benefit recovery i 00 waht
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Benefit Recoveryinthe
Minnesota
Title XIX Prosram
Intonnatton 1
Resource
Csnter
March 1980
Health Care Financin3 Administration
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THE HEALTH CARE FINANCING ADMINISTRATION (HCFA) was established to
combine health financing and quality assurance programs into a single
agency. HCFA is responsible for the Medicare program, Federal partici-
pation in the Medicaid program, the Professional Standards Review program
and a variety of other health care quality assurance programs.
The mission of the Health Care Financing Administration is to promote the
timely delivery of appropriate, quality health care to its beneficiaries
- approximately 47 million of the nation's aged, disabled and poor. The
Agency must also ensure that program beneficiaries are aware of the
services for which they are eligible, that those services are accessible
and of high quality and that Agency policies and actions promote effi-
ciency and quality within the total health care delivery system.
THE MEDICAID/MEDICARE MANAGEMENT INSTITUTE (M/MMI), within the Health
Care Financing Administration, Bureau of Program Operations, works with
Federal, State, and contractor staff toward improved management of the
Medicaid and Medicare programs.
The M/MMI promotes program management improvements through problem
analysis and technical assistance for corrective action, and fosters
exchange of ideas and techniques through conferences, workshops, training
and publications.
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BENEFIT RECOVERY
IN THE
MINNESOTA TITLE XIX PROGRAM
MARCH 1980
BETH A. WAHTERA
MANAC2R, BENEFIT RECOVERY
DEPARTMENT OF PUBLIC WELFARE
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TABLE OF CONTENTS
CHAPTER TITLE PAGE
I. INTRODUCTION 1
II. GENERAL PROGRAM STATISTICS 3
Program Size 3
Program Costs 3
Average Cost By Selected Provider Types 3
Provider Participation 4
Health Insured Recipients 4
III. ORGANIZATIONAL STRUCTURE 5
Heal th Recovery Secti on 5
Tort Liability Section 6
Accounts Receivable Section 7
Data Control Section 8
lY. LEGISLATIVE AUTHORITY 33
Enabling Legislation 33
Recent Legal Devel opmen ts 37
Decisions of the Supreme Court 39
Legislative Analysis 40
V. CURRENT PROCEDURES 47
Collection of Health Insurance Information 47
Identification and Submission of Health
Insurance Claims 48
Health Insurance Reports 49
Identification of Other Third Party Liability 49
Uncontested Liability 51Contested Liability 52
Contested Worker' s Compensation 53
Accounting of TPL Recoveries 54
Health Insurance Recoveries 55
Other TPL Adj ustments 56
VI. OTHER HEALTH COVERAGE (OHC) FILE 89
Introduction 89
Overv i ew 89
Collection of Health Insurance Data 89
Health Insurance Billing 90
Collection of Other TPL Data 90
Accounts Receivable Function 91
OHC Input Documents 91
Health Insurance Information Form (HIIF) 91
Health Insurance Information Request Form (HIIRF) 92
Insurance Adjustments and Recoveries Form (lARF). 92
Tort Letters Closing Form (TCF) 92
General Subsystems Desi gn 99
Collection of Health Insurance Data 99
Health Insurance Billing 104
Collection of Other TPL Data 105
Accounts Receivable Processing 106
VII. SUMMARY 133
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LIST OF EXHIBITS
EXHIBIT PAGE
III-l Department of Public Welfare Organizational Chart 10
III-2 Health Care Programs Division Organizational Chart 11
III-3 Benefit Recovery Unit Organizational Chart 12
III-4 Position Description: Manager, Benefit Recovery 13-16
III-5 Position Description: Administrative Assistant 17-20
III-6 Position Description: Legal Technician 21-24
III-7 Position Description: Senior Account Clerk 25-27
III-8 Position Description: Medical Claims Analyst 28-31
IV-1 Minnesota Statutes 62A.045 35
Minnesota Statutes 256B.042 35
Minnesota Statutes 256B.37 35
Minnesota Statutes 2568.06 35
Minnesota Statutes 256B.39 35
IV-2 DPW Rule 47 (Third Party Liability) 36
IV-3 DPW Rule 47 (Premium Payment) 37
IV-4 Minnesota Statutes 176.191 38
IV-5 Minnesota Statutes 176.521 38
IV-6 Vetsch vs. Schwan's Sales Enterprises (Syllabus)
(283 NW 2nd 884; 1979) 39
IV-7 Instructional Bulletin #78-37 41-42
IV-8 Information Bulletin #79-11 43-46
V-1 Health Insurance Information Form (HIIF) 57-58
V-2 Benefit Recovery Information Form (BRIF) 59
V-3 County Instructional Bulletin #77-28 60
V-4 Third Party Liability (TPL) Codes 61
V-5 Health Insurance Claim Form (HICF) 62-63
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LIST OF EXHIBITS
EXHIBIT PAGE
V-6 Assignment of Benefits for Private Health
Care Coverage 64
V-7 Notice of Subrogation 65
V-8 Injury Codes 66
V-9 TPL Report: Work Accidents 67
V-10 TPL Report: Auto Accidents.. 68
V-11 TPL Report: Accidents - Possible Tort Liability 69
V-12 TPL Report: Diagnosis Reflects Possible Tort Liability.... 70
V-13 Accident/ Injury Inquiry 71-72
V-14 TPL File Summary 73
V-15 TPL Cover Letter 74
V-16 Notification of Potential Interest 75
V-17 Assigned Claims Bureau - Application of Benefits 76
V-18 Medical, Surgical, Hospital Lien 77-78
V-19 Workers' Compensation Petition to Intervene 79-80
V-20 Daily Receipts Register 81
V-21 Multiple Adjustment Form 82
V-22 A/R Copy - Health Insurance Claim Form 83
V-23 Recipient Adjustment Form 84
V-24 Third Party Participation Report 85
V-25 Adjustment Report 86
V-26 Third Party Payment Analysis Report 87
V-27 Total Report 88
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LIST OF EXHIBITS
EXHIBIT PAGE
VI-1 Health Insurance Information Form 93-94
VI-2 Health Insurance Information Request Form 95-96
VI-3 Insurance Adjustments and Recoveries Form 97
VI-4 Tort Letters Closing Entries Form 98
VI-5 Health Insurance Claim Form Purged Cases Listing 107
VI-6 Insurance Adjustments and Recoveries Form/Health
Insurance Claim Form Match Data Report 108
VI-7 Insurance Adjustments and Recoveries Form/HealthInsurance Claim Form Match Exceptions Listing 109
VI-8 Insurance Adjustments and Recoveries Form/Excess
Recoveries Listing 110
VI-9 Other Health Coverage/Case Information
Match Data Report Ill
VI -10 Worker Message Listing 112
VI-11 Possible Insurance Coverage Listing 113
VI-12 Insurance Possibly No Longer In Force 114
VI-1 3 Adjustments Requested to Insured Claims 115
VI-14 Other Health Coverage/Adjudicated Claims
File Match Data 116
VI -15 Medical Assistance Identification Number/File Number Cross
Reference Listing 117
VI-16 File Number/Medical Assistance Identification NumberCross Reference Listing 118
VI-17 Recipient Name/File Number Cross Reference Microfiche 119
VI-18 Potential Tort Liability Claims Listing 120
VI -19 New Tort Claims File/Tort History File
Match Data 121
VI-20 Tort Claims Reference Microfiche 122
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LIST OF EXHIBITS
EXHIBIT PAGE
VI-21 Tort Claims Accident/Injury Inquiry 123-124
VI-22 Age of Health Insurance Claim Form RecordsAwai ti ng Resol uti on 1 25
YI-22a (Carrier Specific) 126
VI-23 Age of Health Insurance Claim Form Records
at Time of Denial 127
VI-23a (Carrier Specific) 128
VI-24 Age of Health Insurance Claim Form Records
at Time of Collection 129
VI-24a (Carrier Speci fic ) 1 30
Vl-25 Health Insurance Claim Form Accounts
Receivable Case Microfiche 131
VI-26 Health Insurance Claim Form Accounts
Recei vabl e Summary Report 1 32
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CHAPTER I
INTRODUCTION
The Minnesota Benefit Recovery Unit was considered fully
operational as of December 1975. It was at that time that system
enhancements first facilitated the generation of the Health Insurance
Claim form and the identification of paid invoices for which potential
third party liability existed. As a result, the State's approach
to TPL utilization drastically changed from the interim procedures
of manually monitoring the existence of TPL to the present
approach of performing post payment recovery for those invoices
paid by Title XIX funds, but for which the provider has not
pursued TPL.
