Sec. 10.20.01.11. Program Recovery and Reimbursement

A. The Department shall seek recovery in all cases when Program benefits have been incorrectly paid.

B. The Department shall accept reimbursement when voluntarily offered by a current or former recipient or someone acting on the recipient's behalf.

C. The Department may institute any proceedings that the Department considers necessary to require collection of uncollected fees.

D. The Program shall refer to the Central Collection Unit in the Department of Budget and Fiscal Planning for investigation and other appropriate action all cases in which a recipient has received coverage erroneously as a result of the action or inaction of the recipient.

E. The Department shall investigate and take appropriate action in all cases in which eligibility has been incorrectly established as a result of the action or inaction of a recipient, representative, or person acting responsibly for the recipient.

F. The Program shall require a recipient to authorize the release to the Department of all data, records, and information by insurance companies, nonprofit health service plans, providers of medical care, employers, unions, governmental agencies, and any other agencies, organizations, or individuals necessary for the Department's pursuit of third-party reimbursement. The authorization extends to all information relevant to third-party reimbursement or third-party health care coverage.

G. The Department shall collect available benefits from third parties determined liable to pay for services received under the Program.

H. A recipient who receives medical services that were or will be paid for by the Program is considered to have made assignment to the Department of the:

(1) Recipient's rights to any third-party payments for medical care; and

(2) Rights of any other individual eligible under the plan, for whom the recipient can legally make an assignment.

I. The assignment created under §H of this regulation shall be effective as long as the recipient is enrolled in the Program and remains effective for all services paid by the Program during this period of enrollment, and for those services which were erroneously provided to ineligible persons and paid for by the Program.

J. If a recipient dies, the Department may make a claim against the estate of the recipient for any unpaid fee established for that recipient in accordance with the following:

(1) Except as provided in §J(4) of this regulation, a claim shall not be made for any fee for services provided more than 3 years before the recipient died;

(2) A claim under this section is a preferred claim against the estate of a deceased recipient;

(3) The claim may be waived by the Department if, in the Department's judgment, enforcement of the claim will cause substantial hardship to dependents of the deceased; and

(4) If a responsible relative who is liable for the cost of care of the recipient has misrepresented assets or submitted fraudulent information and, by doing so, has avoided any part of the claim for the cost of care, there is no limitation on the time in which the claim may be brought against the estate.