About Third Party Liability Casualty Recoveries
The Pennsylvania Department of Human Services (DHS) is the sole state agency in charge of administering the Medical Assistance (MA) Program to provide health insurance benefits to eligible Pennsylvania residents. The MA Program is jointly funded with state and federal tax dollars. To ensure that DHS and the federal government do not pay for services when other coverage is or becomes available, Title XIX, § 1902(a)(25) mandates the recovery of any funds paid by MA when a responsible third party is liable for those health care costs.
Section 1902(a) (25) (A) and (G) of the Act. Section 6035(a) of the Deficit Reduction Act (DRA) amended section 1902(a)(25)(A) of the Act to clarify that the “third parties” subject to the provisions of 1902(a)(25) include: (1) self-insured plans, (2) pharmacy benefits managers (PBM), and (3) “other parties that are, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service”, including workers’ compensation, automobile insurance, and liability insurance plans. The DRA also replaced reference to “a health maintenance organization” with “a managed care organization” (MCO) in identifying the types of third parties to which the provisions of section 1902(a) (25) apply.
Title 42 of the Code of Federal Regulations, Part 433.138 and 139 and PA Public Welfare Code, Title 55, Chapters 1101.63, 1101.64 and 1101.69A provide the mandate to recover the resources available to pay the claim. In order to comply with this mandate, DHS created the Third Party Liability (TPL) Program. Public Welfare Code Title 62 P.S. § 1409, Third Party Liability – Effective 9/2/2008
62 P.S. 1409
When a third party reimburses a provider in part or in full for claims that MA paid, a refund is due the state’s MA program. Pursuant to the federal mandate, TPL identifies responsible third parties and pursues reimbursement to DHS. Pennsylvania Code, Chapter 259 governs TPL and casualty recovery rights. (Redirect to the PA Code W
Casualty Recoveries by the Division of Third Party Liability FAQ
TPL Web Portal
The Department of Human Services (DHS), Division of Third Party Liability (TPL), offers a Web Portal to allow registered business partners (requestors) to submit requests and related documents online.
Effective July 2018, DHS will be providing automated responses to registered business partners in the course of working on a case. Essentially the portal will keep an electronic record of requests to TPL and responses back to the requestor.
Certain case statuses will be shared with the requestor:
- Request is Received
- Case is Open
- Statement of Claim Requested
- Statement of Claim Available
- New Correspondence (response from TPL to requestor)
- Awaiting Reimbursement
- Check Processed
In addition, several enhancements to the existing web portal will include the following:
- Casualty, Estate and SNT forms will be updated to add more clarity.
- Requestor will be provided with the name and phone number of the Agent/Investigator assigned to the case.
Request submission through the TPL Web Portal will become mandatory in the future.
To sign up for a Business Partner account, please click here.
Once registered, your agency's administrator will be able to approve or deny access to others in your agency by clicking here.
***The first individual to register under your FEIN will become your organization's "administrator." Please refer to the below registration guide for further information.***
Once you have registered with the TPL Web Portal, you will be able to submit claims on your personal dashboard by clicking here.
To view/download the TPL Web Portal Registration User Guide, please click here.
To view/download the TPL Web Portal Dashboard User Guide, please click here.
To view/download a TPL Web Portal Tip Sheet, please click here.
Please email TPLwebportalhelpdesk@pa.gov with any questions or concerns regarding the TPL Web Portal.
Requesting a statement of claim (SOC) from DHS:
- As an attorney taking a new case, contact TPL immediately to determine if there is a claim. As soon your client has signed an agreement for you to represent them, you should then send a completed statement of claim (SOC) request form to TPL. If you wait until the case progresses and/or settles before contacting TPL, it could result in a delay due to the volume of other requests that are already in queue ahead of the new request. Click on the icon below to obtain a copy of the blank form. This form must be completed with all available information to enable TPL to begin processing. The more detailed the information provided, the less the likelihood of a delay and/or request for additional information.