In fiscal year 1979, $10.3 million was collected in third party
payments. This figure does not include estate and excess asset
recoveries which are recovered at the county level but accounted
for by the Benefit Recovery Unit. The total amount of these
recoveries was $2.6 million during that fiscal year. Minnesota
does not consider Medicare dollars as TPL related and therefore,
these figures are not included in the $10.3 million. Expenditures
directly attributable to the Benefit Recovery operation during
fiscal year 1979 were $263,304 at a staffing complement of 19.
A very important point in reviewing the third party operation in
Minnesota is that the State has not taken a strict post payment
recovery approach. The provider is given an option in the utiliza-
tion of third party resources in that he/she may bill the insurance
carrier in lieu of billing Medical Assistance (MA). It has been
our experience that some providers, primarily the inpatient hospital
group, bill the insurance carrier in cases where they are aware that
existing insurance will pay more or equal to that of the MA reimburse-
ment rate. For this reason, there exists an unknown amount of
additional TPL dollars that are, in fact, cost avoided . Inasmuch
as the bill is never submitted to MA, however, this amount cannot
be determined. This holds true for all States.
Hopefully, the information contained in this document will
accomplish the following three objectives:
(1) Provide adequate descriptions of current TPL
procedures and policies that have substantially
changed since the publication of the 1977 document
without being of insufficient detail nor inundating
the reader.
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(2) Provide a generalized overview of the Minnesota
Title XIX program and the Benefit Recovery
Unit to be used as a reference point in
conjunction with the more detailed aspectsof third party as contained herein.
(3) Provide detail and description of the present
status of the activity, specifically the
implementation of the OHC file.
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PROGRAM SIZE
CHAPTER II
GENERAL PROGRAM STATISTICS
Fiscal Year 1978 Fiscal Year 1979
MA eligible (monthly average) (monthly average)
individuals 206,808 200,813
Cases 118,737 117,761
This represents a 2.9% decrease in the number of individuals
eligible for Medical Assistance in Minnesota for fiscal year 1979,
as compared to fiscal year 1978.
PROGRAM COSTS
Fiscal Year 1978 Fiscal Year 1979
407,486,535 461,615,000
This reflects a 13.3% increase in fiscal year 1979 as compared
to fiscal year 1978. (In addition to all Federally required
services, Minnesota also provides coverage for all additional
services for which Federal financial participation is received.)
AVERAGE COST BY SELECTED PROVIDER TYPES
Fiscal Year 1978
Inpatient hospital
(per day)
155.41
Physician(per visit or service)
15.25
Dental
(per visit or service)
13.59
Outpatient hospital
(per visit)
16.90
Fiscal Year 1979
166.79
16.15
14.87
17.58
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PROVIDER PARTICIPATION
In 1979, 22,002 providers were enrolled in the Minnesota
Medicaid program. Of all providers licensed to practice in the
State, the program participation rate by selected provider types
is:
Provider Participation Rate
Hospitals
Physicians
Dentists
Nursing Homes
Optometrists
Chiropractor
Pharmacy
HEALTH INSURED RECIPIENTS
In December 1979, 13.30% of the recipients in Minnesota were
identified as being insured by some type of health policy.
100%
90%
84%
98%
100%
90%
100%
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CHAPTER III
ORGANIZATIONAL STRUCTURE
The Benefit Recovery Unit is located within the Health Care
Programs Division (formerly the Medical Assistance Division) of
the Bureau of Income Maintenance in the Department of Public
Welfare. (See organizational charts Exhibits III-l through 3.)
The unit itself is divided into four sections:
Health Recovery
Tort Liabil ity
Accounts Receivable
Data Control
The duties, responsibilities and staffing of each section
are as follows:
HEALTH RECOVERY SECTION
Staffing: 1 Medical Claims Analyst Supervisor
1 Medical Claims Analyst Senior
3 Medical Claims Analysts
This section is primarily responsible for the recovery of
health insurance proceeds due the Title XIX program. It is the
responsibility of the Medical Claims Analysts to:
(1) Ensure the complete health insurance information
exists in the health file to facilitate health
billing.
(2) Obtain additional information as needed by the
insurance carriers for the processing of claims.
(3) Visually identify whenever possible those health
insurance claims that are not insurancereimbursable.
(4) Ensure that the health file is correctly updated
from responses received by insurance carriers.
(5) Ensure that the county is notified of any changes
in insurance coverage which would require Case Infor-
mation (CI) file updates.
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(6) Pursue recovery from providers, Title XIX
recipients, and policyholders to whom health
insurance benefits were paid in error.
(7) Review health insurance policies for cost-
effectiveness when submitted for premium payment
consideration.
(8) Ensure that all billable Health Insurance Claim
forms are submitted correctly and in a timely manner.
The Medical Claims Analyst classification requires experience
in the insurance industry or a health care related field, and/or
knowledge in medical billing or medical terminology.
TORT LIABILITY SECTION
Staffing: 1 Legal Technician (Supervisor)
1 Medical Claims Analyst
1 Clerk II
This section is primarily responsible for obtaining all
pertinent information necessary for the determination of other
liability and for pursuing recoupment from the financially
liable resource as appropriate. It is the responsibility of
the Clerk II to:
(1) Identify all Medical Assistance recipients from Worker's
Compensation pre-trial dockets.
(2) Prepare for mailing all accident/injury inquiries
to recipients.
(3) Document all accident/injury responses.
(4) Obtain all Title XIX medical payment documentation
as needed.
(5) Perform all other support activities as necessary.
It is the responsibility of the Medical Claims Analyst to:
(1) Identify those accident/injury responses for which a
potential third party may exist.
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(2) Obtain additional information as needed from appro-
priate sources to enable accurate identification of TPL.
(3) Identify all related medical care payments as reflected
on the Master Claims History.
(4) Determine the extent, if any, of future related medical
care.
(5) Ensure that the Department's interests are protected
through the appropriate legal means.
(6) Ensure that all interested parties are promptly notified
of the Department's interests.
(7) Ensure that accurate reimbursement due the Departmentis obtained.
(8) Refer to the Legal Technician all cases of a difficult
nature and/or requiring legal expertise.
In addition to those responsibilities listed for the Medical
Claims Analyst, it is the responsibility of the Legal Technician
to:
(1) Keep apprised of legal developments pertaining to the
third party operation.
(2) Negotiate settlements with attorneys so as to maximize
Title XIX recoveries.
(3) Provide guidance, supervision and legal expertise to
Tort Section personnel.
(4) Report to the Manager on the status of settlement
negotiations, legal decisions, etc.
(5) Refer all settlement offers to the Manager for approval.
ACCOUNTS RECEIVABLE SECTION
Staffing: 1 Account Clerk Senior (Supervisor)
2 Account Clerks
1 Clerk II
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This section is primarily responsible for the accurate
accounting of all third party recoveries and health insurance
denials. It is the responsibility of the Clerk II to:
(1) Ensure that all properly identified health insurance
checks are accurately matched with the corresponding
accounts/receivable copy of the Health Insurance Claim
form.
(2) Ensure that all adjustments are accurately entered
into the system so as to reflect in Master History.
(3) Ensure that all deposit slips/checks have been properly
recorded by the Accounting Division.
In addition to the responsibilities outlined for the Clerk II
position, it is the responsibility of the Account Clerks to:
(1) Thoroughly research all checks/denials that are not
readily identifiable.
(2) Obtain additional information as necessary to properly
identify checks/denials.
It is the responsibility of the Accounts Receivable Super-
visor to:
(1) Ensure that efficient and effective procedures are
maintained so as to enable timely and accurate
accounting of recoveries and denials.
(2) Ensure that efficient procedures exist between the
Invoice Processing Division, Accounting Division,
county workers, and others who interface with the
Accounts Receivable Section's activities.
(3) To report to the Manager on the status of the Accounts
Receivable Section.
DATA CONTROL SECTION
Staffing: Administrative Assistant (Supervisor)
1 Clerk Typist Intermediate
2 Clerk Typists
2 Student Workers (as needed)
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This section is primarily responsible for performing all
support activities related to the unit. It is the responsibility
of the section to:
(1
(2
(3
(4
(5
(6
It
(1
(2
(3
(4
Thi
(1
(2
(3
(4
(5
Properly maintain the health insurance files.
Disseminate all incoming mail.
Perform all typing.
Properly account for all incoming Health Insurance
Information forms and assignments.
Obtain additional information as requested by the
Health Recovery Section for health insurance billing.
Communicate with county personnel as necessary.
is the responsibility of the Administrative Assistant to:
Ensure that effective and efficient procedures are
maintained within the Data Control Section and between
all interfacing sections, divisions, local agencies.
Analyze third party statistics from monthly financial
reports and compile reports from such data.
Perform research and compile reports as assigned.
