Minnesota Administrative Rules

9505.0070 THIRD-PARTY LIABILITY.

Subpart 1.

Definition.

For purposes of parts 9505.0070 and 9505.0071, "assignment" or "assignment of benefits" means the written authorization by a person, the person's authorized representative, a policyholder, or other authorized representative, to transfer to another individual, entity, or agency his or her right or the rights of his or her dependents to medical care support or other third-party payments.

Subp. 2.

Third-party payer; primary coverage.

A third-party payer who is liable to pay all or part of the cost of a health service provided to a medical assistance applicant or recipient shall be the primary payer. The third party payer's coverage of or liability for a health service provided to a medical assistance applicant or recipient must be used to the fullest extent available before a medical assistance payment is made on the recipient's behalf.

Subp. 3.

Provider responsibility to obtain information and assignment of benefits.

The provider shall obtain information about the recipient's potential health service coverage by a third party payer from the recipient, from the recipient's responsible relative, or from the remittance advice provided by the department upon rejection of a claim because of the department's identification of a potential third-party payer. Further, the provider may obtain an assignment of benefits from the recipient, policyholder, or other authorized individual or representative. In the case of a dependent child insured under a policy held by a parent or other individual who does not have custody of the child, the provider may obtain the assignment from the individual who has custody of the child.

Subp. 4.

Provider billing; third party.

When a provider is informed by a recipient, the recipient's responsible relative or authorized representative, a local agency, or the department that the recipient has health service coverage by a third-party payer, the provider shall bill the third-party payer before seeking medical assistance payment for the health service.

Subp. 5.

Provider billing; department.

Except as in subpart 7, the provider shall not submit a claim for medical assistance payment until receiving from the third-party payer payment, partial payment, or notice that the claim has been denied. A provider may submit a claim for medical assistance payment for the difference between the amount paid by the third party and the amount payable by medical assistance in the absence of other coverage. However, no medical assistance payment will be made to a provider under contract with a private health coverage plan when the private health coverage plan calls for the provider to accept the plan's payment as payment in full. The provider who submits a claim for medical assistance payment by the department after a third-party payer has paid part of the claim or denied the claim shall submit with the claim the additional information or records required by the department to document the reason for the partial payment or denial.

Subp. 6.

Time limit for submission of claims.

A provider must submit claims to the department according to the 12-month billing requirement in part 9500.1080, subpart 2.

Subp. 7.

Provider billing; third party failure to respond.

A provider who has not received either a payment or denial notice from a third-party payer within 90 days after submitting the claim for payment may bill the medical assistance program. The provider shall submit to the department, no later than 12 months after the date of service to the recipient, a copy of the original claim to the third-party payer, documentation of two further attempts to contact the third-party payer, and any written communication the provider has received from the third-party payer.

Subp. 8.

Recovery of payments to recipients.

Notwithstanding part 9500.1080, subpart 1, a provider may bill a recipient to recover the amount of a payment received by a recipient from a third-party payer. The department is liable only to the extent that the amount payable by medical assistance exceeds the third-party liability.

Subp. 9.

[Repealed, 26 SR 977]

Statutory Authority:

MS s 256B.04; L 2000 c 340 s 17

History:

11 SR 1069; 26 SR 977

Published Electronically:

August 12, 2008