Third Party Liability and Recovery

Health Management Systems, Incorporated (HMS) provides Third Party Liability (TPL) Match and Recovery Services for the New York State Office of the Medicaid Inspector General (OMIG).

Under State Contract C201501 effective 4/7/16-4/6/21, HMS identifies, verifies and recovers Medicaid overpayments from liable Third Parties for cost savings and recovery purposes. This ensures that Medicaid costs are paid by appropriate liable third parties as well as recovers paid Medicaid claims for which TPL was not known or available at the time of Medicaid payment. This is accomplished primarily through:

  • Estate and Casualty Recoveries;
  • Prepayment Insurance Verification; and
  • Third party Retroactive Recovery Projects.

 

Estate and Casualty Recoveries

HMS performs all estate and casualty recoveries for the OMIG. These activities encompass all Medicaid enrollees in fee-for-service or managed care programs.

Federal and State Law require that the Medicaid Program be the payor of last resort. Recovery of Medicaid payments made on behalf of injured individuals from persons liable for those injuries is required by section 1902(a)(25) of the Social Security Act, 42 USC 1396a(a)(25). Estate recovery from probate estates is mandated by section 1917(b) (1) (B) of the Social Security Act, 42 USC 1396p (b) (1) (B). The Medicaid Program must take all reasonable measures to determine the legal liability of third parties to pay for health care for individuals eligible for Medicaid.

Chapter 58 of the laws of 2008 amended NYS Social Services law §369 to give the State authority to make recoveries from estates, personal injury actions and other areas, as well as permitting New York State Department of Health (NYSDOH) (and thereby, OMIG) to contract with one or more entities to undertake this function (SSL §369 (7)).

View more information about HMS’ estate and casualty recovery services in NYS

If you have any questions or need assistance regarding the Estate and Casualty recovery program please contact Customer Service at:

Estate & Casualty
1-877-331-1460
Fax: 1 877-476-9126
[email protected]

NYC Casualty Only
1-844-449-3444
Fax: 1-844-449-3444
[email protected]

Prepayment Insurance Verification (PPIV)

HMS identifies and verifies new commercial insurance coverage and loads updated TPL information to the Medicaid Management Information System (MMIS). By identifying third party coverage and updating the MMIS Third Party File prior to payments made by Medicaid, claims are rejected until Third Party resources are utilized. In addition, the current contract includes Medical Support Enforcement data matching for the IV-D program in the Office of Temporary & Disability Assistance.

Third Party Retroactive Recovery Projects

HMS performs a recovery process that utilizes the known TPL liability coverage information maintained on MMIS. HMS recovery projects include provider recovery reviews; direct billing; Medicaid managed care reviews; and EPIC Program Recoveries.

HMS conducts provider recovery reviews. HMS prepares and sends reports that show claim information and comprehensive billing data to providers. The providers in turn are required to bill the insurance carrier within 90 days and submit documentation of a denial or indicate they have voided/adjusted the Medicaid claim or request that HMS submit the claim to MMIS for voiding/adjusting.

HMS also directly bills carriers. Carriers will remit checks payable to NYSDOH which are mailed or electronically transferred to a designated State controlled bank account.

HMS pursues retroactive recovery on encounter claims through both provider recovery and the direct billing process. In response to Managed Care Third Party Reviews, there are instances which providers refund a Managed Care Organization in error for recoveries due to the State. HMS records these occurrences and performs a periodic outreach to the Plans Requesting a refund.

HMS conducts a Third-Party Retroactive Recovery project on behalf of the NYS Elderly Pharmaceutical Insurance Coverage (EPIC) program. This project recovers costs associated with prescriptions erroneously billed to and paid by EPIC.