Assist in and/or conduct training seminars as needed.
s chapter also includes examples of position descriptions for:
Manager, Benefit Recovery - (Exhibit III-4)
Administrative Assistant - (Exhibit III-5)
Legal Technician - (Exhibit III-6)
Senior Account Clerk - (Exhibit III-7)
Medical Claims Analyst - (Exhibit III-8)
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Exhibit III-l
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Ejdiibit III-2
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Exhibit III-4
State of Minnesota A
POSITION DESCRIPTION A
EMPLOYEE'S NAME
AGENCY/DIVISION
Public Welfare/Incone Maintenance
ACTIVITY
Benefit Recovery
CLASSIFICATION TITLE
Medical Payment Recovery
Supervisor
WORKING TITLE (if different)
Manager
POSITION CONTROL NUMBER
PREPARED BY PREVIOUS INCUMBENT APPRAISAL
PERIOD to
EMPLOYEE'S SIGNATURE (this position description
accurately reflects my current iob>
DATE SUPERVISOR'S SIGNATURE (this position description
reflects the employee's current job)
DATE
POSITION PURPOSE
This position exists to administer the Benefit Recovery Program and ensure its ongoing
development in order to facilitate maximum utilization and recoupment of all third
party resources available for payment of medical expenses incurred by Title XIX
recipients.
REP0RTA8ILITY
Reports to:Qirector. Medical Assistance
Supervises: Staff of 18: Medical Claims Analyst Supervisor, Legal Technician, SeniorAccount Clerk, Executive I, Clerk II (2), Clerk Typist (3),
Clerk Typist Senior, Medical Claims Analyst (5), Account Clerk(2
Medical Claims Analyst Senior
DIMENSIONS
Budget:
Clientele:
$283,378
211,000 Title XIX recipients
87 counties
14,178 Providers
Health insurers, No-Fault auto insurers. Worker's Compensation insurers,
and other casualty/liability insurers throughout the country.
(3-78) WHITS: Employee YELLOW: Supervisor BLUE: Agency personnel office SALMON: Dept. of Personnel
13
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Exhibit III-4
(continued)
POSITION DDESCRIPTION D
EMPLOYEE'S NAME POSITION CONTROL NUMBER
596200
Resp
No.
1.
2.
3.
4.
PRINCIPAL RESPONSIBILITIES, TASKS AND PERFORMANCE INDICATORS
It is my responsibility tc ensure that existing recovery proceduresare followed so that taxpayer dollars in the Title XIX program are
reduced.
1. Maintain procedures for collecting health insurance information
on Title XIX recipients.
2. Maintain procedures for identifying potential third partyliability situations.
3. Maintain procedures for adequate investigation and determination
of liable party.
4. Maintain procedures for recouping funds through the appropriate
recovery means, i.e. filing medical -surgical liens; Worker's
Compensation interventions; direct billing to health insurance
carriers.
5. Maintain procedures to ensure that satisfactory reimbursement
to the Department of Public Welfare is achieved through
negotiations, etc.6. Promote payrrant of cost effective health insurance policies.
It is rriy responsibility to evaluate and monitor the Benefit Recovery
operation on an ongoing basis so that maximum efficiency and
effectiveness is realized.
1. Review monthly MARS reports which reflect third party liability
recoveries.
2. Evaluate on a monthly basis recoveries made to date.
3. Implement internal procedural changes as needed.
4. Propose policy/system changes as needed.
5. Ensure that computer support system meets the operation's needs.
6. Report to MA Director on a monthly basis.
It is my responsibility to ensure that the Department is in compli-
ance with federal regulations and state law in regard to the third
party liability aspect of Title XIX so that MA is the payor of
last resort.
1. Keep apprised of recent and/or proposed legislation which direct-
ly or indirectly impacts the operation.
2. Consult with both The Attorney General's office and federal
representatives regarding policy and/or procedural matters.
3. Plan, direct and implement procedures or revisions as required
by legislation.
4. Seek additional legislation as needed to further the objectives
and goals of the operation.
It is my responsibility to disseminate information and provide
technical assistance to all parties involved in the BR function
so that the objectives of the operation are achieved.
1. Conduct training seminars for county personnel.
2. Determine cost-effectiveness of health insurance policies.
3. Compose Policy and Instructional Bulletins to reiterate
procedure/policy and/or advise parties of new procedures/policy.
4. Maintain ongoing communications with third party liability
personnel at federal level and in other states.
Keep apprised of activities within Invoice Processing, Policy,
etc. which may impace the BR operation.5.
Priority %ofTime
Discretion
25% A
15%
A 15%
15% A
PE-00042-02 (3-78) WHITE: employee YELLOW: Supervisor BLUE: Agency personnel office SALMON: Dept of Personnel
14
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Exhibit II1-4
(continued)
POSITION nDESCRIPTION D
EMPLOYEE'S NAME POSITION CONTROL NUMBER
596200
Resp.
No
5.
PRINCIPAL RESPONSIBILITIES, TASKS AND PERFORMANCE INDICATORS
It 1s my responsibility to ensure that the OHC File is successfully
implemented so that maximum recoveries may be realized through itsuse.
1. Plan and establish ongoing procedures necessary for full
implementation of the system.
2. Provide specifications for the system to support systems
liason person.
3. Consult with systems staff as needed.
It Is my responsibility to provide supervision to the Benefit
Recovery personnel so that the unit operates effectively and
efficiently.
1. Establish specific goals and objectives to be met by each section
of the unit.
2. Evaluate the ongoing activities of each unit on a weekly basis.
3. Provide assistance and direction to BR staff.
4. Ensure that adequate training needs for staff members are met.
5. Administer and monitor the functions of the unit.
6. Maintain both full staff and supervisor meetings on a scheduled
basis or as needed.
Priority % of Discretion
Time
15%
15%
(3-78) WHITS: Employee YELLOW: Supervisor BLUE: Agency personnel office SALMON: Dept. of Personnel
15
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Exhibit III-4
(continued)
POSITION CDESCRIPTION L
EMPLOYEE'S NAME POSITION CONTROL NUMBER
596200
NATURE AND SCOPE (relationships; knowledges, skills and abilities; problem solving and creativity; and freedom to act.)
Nature and Scope :
Relationships: Comnunicate verbally and in writing with all appropriate parties invol-
ved in third party function. This includes writing policy, provider and instructional
bulletins as well as conducting training seminars and preparing and compiling trainingmaterials and handouts. Parties with which communications must be maintained are:
county agency staff, medical providers, insurance carriers, other state agencies, regional
and central office federal government staff, lav/yers. Health Insurance Association of
America, provider groups such as Clinic Managers Association, Title XIX recipients, and
personnel in other divisions of DPW.
Skills, Knowledge and Abilities :
Requires extensive knowledge of technical and administrative aspects of the various
types of insurance and other liability situations. Requires verbal and written communi-
cation skills and adeptness in human relation techniques. Requires ability to exercise
good judgement as well as supervisory abilities.
Insurance background is vital to effectively determine and pursue utilization of
assailable benefits. Insurance knowledge is required in establishing procedures and
policies with various insurance carriers amenable to all parties to facilitate reimburse-
ment due the Department. Verbal and written communication skills are vital to ensure
effective and accurate dissemination of information relative to the operation. The
ability to exercise good judgement is required in many facets of this position. Primarily
however, this ability is of utmost importance in determining liability situations which
are cost-effective to warrant investigation and in negotiating and agreeing on compromised
settlements on the Department's behalf. Supervisory abilities are necessary to ensure
that proper and effective utilization of human resources is achieved whereby, through
such utilization, the goals and objectives of the operation are met.
Problem Solving :
The type of problems incurred in this position are as follows:
1. Problems relating to the insurance industry and other third party payors.
2. Problems relating to computer support system.
3. Problems relating to legislation involving the third party function.
4. Problems relating to county interaction with Benefit Recovery.
5. Problems relating to BR's interface with other operations within the Department.
Problems relating to the abovementioned five areas are routinely handled by this position.
Should satisfactory results not occur, however, certain problems would be referred to a
higher authority on a case by case basis. Some examples which would be referred
accordingly are:
1. Problems relating to conflicting interpretaion of legislative intent would be
referred to Attorney General's office.
2. Problems relating to Benefit Recovery's interface with other divisions would be
referred to the MA Division director.
Many opportunities for creatinifty exist inasmuch as the operation is relatively new and
certain aspects of it may not have previously surfaced or existed. This position can
exercise creativity in dealing with such aspects of the operation. Creativity may also
be exercised in establishing new procedures required by legislative and/or program
changes. Creativity can also be used in problem-solving matters.
