Sec. 10.67.04.18. Third-Party Liability

A. An MCO is responsible for the identification of, and collection of, moneys owing from responsible third parties liable for the cost of medical care furnished by the MCO to enrollees.

B. Upon request from the Department or the U.S. Department of Health and Human Services, an MCO shall convey any information regarding third-party liability to the Department, to the U.S. Department of Health and Human Services, or to another MCO.

C. The Department shall notify an MCO of any third-party liability identified during the course of eligibility determination.

D. The MCO shall submit to the Department any new or changed third-party information in an automated format on a monthly basis.

E. The Department shall provide the MCOs with any new or changed information on a monthly basis in an automated format.

F. In order to facilitate the Department's and the U.S. Department of Health and Human Services' monitoring of its third-party liability collection activities, an MCO shall:

(1) Submit to the Department, on a monthly basis, reports on third-party collections and activities during the month, including but not limited to amounts the MCO has cost-avoided and recovered and current accounts receivable for all third-party liability cases;

(2) Submit to the Department, on a quarterly basis and in a format specified by the Department, amounts the MCO has cost-avoided and recovered and the number of cases the MCO has handled in each case area during the quarter;

(3) Cooperate in site inspections by either the Department or the U.S. Department of Health and Human Services for monitoring purposes; and

(4) Submit a detailed report of third-party liability collection activities including, but not limited to, cost avoidance, recovered amounts, and current amounts receivable for cases selected by the Department.

G. When both the Department and an MCO have a right of subrogation, they shall coordinate settlement negotiation, ensuring that the funds available are prorated to allow sufficient compensation to settle each party's claim amount.

H. For insurance coverage identified by an MCO with a retroactive effective date, an MCO shall comply with Insurance Article, §15-1008, Annotated Code of Maryland.

I. An MCO may not deny a provider’s request for a preauthorization solely because a recipient has, or is thought to have, third-party insurance.

J. The requirement in §I of this regulation may not apply if an MCO has a process in place to ensure that a claim will not be denied for lack of preauthorization if the claim ultimately becomes the MCO’s responsibility for one of the following reasons:

(1) The recipient does not have third-party insurance; or

(2) The service received is a noncovered service under the third-party insurance.