QUEST Integration – Third Party Liability (TPL)

Original Effective Date:

08/01/1994

Current Effective Date:

01/01/2015

State and federal regulations mandate that other sources of medical coverage are primary to QUEST Integration, just as they are for Medicaid. Except for EPSDT screening exams, which are exempt from this policy, QUEST Integration patients with other coverage must use their primary benefits before QUEST Integration. This includes coverages from other government programs such as Medicare and CHAMPVA.

Members with other coverage must report this coverage to their Med-QUEST Integration worker to include as part of their QUEST Integration eligibility record and appear on their QUEST Integration membership card. When checking a patient’s card, please verify any listed TPL coverage with the patient in case TPL changes or cancellations have not yet been reported to Med-QUEST Integration. If the card does not indicate other insurance, it is always a good idea to confirm this with the patient in case of unreported TPL.

TPL Changes to Eligibility Files

Members must submit written documentation of a TPL cancellation to their Med-QUEST Integration worker whenever a listed TPL is no longer in effect. Changes to TPL information are done by Med-QUEST Integration, not by HMSA’s Plan for QUEST Integration Members. Eligibility file changes are transmitted to HMSA by Med-QUEST Integration, and new cards are generated based on this updated information. Members should follow-up with their Med-QUEST Integration worker if they do not receive new cards with updated TPL information. Until TPL changes are reflected on a patient’s eligibility file, claims must be submitted with a copy of the TPL cancellation documentation or they may be delayed or denied (see QUEST – Third Party Liability – Coordination of Benefits – QUEST Integration and Other Private Insurances (Fee-for-Service Plans) and QUEST – Third Party Liability – Coordination of Benefits – QUEST and Medicare).

Providers who learn of TPL coverage that is not reflected on the card should direct the patient to report this coverage to Med-QUEST Integration. Providers also may contact QUEST Integration Provider Services with details of the other coverage. The TPL should be applied before submitting the claim to QUEST Integration, noting the name of the TPL, the policy number, subscriber’s name, and the amount of the TPL payment in the appropriate areas of the claim.

Other Liability

Medical claims for illness or injury for which a third party may be responsible should be submitted to the responsible party’s insurance carrier.

Examples of situations for which a third party may be financially responsible:

• Patient was bitten by a neighbor’s dog
• Patient fell on the front steps of a friend’s house
• Patient fell in a department store

If claims were submitted to the responsible party’s insurance carrier and subsequently denied, attach a copy of a letter denying responsibility for payment from the liability insurance carrier to the QUEST Integration claim.

Note: If the injured party subsequently receives a settlement from the responsible party, Med-QUEST Integration will recoup monies paid on behalf of the patient for claims arising from the illness or injury.

HMSA will review these documents and determine whether to pay claims on a case-by-case basis. Payment will be based on QUEST Integration benefits and the patient’s eligibility on the date of service. Any precertification requirements also will be applied.

Recoupments

If HMSA pays for services that should have been billed to a responsible third party, HMSA will recoup the payment.

CHAMPVA and CHAMPUS

CHAMPVA is the Civilian Health and Medical Program of the Department of Veterans Affairs, a benefits program for the spouse or children of a living or deceased veteran who has or had a permanent and total service-connected disability or condition. The CHAMPVA Center in Denver, Colo., administers the program, and only the CHAMPVA Center determines eligibility, authorizes benefits and processes its claims. CHAMPVA is secondary to all other health plans except a state’s medical assistance program; therefore, a claim submitted to CHAMPVA for QUEST Integration members must clearly note that QUEST Integration is a medical assistance program so that CHAMPVA benefits are applied.

CHAMPUS is the Civilian Health and Medical Program for the Uniformed Services and is administered by the Department of Defense for military retirees and the families of active duty, retired and deceased service members. All eligible beneficiaries are enrolled in the Defense Enrollment Eligibility Reporting System (DEERS), and updates are handled by the military sponsor’s nearest personnel office.

Claims Filing Deadline

Claims that are coordinated with a primary insurer must be submitted to QUEST Integration within 365 days from the date of service.

If the primary insurance payment is delayed and you are unable to submit your claim within 365 days from the date of service, you must submit a request for waiver of the filing deadline. Otherwise, the claim will be rejected due to the filing deadline. Request a waiver in writing, including the reason for the late filing and a breakdown of the dates and follow-up activities undertaken to resolve the billing. Provide a copy of the other insurance payment/denial report, as well as copies of any other documentation that supports the late filing. Send waiver requests to QUEST Integration Provider Service at:

HMSA-QUEST Integration Operations

Attn: Research & Correspondence

P. O. Box 3520

Honolulu, HI  96811-3520

Revision History