Freedom to Act :, , , ^ ^ ^ ^ ^
—Reports to MA Director on a monthly basis via written monthly status reports, and repor-qs
on a written or verbal basis as needed on other matters which may arise requiring his
attention, approval, etc.. ^ ^ -, ^ ^^ • *u
Freedom to actis bounded by the federal regulations and state laws defining the
responsibilities and authorities of the Benefit Recovery operation within the Title XIX
Program. '
~~
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Exhibit III-5
EMPLOYEE'S NAMEScate of Minnesota A
POSITION DESCRIPTION AAGENCY DIVISION'
Public Weifare /Incone Maintenance
ACTIVITY
Benefit Recovery Unit
CLASSIFICATION TITLE
Executive I
WORKING TITLE (if different)
Administrative Assistant
POSITION CONTROL NUMBER
PREPARED BY PREVIOUS INCUMBENT APPRAISAL
PERIOD to
EMPLOYEE'S SIGNATURE (this position description
accurately reflects my current job)
DATE SUPERVISOR'S SIGNATURE (this position description
reflects the employee's current job)
DATE
POSITION PURPOSE
To assist the Manager of the Benefit Recovery Unit in coordinating and- evaluating
all collection activities so that all third party resources in the Title XIX
program are utilized to the greatest extent possible.
REPORTABILITY
Reports to: Manager, Benefit Recovery Unit
Supervises: 3 Inter. Clerk Typists
2 Clerk Typists
1 Clerk II
2 Student Workers
DIMENSIONS
Budget:
Clientele: 220,000 Title XIX Recipients87 Counties
10,000 Medical Providers
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Ebdiibit III-5
(continued)
POSITION nDESCRIPTION D
EMPLOYEE'S NAME POSITION CONTROL NUMBER
Resp.
No.
1.
2.
3.
4.
5.
PRINCIPAL RESPONSIBILITIES, TASKS AND PERFORMANCE INDICATORS
.It is my responsibility to supervise and coordinate Data Control
activities anong clerk/clerk typists to ensure an accurate and
current status.
a. To meet with staff on weekly basis to discuss and correct pro-
cedures and problems.
b. To evaluate and reassign responsibilities among staff as the
need arises.
c. To evaluate staff during probationary periods and/or as needed.
It j.s n^ responsibility to report to the Manager on weekly basis the
status of the Data Control section so that activities of Data
Control and other Benefit Recovery sections can be effectively and
efficiently coordinated.
a. To report to Manager vjhen problems arise that I am unable to
solve or v^en I feel she shouM becone involved.
b. To deliver a written v^ekly report to Manager on Fridays.c. To rreet with other Benefit Recovery Unit supervisors as needed
to resolve problems or discuss procedures.
It is my responsibility to review and conpile statistical data on
Benefit Recovery operations so that continual evaluation is iiBde
of the status of the Unit.
a. To review all v^ekly corrputer reports vAiich indicate potential
and actual collections for obtaining accurate data.
b. To research and conpile recovery reports as requested by Manager
c. To cctipile monthly statistics fron all available resources indi-
cating ratios of recovery.
d. To effectively reconrend changes in collection of statistical
data.
It is my responsibility to provide training as necessary so that all
involved parties remain updated as to Benefit Recovery operation.
a. To effectively recoimend v^en training for county personnel,
insurance carriers, providers of health care is necessary.
b. To prepare or provide for appropriate training material.
c. To conduct and/or assist in training seminars.
d. To ensxare that participants are properly registered and adequate
training accaiiTBdations are provided.
e. To sutmit written evaluation on all aspects of training seminars
upon coipletion and to effectively recoimend changes for future
seminars.
It is nr^ responsibility to coordinate staff development and ensure
adherance to personnel policies so that human resources are de-
veloped and utilized to the fullest extent.
a. To obtain staff develcpnent information from available resources
b. To inform individuals of available staff training courses.
c. To ensure that probationary evaluations and annual evaluations
are rrade by the appropriate supervisor for all Benefit Recovery
personnel on a timely basis.
Priority
A
Time
10
Discretion
10
20
10
10
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Ejdiibit III-5
(continued)
POSITION BDESCRIPTION D
EMPLOYEE'S NAME POSITION CONTROL NUMBER
No.
6.
7.
8.
9.
PRINCIPAL RESPONSIBILITIES, TASKS AND PERFORMANCE INDICATORS
It is iTiy responsibility to coordinate procedural changes necessitate(^
by the Other Health Coverage so that a sirooth transition from the
manual to the mechanized system results.
a. To ensure that loading of manual files into conputer file is don^
efficiently and accurately.
b. To ensure that all Benefit Recovery staff menbers are full in-
formed and understand the steps if inplementation prior to the
actual iirpleirentation date.
c. To effectively recanmend changes in procedures which would assis-^
all involved parties during the transition.
It is my responsibility to keep the Manager informed of the status of
all vork activities and problem areas so that appropriate action can
be taken.
a. To effectively recornrend changes v^ich would increase effective-
ness and be beneficial to the Unit.
b. To request inirediate assistance from Manager for difficult
problem areas.
c. To collect data, meet with other personnel in order to report to
Manager
It is my responsibility to handle special projects as assigned so
that projects are conpleted accurately and effeciently.
a. To research and obtain information as requested from Feder-al-
Govenment, Departnent of Public Welfare personnel, other
states, etc.
b. To make effective recormendations from data corrpiled for
special reports.
It is my responsibility to act as liason between Benefit Recovery
and Systems Division so that maxinum and effective usage of conputer
system is assured.
a. To meet with Systems personnel as needed for supplying data
necessary for effective ccrrputer enhancements.
b. To meet with Systems personnel as necessary for obtaining
technical assistance.
c. To effectively recoimend technical system changes v^iich v^Duld
enhance coolection efforts.
d. To meet with Systems personnel to determine feasibility of
irtplementing such changes.
Prioritv
A
% erf
Time
10
Discretion
10
10
10
B
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Exhibit III-5
(continued)
POSITIONDESCRIPTION C
EMPLOYEE'S NAME POSITION CONTROL NUMBER
NATURE AND SCOPE (relationships; knowledges, skills and abilities; problem solving and creativity; and freedom to act.)
RELATICSnISHIP : This position requires continual interaction with other Benefit Recovery
personnel, other DFW personnel, such as the Systems Division and the POlicy Unit, and
county Vi^lfare workers to ensure optiraam perforinance in tJe Benefit Recovery third party
collection procedures.
SKILLS, KNa^JLEDGE: This position requires adeptness in human relations, above-average
cannunication skills, and knowledge of business procedures, knowledge of the basic
elements of a coirputer system is necessary.
TTais position rrust be able to effectively comrunicate and interact with nuirerous per-
sonnel in order to elicit support and cooperation in obtaining and disseminating infor-
mation on all aspects of the Benefit Recovery operation. This position requires the
ability to act independently and to make decisions accordingly. It also requires
initiative and the ability to follow through an difficult work assignments to ensure
their catpletion and accuracy.
The ability to work with numbers is vital in that the position requires review of
statistical caiputer reports and the coirpiling of these statistics to accurately reflect
the status of the unit.
PROBLEM SOLVING: Problems in this position may arise during the review and evaluation
of conputer-generated reports in that accurate data might not always be reflected. In
order to be assured that all ccitputer produced data is being accurately recorded,
ongoing review and sanpling of data raist be done.
FREEDOM TO NJI: Meet with Manager to discuss problem areas. Reports directly yo Manager.
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Bdiibit 1 11-6
State of Minnesota
POSITION DESCRIPTIOnAEMPLOYEE'S NAME
AGENCY/DIVISION
Public Welfare/Inccare Maintenance
ACTIVITY
CLASSIFICATION TITLE
Legal Technician
''•'C = KING TITLE (If different
Benefit pggQveryPOSITION CONTROL NUMBER
PREPARED BY PREN'IOUS INCUMBENT APPRAISAL
PERIOD
EMPLOYEE'S SIGNATURE (this position description
accurately reflects my current job)
DATE SUPERVISOR'S SIGNATURE (this position description
reflects the employee's current job)
DATE
POSITION PURPOSE
This position exists to Investigate and determine whether a third party resource exists
for payment of medical expenses Incurred by Title XIX recipients and to pursue recoup-
ment and/or utilization of such resources through the appropriate means.
REPORTABILITY
Reports to:
Benefit Recovery Manager
Supervises- Two Medlcal Claims Analysts
One Clerk II
DIMENSIONS
Budget:
Clientele:
Not applicable
Title XIX recipientsr 87 counties
Liability carriers thro ghout the country
Worker's Compensation carriers
Attorneys representing Title XIX recipients
Medical Providers
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Exhibit III-6
(continiif^d)
POSITION nDESCRIPTION D
EMPLOYEE'S NAME POSITION CONTROL NUMBER
090950
Resp
No.PRINCIPAL RESPONSIBILITIES, TASKS AND PERFORMANCE INDICATORS
It is my responsibil-lty to determine the existence of a potential
third party payor so that utilization of the financially liableresource may be pursued.
