payment or collection of debt to
the third party resource for payment, and; comply with the provisions
of subsection (e) of this section. This section does not require a
refund to Medicaid or prohibit a provider from filing a statutory
provider lien prior to submitting reasonable requests for information
to a third party resource or a representative of a recipient to assess
the likelihood of recovery from a third party resource.
(e) Providers may retain a payment from a third party
resource in excess of the amount Medicaid would otherwise have paid
only if the following requirements are met:
(1) the provider submits an informational claim to
HHSC within the claim filing deadline contained in §354.1003
of this chapter indicating the identity of the third party resource
from whom recovery is being pursued;
(2) the provider gives notice to the recipient, or
the attorney or representative of the recipient, that the provider
may not or will not submit a claim for payment to Medicaid and the
provider may or will pursue a third party resource, if one is identified,
for payment of the claim. The notice must contain a prominent disclosure
that the provider is prohibited from billing the recipient or a representative
of the recipient for any Medicaid-covered services, regardless of
whether there is an eventual recovery or lack of recovery from the
third party resource or Medicaid;
(3) the provider establishes its right to payment separate
of any amounts claimed and established by the recipient; and
(4) the provider obtains a settlement or award in its
own name separate from a settlement obtained by or on behalf of the
recipient or award obtained by or on behalf of the recipient, or there
is an agreement between the recipient or attorney or representative
of the recipient and the provider, that specifies the amount which
will be paid to the provider after a settlement or award is obtained
by the recipient.
(f) Providers who have filed informational claims with
HHSC but have not made a recovery from a third party resource within
18 months from the date of service must make a choice before the end
of the 18th month from the date of service to:
(1) continue to pursue a claim against the third party
resource for payment and forego the right to submit a claim for payment
to Medicaid; or
(2) convert the informational claim to a claim for
payment from HHSC and receive payment from HHSC as payment in full
for all Medicaid-covered services.
(g) Providers who pursue a third party resource for
payment and who subsequently fail to recover from the third party
resource within 18 months from the date of service, or recover less
than the Medicaid payable amount within 18 months from the date of
service, may submit a claim for payment to HHSC for the difference
between the amount recovered and the Medicaid payable amount, only
if the requirements of subsections (d) and (e) of this section are
met.
(h) Providers are limited to the Medicaid payable amount
and the provider is required to accept the amount paid by HHSC as
payment in full if a claim for payment is submitted and paid by HHSC:
(1) before a third party resource claim is paid; and
(2) the provider failed to comply with each of the
requirements under subsections (d) and (e) of this section.
(i) Except as provided by subsection (d) of this section,
payments made by third party resources to a provider, after the provider
has been paid by HHSC, must be forwarded by the provider to HHSC for
distribution according to the provisions of §354.2334 of this
chapter (relating to Notices and Payments).
(j) Any provider who accepts Medicaid payment as payment
in full for health care items or services and retains any amount in
excess of the Medicaid payable amount from a third party resource
and conceals or fails to account to HHSC for the third party resource
amount, resulting in excessive or duplicate payment for the same health
care item or service may be referred for investigation and prosecution
for violations of state or federal Medicaid or false claims laws,
or both.
(k) Providers are prohibited from submitting a bill,
or other written demand for payment or collection of debt for any
Medicaid-covered service from an individual who the provider knows
or should know is a Medicaid eligible recipient or from the legal
representative of a recipient, regardless of whether a claim for payment
for the service is submitted to HHSC. This section does not prohibit
a provider from submitting reasonable requests for information to
a recipient, or representative of a recipient, to assist the provider
in identifying a third party resource. However, any inquiry which
would lead a reasonable person to believe that the provider was making
a demand for payment, or attempting to collect an unpaid debt, will
bring the provider within the limitations and prohibitions as follows.
(1) If a provider attempts to recover any amount from
a recipient for a Medicaid covered service, HHSC may provide for a
reduction of an amount otherwise payable to the provider in addition
to referring the provider for investigation and prosecution for violations
of state or federal Medicaid or false claims laws, or both.
(2) The amount of the reduction may be up to three
times the amount the provider sought in excess of the Medicaid payable
amount.
(l) Providers are prohibited from refusing to provide
health care items or services to a Medicaid recipient because the
recipient has a third party resource that may potentially be liable
for payment of the health care items or services.
(m) HHSC will not accept and cannot pay any claim for
payment under this section submitted after 18 months from the date
of service, regardless of whether an informational claim has been
timely filed.
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Source Note: The provisions of this §354.2322 adopted to be effective April 30, 1999, 24 TexReg 3083; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4562; amended to be effective March 28, 2004, 29 TexReg 2867; amended to be effective February 22, 2024, 49 TexReg 855 |