Kansas Family Medical Assistance
Manual (KFMAM)
Eligibility Policy - 11/22/2024
02530
2531 - Ascertain and document legal liabilities of third parties (e.g., private or group health insurance coverage, Medicare, VA, etc.) or of pending lawsuits which might establish such a liability. We cannot require an applicant/recipient provide the information as a condition of eligibility. If partial information is known at the time of the application approval, a partial referral shall be submitted. The MMIS fiscal agent will attempt to identify the needed TPL information in order to create an accurate record. If the fiscal agent is unable to locate the record using the information provided, it is the responsibility of the agency to obtain the information from the consumer. If the consumer either refuses the information or fails to contact the agency, coverage should be denied/closed due to failure to cooperate. Good cause shall apply in instances where the consumer is unable to provide the information but shows an attempt to cooperate.
Note: Condition of eligibility in this sense indicates that Medicaid cannot be denied due to the existence of TPL or for failure to provide full information up front. It does not exempt the consumer from cooperating with the agency in obtaining the information when needed.
All existing health insurance coverage must be notated in the MMIS system. Failure to do so can result in claims being paid incorrectly or in error. However, certain third-party coverage such as Indian Health Services, VA, and Kansas Health Insurance Association coverage are not to be included on the TPL file. Third Party Liability information is captured through the application process and entered KEES. A referral is automatically sent to the MMIS upon case approval. To generate the referral, the following fields must be complete: Case Number, Client ID, Policy Holder Name, Carrier Name, and Policy ID. For partial referrals, use ‘unknown’ in the fields that are unknown at the time of application approval.
2531.01 - Inform the Medical Subrogation Unit in writing of failure of Medicaid consumers to utilize such third-party liability or of pending lawsuits, insurance settlements, etc. which might establish such liability. This is not applicable to CHIP. The Medical Subrogation referral form (Injury) shall be used to notify the unit. (See the Forms.)
2531.02 - Request assistance from Medical Subrogation Unit in writing to help obtain third party resource information from non-cooperative sources such as birth mothers, adoption agencies, or adoptive parents when a Medicaid or MediKan consumer is adopted. This is not applicable to CHIP. The Medical Subrogation referral form (Adoption) shall be used for this purpose. (See KFMAM Forms.)