1. To review Accident/ Injury letter responses and other leads
to determine the liable party.
2. To obtain additional information from providers, recipients,
attorneys, etc. to make an accurate determination of liability.
3. To obtain written denials and/or satisfactory indication of the
lack of a responsible third party where financial liability is
questionable.
It is my responsibility to pursue recoupment and/or utilization of
the financially liable third party resource through the appropriate
means so that reimbursement to DPW is achieved.
1. To ensure that complete information is obtained regarding all
liability cases.
To file the medical-surgical lien in a timely manner where
appropriate.
To file an Intervention as appropriate in Worker's Compensation
cases.
To communicate directly with attorneys representing recipients.
To communicate directly with liability insurers for reimburse-
ment.
To provide all appropriate parties with complete documentation
to substantiate the Department's interest.
2.
4.
5.
6.
It is my responsibility to ensure that maximum reimbursement due
the Department is received so that taxpayer dollars in the Title
XIX Program are reduced.
1. To consult with the BR manager and/or Attorney General's staff,
on a case by case basis, to determine the dollar amount that
would be satisfactory in compromised settlements.
2. To negotiate with private attorney's, insurers, etc. to obtain
the most equitable recovery amount.
3. To obtain final approval of the compromised recovery amount
from the Benefit Recovery manager.
It is my responsibility to provide technical assistance so that the
Benefit Recovery procedures operate within the constraints estab-
lished by law.1. To keep apprised of areas of law directly or indirectly
impacting the Benefit Recovery operation.
To provide the legal basis and clarification of Benefit Recovery
procedures to county personnel, insurance carriers. Benefit
Recovery personnel , etc. as needed.
To do legal research for special projects as assigned by the
Benefit Recovery Manager.
To consult with Attorney General's office as required.
2.
3.
4.
Priority % of Discretion
Time
25
25
25
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Exhibit III-6
(continued)
POSITION nDESCRIPTION D
EMPLOYEE'S NAME POSITION CONTROL NUMBER
090950
Resp.
NoPRINCIPAL RESPONSIBILITIES, TASKS AND PERFORMANCE INDICATORS
To provide supervision to the tort section personnel so that the
section operates efficientlyand effectively.
1. To provide technical assistance and guidance In problem cases
Involving third party liability.
To review on an ongoing basis the status and progress of the
tort section.
To apprise the Benefit Recovery manager of the status of the
section via a written report on a weekly basis.
To obtain and review daily work sheets from tort personnel.
To consult with Benefit Recovery manager on problem cases or
areas as required.
To make recommendations regarding procedural and/or policy
changes when necessary.
To delegate assignments, etc. as needed.
Priority % of Discretion
Time
20
2.
3.
4.
5.
6.
7.
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Exhibit III-6
(continued)
POSITION rDESCRIPTION L
EMPLOYEE'S NAME POSITION CONTROL NUMBER
090950
NATURE AND SCOPE (relationships; knowledges, skills and abilities; problem solving and creativity; and freedom to act.)
RELATIONSHIPS ; To communicate verbally or in writing with recipients, county personnel.
Insurance carriers, other Benefit Recovery personnel, other divisions of DPW, attorneys,
and providers to assure that appropriate and effective menas of recouping third party
dollars is achieved.
pOWLEDGE, SKILLS AND ABILITIES : Extensive legal background and knowledge of No-Fault
Auto, Worker's Compensation, tort liability, and Minnesota statutes and applicable
federal regulations affecting these areas is vital in effectively determining liability
and pursuing recoupment through the appropriate legal means. Legal background is also
vital in Interpreting legislation to other individuals Involved in the third party
aspect and in effectively researching legal matters involving the same. Knowledge of
applicable legislation Is required to ensure that the unit is not only operating within
its legal constraints but that It 1s also fully utilizing the authority as provided by
law in the recoupment of Medical Assistance funds.
Adeptness in human relations is vital in communicating with recipients, third party
payors, attorneys, and other Involved parties to elicit cooperation and to facilitate
reimbursement to the Department. Human relation skills are also required in negotiating
settlements with attorneys or third parties.
Written and verbal communication skills are vitally Important Inasmuch as conmunl cation
1s the basis for determining the possibility of a financially liable resource and for
ultimately recovering Medical Assistance funds.
The ability to supervise and effectively utilize human resources is important to ensure
that the ongoing procedures of the section are maintained and that the overall objectives
are met.
PROBLEM AREAS : Problems may arise in the failure of a recipient and/or his/her attorneyin providing the information necessary for DPW recovery. This position has the authority
to pursue all other means of obtaining information and, when unsuccessful, to notify
the county of the recipient's failure to cooperate, thereby making the recipient in-
eligible for Medical Assistance.
Problems may also arise in the reluctance of an attorney or insurer to agree to a settle-
ment satisfactory the Department. This position has the authority to negotiate the best
possible settlement arrangement but must obtain final approval by the Benefit Recovery
Manager.
Problems may also arise in the lack of understanding or knowledge on the part, of Insurors
and/or attorneys of the Department's legal authority to recover Medical Assistance
expenditures. This position has the authority and responsibility of citing appropriatelegislation thereby facilitating reimbursement. Any matters of a questionable or more
difficult nature are referred to or discussed with the Benefit Recovery Manager.
FREEDOM TO ACT ; This position reports to the Benefit Recovery manager on the status of
the section via a weekly written report. Weekly meetings are also held for consultation
of cases of a difficult or questionable nature.
All matters of an urgent nature are brought to the Manager's attention as necessary.
Freedom to act is bounded by the rules and regulations governing the third party aspect
of the Title XIX Program.
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Exhibit III-7
State of Minnesota A
POSITION DESCRIPTION A
EMPLOYEE'S NAME
AGENCY/DIVISION
Public Weifare /Income Maintenance
ACTIVITY
Benefit Recovery
CLASSIFICATION TITLE
Senicr Account Clerk
WORKING TITLE (if different) POSITION CONTROL NUMBER
PREPARED BY PREVIOUS INCUMBENT APPRAISAL
PERIOD to
EMPLOYEE'S SIGNATURE (this position description
accurately reflects my current job)
DATE SUPERVISOR'S SIGNATURE (this position description
reflects the employee's current job)
DATE
POSITION PURPOSE
To assLire that maximum recovery benefi-ts received from recipients, health care providers
and insurance cortpanies are processed and put into the system in an accurate and timely
manner so that all Department of Public Vfelfare and Health Care Provider records are
updated.
REPORTABILITY
Reports to: Recovery Coordination Supervisor
Supervises: NO One
DIMENSIONS
Budget:
Clientele: 10,000 Health Care Providers87 Minnesota Counties
220,000 Title XIX Recipients
Insurance conpanies throughout the United States insuring Medicaid recipients.
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Exhibit III-7
(continued)
POSITION nDESCRIPTION D
EMPLOYEE'S NAME POSITION CONTROL NUMBER
Resu
No.
1.
2.
4.
5.
PRINCIPAL RESPONSIBILITIES, TASKS AND PERFORMANCE INDICATORS
•It is m/ responsibility to naintain written and verbal camunication^ Awith all involved parties so that additional information may be
gained on documents in need of such information.a. To cormunicate as needed with Health Care Providers on any recovery
submitted by them needing information for adjustirent,
b. To cormunicate as needed with Insurance Cortpanies on any recover^
submitted by them needing information for adjustments.
c. To coordinate comrunications between the provider and the insurai}ice
conpany in the event of an overpayment, duplicate payment or a
payment made in errar.
d. To process any requests for refunds made in error to the Departir^nt
It is my responsibility to coordinate reimbursements so that accurate i B
accounts are maintained within technical program requirements.
a. To conplete adjustirent invoices conpling concise data which updalfes
both provider and DPW technical records.b. To assure proper reimbursement of insurance paynents exceeding
DFW allowances.
It is my responsibility to enact procedures between Accounts Receivaltile C
and the other sections involved with the handling of Medicaid
recoveries to ensure that recoveries are processed in an efficient
manner.
a. To establish procedures' betv,^en Accounts Receivable and the
remaining sections of Benefit Recovery.
b. To establish working relations with the DFW Accounting Section
to assure proper handling and distribution of incoming recover ie^.
c. To maintain conrrunication with Health Insurance COnpanies tterebj-
gaining needed information and a better vorking relationship.
d. To coordinate procedures with the 87 Minnesota counties to ensre
a mere rapid appropriation of county shares.
e. To inform the proper departments and personnel of new irethods of
handling recoveries.
