TITLE 1: GOVERNMENT
DIVISION 2: EXECUTIVE BRANCH
§ 20210. Third-party Liability. The Commonwealth Medicaid Agency shall assure, to the extent possible, the identification of a liable third-party to pay for services under the plan and for payment of claims involving third parties by: (a) Inquiring during the application/interview process about the probable existence of a liable third-party; (b) Requiring, as a condition of eligibility, that each legally able applicant and recipient assign his or her rights to medical support or other third-party payments to the Commonwealth Medicaid Agency and cooperate with the agency in obtaining medical support and payments; (c) Paying claims involving probable third-party liability as follows: (1) If the agency has established the probable existence of third-party liability at the time the claim is filed, the agency must reject the claim and return it to the provider for a determination on the amount of liability. When the amount of liability is determined, the agency must then pay the claim to the extent that payment allowed under the agency’s payment schedule exceeds the amount of the third-party’s payment. (2) If the probable existence of third-party liability cannot be established or third-party benefits are not available to pay the recipient’s medical expenses at the time the claim is filed, the agency must pay the full amount allowed under the agency’s payment schedule. (3) If after a claim has been paid, the agency learns of the existence of a third-party resource, the agency must seek reimbursement from the third-party within 60 days after the end of the month it learned of the existence of a liable third-party or benefits become available. (4) The Commonwealth Medicaid Agency establishes a cumulative threshold amount of not less than $50.00 for seeking reimbursement. It is not considered cost effective to seek reimbursement below this amount in any given month. Source: PL 21-28, § 2 (May 22, 2020). Commission Comment: The Commission numbered this section pursuant to 1 CMC § 3806(a).