- Please do not send in multiple requests for the same client and same date of incident (DOI).
- All requests are reviewed based on the date they are received.
- After TPL reviews a request , one of the following will occur:
- A casualty case is opened
- A “No Recovery” letter is sent (see Step 5)
- Additional information is requested if necessary.
- DHS provides a written response informing that there is no recovery to pursue if any of the following conditions are met:
- a. No Lien letter – Sent when client is open in a non-MA category/non-recoverable category.
- MA End letter – Sent when the client has previously received MA but the MA ended prior to the DOI.
- No Recovery letter – Sent when client has never received MA.
- PCO Referral letter – Sent when client was opened in Private Coverage Option (PCO) category for which DHS does not have first recovery rights for the accident. PCO coverage ended 8/31/2015.
- e. Managed Care Organization (MCO) Referral letter/OIG Referral – For Worker’s Compensation inquiries, this letter is sent when client was in a Managed Care Plan, as DHS does not have first rights to recovery. This letter is also sent if a client received Cash Assistance benefits only (no Medical Assistance claims have been paid), then TPL refers the correspondence to the Pennsylvania Office of Inspector General (OIG).
- If the DOI is within the last 6 months, TPL cannot create a SOC until at least 180 days have elapsed from the DOI. Providers are allotted that amount of time to timely file claims and receive payment.
- If your request is extremely time sensitive, please provide a detailed explanation to justify TPL reviewing the request ahead of others already in the queue. Send that explanation to the following email: TPL-Casualty@pa.gov
TPL staff will review your request and determine the appropriate course of action.
- If it is determined to be very time sensitive, TPL staff will acknowledge your request via email and the request will be given immediate attention.
- If TPL staff determines the request does not merit immediate attention, the request will be passed on for routine processing. You will receive an email response reporting this action.
- Once a request is reviewed and a case is opened, it is assigned to an Agent or Investigator (A/I). The assigned A/I is the official contact on the case and all future inquiries regarding the case should be directed to them.
- Should the case change hands because of staff turnover, TPL will notify you by letter of the new worker assigned to your case.
- The assigned A/I sends the requestor a subrogation letter, and if necessary also requests any additional details needed to proceed. If you have any inquiries related to your request, please contact the A/I and reference the CIS# (TPL assigned case number, which is actually your client’s MA recipient identification number) and DOI. After all necessary details have been received; the A/I will submit a request for a statement of claim to be created.
- A completed SOC includes claims paid by MA and by any MCO that the client was enrolled in relating to the incident and also any cash assistance that was paid to the recipient or paid for any child the recipient has a legal responsibility to provide for.
- When the case settles, provide the assigned A/I a proposed distribution sheet (PDS) to initiate negotiations of TPL’s claim.
- Once an agreement is reached with TPL, you will receive an agreement letter that reflects the amount due.
- Please be sure any payment sent to TPL includes your client’s CIS # and DOI (if your client has multiple DOIs). Failure to do this can slow the posting of the check or result in it getting posted to the wrong DOI.
Once a payment has been received and processed, the A/I generates an acknowledgement letter for your records.
Miscellaneous Casualty related information:
Proposed Distribution Sheet (PDS)
Attorneys must provide a proposed distribution sheet (PDS) to verify the gross amount of the award, the fees and costs, the client’s net and compare the information to the claims amount. A verbal confirmation of the settlement amount is not acceptable. Pa.R.P.C.1.15(b) requires attorney to provide DHS with a full accounting of funds in which DHS has an interest. If the PDS amount does not match the amount provided in the settlement check, DHS will not process the payment. A final distribution sheet must be submitted even when the amount of the check received matches the proposed distribution sheet amount.
Cash Assistance and Collections:
The Department’s claim for MA reimbursement may include a claim for Cash Assistance (CA) reimbursement. Under 23 Pa.C.S. §4604(d), CA must also be repaid from the proceeds of a personal injury claim and the Department has a lien to enforce this right.
Special Needs Trusts