It is ray responsibility to conplete adjustment invoices on incoming
recoveries so that they may be entered into the system and the
recipient payment history updated.
a. To sort checks according to the type of recovery they represent,
b. To cotplete the proper Mjustment Form on any type of recovery.
c. To maintain a file for all recoveries submitted by health care
providers, counties and recipients.
d. To obtain necessary information vtere necessary through use of
recipient record files, microfilm copies, and recipient payment
histories.
e. To investigate those cases vtere more than one insurance coipany
pays the same claim.
f . To process refunds for those claims that are over-paid.
It is nTj' responsibility to ccraplete Error Correction Forms so that
all incorrect adjustments input into the corrputer will be accepted
as correct and then adjudicated.
a. To gain correct information through the use of recipient record
files, microfilm copies, and recipient payment histories.
b. To carplete Error Correction Forms and submit them to be enteredinto the system.
Priority %crf
Time
30
Discretion
B
30
30 B
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Ebdiibit III-7
(continued)
POSITION rDESCRIPTION V
EMPLOYEE'S NAME POSITION CONTROL NUMBER
NATURE AND SCOPE (relationships; knowledges, skills and abilities; problem solving and creativity; and freedom to act.)
REIiATlCNSHIP: To conmunicate in person, by telephone cr letter with recipients, Health
Care Providers, counties, other state agencies and health insurance catpanies to coordinate:
all efforts and cocperation to assure that correct aid proper action is executed on all
Medical Assistance recoveries.
SKILLS, KNCWLEIDGE & ABILITIES: Requires extensive accounting background in addition to
a thorough knowledge of the Departirent of Public Wfe Ifare's Centralized Disbursements
system and the radical Assistance Program. Verbal and written ccmtiunicatian skills, and
a general knowledge of insurance billing are also an essential part of this position.
An accounting background is necessary due to the reports that must be maintained and
updated and is irrpsrative vAien considering the large scale balancing that is done.
Knowledge of the Centralized DisburseitEnts System and the Medical Assistance .Program allowsi
the eitplpyee to understand the overall effect of viiat is being done by the Benefit Recover^'
Unit.
The coniTunication skills are needed vAiile attenpting to gain information needed to process
recoveries and the knowledge of insurance billing helps to determine vtether or not a
claim is positively being denied.
Technical skills and adeptness in human relations are very inportant to this position,
Ccntainication with counties, recipients, health care providers, and insurance ccirpanies
necessitates the ability to respond or question any problem in knowledgable and understand--
able terms. Camunication of this type requires a through knowledge of the position.
PRCBLEM SOLVING: There are three major areas vv^ich problems will arise:
a. Problems arising due to insufficient data necessary for the adjustrtei^t
of recoveries.
b. Problems originating from the Error Correction Forms generated.c. Problems arising from requests for refunds.
The first two problem areas both deal with insufficient or incorrect data received. They
result priiTiarily from recoveries submitted by the counties and the Health Care Providers.
The third problem area is a result of
a payment to the Department in error.
an insurance conpany, county or medical provider making
Procedures for these problem areas have been established and are handled as corrpletely
as possible by this position. Extremely difficult situations will be referred to the
Benefit Recovery Manager.
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Ejdiibit III-8
State of Minnesota A
POSITION DESCRIPTION A
EMPLOYEE'S NAME
AGENCY/DIVISION ACTIVITY
CLASSIFICATION TITLE
Mpfiical Claims Analyst
WORKING TITLE (if different) POSITION CONTROL NUMBER
PREPARED BY PREVIOUS INCUMBENT APPRAISAL
PERIOD to
EMPLOYEE'S SIGNATURE (this position description
accurately reflects my current job)
DATE SUPERVISOR'S SIGNATURE (this position description
reflects the employee's current job)
DATE
POSITION PURPOSE
To collect health care benefits fron private rredical insurance carriers to assure
utilization of third party resources.
REPORTABILITY
Reports to: Recovery Coordinaticn Supervisor
Supervises: NO One
DIMENSIONS
Budget:
Clientele: 220,000 Title XIX I^cipients87 counties
i^prCKimately 10,000 ivtedicaid Providers
Insurance conpanies throughout the United States, insuring I^dicaid recipients
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Ejdiibit III-8
(continued)
POSITION nDESCRIPTION D
EMPLOYEE'S NAME POSITION CONTROL NUMBER
Resp.
No.
1.
2.
3.
4.
PRINCIPAL RESPONSIBILITIES.TASKS AND PERFORMANCE INDICATORS
It is m^' responsibility to naintain the current procedures of the
Recovery coordination section so that efficient and proper collectioifi
of benefits nay be made.
a. To collect benefits on behalf of Medi:;al Assistance recipientsfrom responsible third parties through assignitent of benefits
cr subrogation.
b. To exercise DIW right of subrogation to collect insurance proceec:
en behalf of Medical Assistance dependent children vten the absent
parent is required to provide nedical care for the children.
c. To identify and refer to the Tort Unit all cases vtere other thiijd
party resources are potentially available, i.e. Workers' Corpen-
sation, Auto, etc.
d. To investigate possible insurance coverage vtere benefits have
not been previously utilized.
It is my responsibility to provide written and verbal ccmTunications
so that all involved parties are advised of procedures and operations;relevant to their interests.
a. To send Health Insurance Claim Forms with assignnent of subrogation
notice and cover letter to health insurance carriers for reimbur4e
ment to the Departitent of Public l-felfare.
b. To correspond v/ith health insurance carriers to determine level
of benefits applicable to involved parties.
c. To sutmit second notices ^/tien appropriate to follow up on
collection of benefits.
Priority
B
It is rry responsibility to naintain current and accurate insurance
information so that expedient claims processing is achieved.
a. To request that counties forward to Benefit Reccveiry Unit initia].
and annually updated assignment of benefits.
b. To request that counties secure initial and on-going recipient
insurance information by obtaining Benefit Recovery Information
Forms at point of intake and redetermination.
c. To request prortpt up-dates ty counties of Case Information File
vten recipient information changes.
d. To apprise counties of recipients v^o have insurance coverage in
cases v^iere the provider of insurance coitpany contacts the Benef:^t
Recovery Unit and reveals such information.
It is my responsibility to maintain procedures between the Claim
Processing Unit and the Benefit Recovery Unit so that efficient
claim handling is assvired.
a. To authorize DHV paynent of those claims that are- not insxaranoe
payable or v^iere no other third party liability exists.
b. To authorize reduced DR-J payment resulting from investigstion of
other health coverzge and third party liability.
c. To establish procedures within the framework of claims prooessinc
to assure providers of minimum claim handling and delays.
B
Time
Discretion
A
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Exhibit I I1-8
(continued)
POSITION nDESCRIPTION D
EMPLOYEE'S NAME POSITION CONTROL NUMBER
Reso
No.
5.
6.
7.
8.
9.
PRINCIPAL RESPONSIBILITIES, TASKS AND PERFORMANCE INDICATORS Priority
It is ny respcnsibility to provide on-going training and assistance B
to all involved partias in the Benefit Recovery Operation, i.e.
counties, provitfers, insurance carriers, etc., so that involved
parties are apprised of the status of the unit as well as any
procedural changes affecting them.
a. To conduct or participate in training seminars throughout the
state.
b. To travel as necessary to those counties to provide additional
training vten requested.
c. To cortminicate with health insurance carriers to insure efficient
handling of Benefit Recovery Health Insurance Claim Forms.
It is my responsibility to review payirent of cost-effective health
insurance policies rraintained by Title XIX recipients, so that
payments ty the Title XIX program are reduced to the greatest
extent possible.
a. To inperpet benefits payable under those policies submitted to
benefit Recovery and make a determination accordingly, as to thejr
cost-effectiveness
It is my responsibility to assist in the inpleitentation of the Other
Health Care file, so that an efficient transition exists.
a. To transpose insxarance data onto the revised Benefit Recovery
Information Form for all cases presently maintaired within Benefit
Recovery.
b. To ensure that incoming Benefit Recovery Information Forms are
accurately ccnpleted.
It is my responsibility to be responsible for an assigned sectionof counties (Block System) as divided amongst Ptecovery Coordination
Staff. So that effective cortitunications exist between county
workers and the Benefit Recovery Unit.
a. To act as liason person for county personnel to provide on-going
assistance and training in Benefit Recovery procedures for that
specific block of counties.
b. To handle apjaroprlately and specific and/or foreseeable problem
areas.
c. To handle accordingly and health claims within those coanties
requiring additional information or verification, etc.
d. To provide on-going review of interfacing activities, involving
Benefit Recovery and those assigned counties.
