Third Party Liability and Recovery

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

The Vendor 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 4/7/16-4/6/25, the Vendor 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:

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

The Vendor 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.

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

The Vendor conducts provider recovery reviews. The Vendor 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 The Vendor submit the claim to MMIS for voiding/adjusting.

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

The Vendor 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. The Vendor records these occurrences and performs a periodic outreach to the Plans Requesting a refund.

The Vendor 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.

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