It is iny respcnsibility to ensure that collection is pursued on
those claims which require additional processing. So that maximum
reimbursement of third party resources is acheived.
a. To establish and maintain procedures as necessary for health
insurance claims v^Aiich cannot be directly suhmitted ty the
mechanized system.
B
TimeDiscretion
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Exhibit III-8
(continued)
POSITION pDESCRIPTION L
EMPLOYEE'S NAME POSITION CONTROL NUMBER
NATURE AND SCOPE (relationships; knowledges, skills and abilities; problem solving and creativity; and freedom to act.)
RELATIONSHIP: To canrunicate in person, by telephone/ letter on training seminars
with recipients, county personnel, legal staff, health carriers, other stat agencies
and providers to coordinate all efforts and elicit support and cocperation to assure
thatcorrect and proper
action isexecuted to recover funds.
SKILLS, KNCWLEDGE & ABrLITIES: Requires extensive technical insurance background
in addition to verbal and written canrrunication skills and a through knowledge of
the Cfepartment of Public Welfare's Centralized Disbursements System.
Insurance experience is recessary to determine those claims v^ich are collectable
in cases v*iere other health coverage exists and to ensure that all insxitrance data
necessary for claim submission is uniformly and accajrately maintained.
Technical insurance knowledge is mandatary to effectively interpet the health insurance
policies and determine appropriately vAiether or not the state will assune premium
paynent based on cost-effectiveness.
l^itten and verbal comTunication skills are vital in collecting informaticn necessary
for claim processing and to determine information concemi ng the ongoing functions
of the Benefit Recovery Unit.
A thorough knowledge of the Departnent of Public Welfare Centralized Disbursement
System is valuable in determining the most efficient itethods of Benefit Recovery
claim processing within the cinfines of the c\in:ent Medical Assistance claims
procedures
Technical skills and adeptness in human relations are vitally inportant to this
position. Caminication with counties, recipients, providers and insiarance carriers
necessitates the ability to represent a question or problem in understanding terms
and to elicit a response in a ta:::tfull manner. Carrrunication of this type demandsa thorcugh knowledge of insurance procedures as v^ll as Department of Public Welfare
systems.
PROBLEM SOLVING: The five major areas in v*iich problems will arise as as follows:
1. Problems arising due to the variety of other payment resources.
2. Problems arising due to insufficient data necessary for the
insurance carriers processing needs,
3. Problems arising frccB a lack of cooperation by insurance carriers,
4. Problems arising fron a lack of uniformity of invoice codeing
procedures by health care providers.
5. Problems arising from a lack of cooperation by recipient and/or
absent parent in providing necessary insurance data.
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CHAPTER IV
LEGISLATIVE AUTHORITY
ENABLING LEGISLATION
During the 1975 legislative session, Minnesota passed
third party legislation which provided for the following:
(See Exhibit IV-1.)
(1) Minnesota Statute 62A.045
Insurance carriers were prohibited from writing Medicaid
exclusionary clauses whereby existing insurance
benefits were reduced or denied due to the individual's
eligibility to receive Medical Assistance.
This provision was mandatory for Minnesota's third party
operation inasmuch as insurance policies commonly contained
Medicaid exclusionary clauses.
(2) Minnesota Statute 256B.042
The State agency was given the authority to file a
medical /surgical lien against any and all causes ofactions attributable to medical care rendered a Title
XIX recipient and paid by Title XIX funds.
This provision gave the State up to one year to file a lien
from the date last item of medical care was furnished. Prior to this
time, only the county had the statutory authority to file a lien.
The filing time period was only 180 days from the date the last
medical care was furnished. This expanded the filing period
to one year.
Additionally, language was deleted which, in essence, negated
any legal recovery from any payments made prior to the filing of
the lien. The language previously stated that the lien did not
apply to medical payments made prior to the lien being filed. This
placed an additional burden on the counties in that many times
liability was not established until after medical payments
had been made.
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(3) Minnesota Statute 256B.37
The State agency was granted the right of subrogation to
facilitate recoupment of health insurance benefits.
This provision gave the Department the right to all benefits
a Title XIX recipient may have under private health coverage.
(4) Minnesota Statute 256B.06 Sub. 11
The State agency was given the authority to require, as
a condition of eligibility, an Assignment of Benefits
from any applicant/recipient of Medical Assistance.
Any recipient refusing to assign his/her health insurance
benefits to the State is considered ineligible for MedicalAssistance. The right of assignment was obtained to facilitate
direct health insurance reimbursement to the Department.
(5) Minnesota Statute 256B.39
Providers furnishing medical care to Title XIX recipients
were required to indicate on any bills released to the
recipient that reimbursement from the State was
contemplated.
This provision is intended to alert the insurance company
that Medical Assistance funds may also be involved and to eliminateinsurance reimbursement to the recipient or policyholder for
medical expenses paid by Title XIX in the event that the recipient
and/or policyholder would submit the bill prior to submission
by the Department.
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Esdiibit IV-1
<2A.045 PAYMENTS TO WELFARE RECIPIENTS. No poUcy of accident and
ackness insurance issued or renewed after August 1, 1975, shall contain any provision
denying or reducing benefits because devices are rendered to an insured or dependent
wbo is eligible for or receiving medical assistance pursuant to chapter 256Br 1975 c 247 s I]
256B.042 THIRD PARTY UABIUTY. Subdivision 1. When the state agencyprovides, pays for or becomes liable for medical care, it shall have a lien for the cost
of the care upon any and all causes of action which accrue to the person to whom the
care was furnished, or to his legal representatives, as a result of the injuries which ne-
cessitated the medical care.
Subd. 2. The state agency may perfect and enforce its lien by following the pro-
cedures set forth in sections 514.69, 514.70 and 514.71, except that it shall have one
year from the date when the last item of medical care was furnished in which to file
its verified lien statement, and the statement shall be filed with the appropriate clerk
of court in the county of financial responsibility. The verified lien statement shall con-
tain the following: the name and address of the person to whom medical care was fur-
nished, the date of injury, the name and address of the vendor or vendors furnishing
medical care, the dates of the service, the amount claimed to be due for the care, and,
to the best of the state agency's knowledge, the names and addresses of all persons,
firms or corporations claimed to be liable for damages arising from the injuries. This
section shall not affect the priority of any attorney's lien.
Subd. 3. To recover under this section the attorney general, or the appropriate
county attorney acting at the direction of the attorney general, shall represent the
state agency.
[ 1975 c 247 5 6; 1976 c 236 s 2]
25<&37 PRIVATE INSURANCE POUCIES. Subdivision 1. Upon furnishing
medical assistance to any person having private health care coverage, the state
agency shall be subrogated, to the extent of the cost of medical care furnished, to any
rights the person may have under the terms of any private health care coverage. The
right of subrogation does not attach to benefits paid or provided under private health
care coverage prior to the receipt of written notice of the exercise of subrogation
rights by the carrier issuing the health care coverage.
Subd. 2. To recover under this section, the attorney general, or the appropriate
county attorney, acting upon direction from the attorney general, may institute or join
a civil action agiinst the carrier of the private health care coverage.
[ 1975c 2^.7 s 7]
S6B.M ELIGIBILITY REQUIREMENTSw Subdivision 1. Medical assistance
may be paid for any person:
(11) Who has applied or agrees to apply all proceeds received or receivable by
him or his spouse from automobile accident coverage and private health care coverage
to the costs of medical carefor himself, his spouse, and children. The state agency
may require from any applicant or recipient of medical assistance the aissigrunent of
any rights accruing under private health care coverage. Any rights or amounts so as-
signed shall be applied against the cost of medical care paid for under this chapter.
2SmJ39 AVOIDANCE OF DUPUCATE PAYMENTS. Billing statements for-
warded to recipients of medical assistance by vendors seeking payment for medical
care rendered shall clearly state that reimbursement from the state agency is contem-
plated.
[ 1975 c247s8]
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Exhibit IV-2
DFW Rule 47
Rule 47 further defines the authority and responsibiliti(
the county and State agencies in the identification and utili:
of third party resources:
5. Third-Party liability. The term third-party as
used herein includes, but is not limited to, insurance
companies, (including HMOs); other governmental pro-
grams such as Medicare: Worker's Compensation: and
potential defendants in le^al actions arising out of any
type of accident or intentional tort. Insurance companies
arc liable for full payment of policy benefits on behalf of
beneficiaries and any overage will be forwarded to the
provider of service. Any recovery through court action
shall be considered as a resource to the recipient in de-
termining eligibility for Medical Assistance. A trust fund
is a resource of hrst recourse.
a. The local welfare agency shall:
(1) Determine and identify any third-party
M'hich has a potential legal liability to pay fur medical
care provided ciigihie Medical Assistance recipients
prior to establishing or continuing recipient eligibility;
and
(2) As provided under state law, file its verified
lien statements within one year from the date the last
item of medical care was furnished.
b. The state agency shall:
(1) Seek recovery of all third-party liability
lieneftls;
(2) Distinguish between third-party liability
which is a current resource and one which is not cur-
rent, based on the following considerations:
(a) Current liability consists of but is not
limited to, known amounts of participation or coverage
payable by liable third parties; the amount of actual
claims, payments or settlements received.
(b) Liability which is not current includes
potential resources such as legal actions or disputable
claims whose results are speculative and uncertain. In
such cases, the state agency shall cither perfect a lien or
refer the matter to the county attorney in the county of
financial responsibility for the purpose of perfecting a
lien.
(3) File its verified lien statement within one
year from the date the last item of medical care was
furnished; and
(4) Refrain from withholding payment on be-
half of an otherwise eiigihie recipient w hen third party
liability cannot be readily determined or collected.
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Rule 47 also permits the MA program to pay insurance premiums
for health policies that are determined to be cost-effective:
Exhibit IV-3
q. Health care insurance premiums. The MA
program shall pay health insurance premiums deter-
mined by the state agency to be cost-effective, for:
(1) Eligible recipients not covered under Title
XVIII of the Social Security Act, when coverage under
the insurance policy justifies the premium charged and
the policy provides coverage only for health care.
(2) Supplemental medical insurance (SMI) ona buy-in basis for eligible recipients covered under Title
XVIII of the Social Security Act.
(3) Such other insurancrprograms as thr^t^te
•eency may approvefor eligible-recipients.
Premium payment could previously be made only for those policies
that were maintained by individuals under age 65 and that were
considered cost-effective. The revised rule now permits payment for
all cost-effective health insurance policies maintained by any
Title XIX recipient. (See Exhibit IV-7, Instructional Bulletin #78-37
and Exhibit IV-8, Information Bulletin #79-11.)
Counties are instructed to submit copies of the entire health
insurance policy to the Benefit Recovery Unit for payment consideration.
Ihe following information must accompany each insurance policy:
(1) Copy of actual health policy.
(2) Amount of premiums.
(3) Premium payment schedule.
(4) Known or available information relative to individual's
medical history, e.g., a chronic medical condition.
RECEOT LEGAL DEVELOPMENTS
Legislation amending the Worker's Ccmpensation Act in 1979 now
provides for full reimbursement to the Department of Public Welfare
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plus 127o interest for any medical expenses paid by Title XIX whichare subsequently found canpensable by the Worker's Conpensationinsurer
Minnesota Statutes 176.191
Exhibit IV-4
IS If the 8mrl0ii «'s see ica I sxpenges Tor 3 personal
19 injury sr= pa id pursuant tc any sragran sdc in L st er ad ay the
20 cosaissioner of public welfare and it cs subsequently
21 dstarainad that the injury is cospensabie pursuant to this
22 snaptar, the workers' conpensation insurer snail reisburs*
23 the coT.sTi 33 i oner of public welfare for the nac:cal expenses
2^ pais ana attributable to the personal injury* including
25 interest at a rate of 12 percent a year.
Also, in 1979, Minnesota Statutes 176.521 was amended toprovide that stipulated settlements of claims are valid only ifexecuted in writing and signed by the parties and intervenors:
Exhibit IV-5
176.32L [ScTTLcMEfiT Q? CLAIMS^ Sabdl v i si an 1.
[YtLl3ITY.I in acreefaent between an sflipla:/s» or hit
dapendartt snc trte enrploysr ar Insurer to settle sn^ ctsicr»
wftich- is not upGO appeal before trte workers' ccnpansatian
court of appeafsr for conipfljnsat i on undar this crrapte-r is.
valid wners It has been executad in wr:trna and signed by
I the partres* and intarverrors In the aatter> and the
Z division has approved the ssttlenrerrt and nade an award
3 thereon* If the natter Is upon appeal before the workers*
i, compensation court of appeals, the workers* compensation
5 court of appeals is- the approving body,-
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DECISIONS OF THE SUPREME COURT
Two recent Minnesota Supreme Court decisions, Myles Brooks
vs. AMF Inc. (278 NW 2nd310;
1979) and Vetsch vs. Schwan's Sales
Enterprises (283 NW 2nd 884; 1979) have strengthened intervenors
'
ri^ts, and therefore, the Department's rights in Worker's
Caipensation cases.
Both decisions stand for the proposition that intervenors in
Worker's Corpensation cases must be reimbursed in full if excluded
fron negotiations which result in a final settlement of an enployee's
Worker's Conpensation claim.
Vetsch vs. Schwan's Sales Enterprises
Exhibit IV-6
SYLLABUS
A health insurer who was excluded from participating in
negotiations resulting in a full, final and complete settlement
of an employee's workers' compensation claim and who was not a
party to the stipulation for an award is entitled to full
reimbursement of the expenses it paid or incurred on behalf of
the employee under an insurance policy excluding claims covered
by workers' compensation, notwithstanding its failure to present
any evidence relating to the compensability of employee's claim.
Reversed and remanded.
In the absence of these two Supreme Court decisions, intervenors
who did not participate in the negotiations were left with the option
of establishing the work-relatedness of the injury which requires
the recipient/employee's cooperation. In consideration that therecipient/employee had settled his/her claim, obtaining his/her
cooperation would be difficult at best.
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Brooks reiterates this by stating that the employee who has
settled has little, if any, reason to cooperate with the intervenor(s),
Further, the employer is unjustly enriched in that reimbursement
is not forthcoming for the medical expenses incurred. Brooks
further states that the basic principle of Worker's Compensation is
to place on industry the burden of economic loss resulting from
work related injuries. When Title XIX absorbs the medical costs,
this concept is defeated. Additionally, it is not economically
feasible for the intervenor to make an adequate investigation
of the strength or weakness of an employee's claims.
The Department filed an amicus brief in the Brooks case
explaining that it was in the same position as the health insurers
and, therefore, suffers the same consequences including financial
loss when not included in settlement negotiations.
LEGISLATIVE ANALYSIS
Analysis of the Supreme Court decisions results in the
following:
(1) Health insurers which pay benefits through policies
that specifically exclude payments for work related
injuries should be reimbursed from the Worker's
Compensation settlement.
(2) Given that Title XIX is payor of last resort , it is in
the identical position as health insurers in thatpayment from Title XIX funds should not be made when
reimbursement is subsequently available through
the Worker's Compensation carrier.
(3) If the health insurers are excluded from the settlement
negotiations, they are entitled to full reimbursement
with interest.
(4) Accordingly, then. Title XIX should also be reimbursed
in full with interest.
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Exhibit IV-7
STATE OF MINNESOTADEPARTMENT OF PUBLIC WELFARE
OF THE CENTENNIAL OFFICE BUILDING GENERAL
INFORMATION
ST, PAUL, MINNESOTA 55155 612/296-6117
Instructional Bulletin #78-37 May 15, 1978
Chairperson, County Welfare Board
Attention: Director
Chairperson, Human Service Board
Attention: Director
Premium Payment for Cost-Effective Irsurance Policies
he new DPW Rule 47 (12 MCAP 2.047) now enables payment of insurance premiums for
health insurance policies maintained by Title XIX recipients age
and over.
those over age 65, Rule 47 covers :
1.) Private health insurance policies which provide benefits supplemental
to Medicare coverage.
2.) Private health insurance policies for recipients not enrolled in Medicare.
those under age 65, premium payment may be made for health insurance policies
are determined to be cost-effective. The Benefit Recovery staff assists
personnel in determining the cost-effectiveness of health policies. A
opy of the actual policy should be submitted to the Benefit Recovery Unit with
following information:
1. ) Recipient Name
2.) Premium Amount
3.) Premium Payment Interval (i.e. annually, monthly,)
addition, any information regarding the recipient's past or current medical
should be indicated when available.
premium amount should initially be made from county funds and then be Indicated
the Summary of Abstract, Line #14.
of insurance premiums for cost-effective policies is economically benefi-
and every effort should be made to ensure that such policies are maintained
the recipient is financially unable to do so.
AN EQUAL OPPORTUNITY EMPLOYER
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Exhibit IV-7
(continued)
Questions regarding this bulletin should be addressed to:
Beth Wahtera, Manager Beth Lehman
Benefit Recovery Unit MA Policy Unit(612) 296-6964 (612) 296-2274
EJD:par
Sincerely,
Edward J. Dirkswager, Jr.
Commissioner
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Exhibit IV-8
STATE OF MINNESOTADEPARTMENT OF PUBLIC WELFARE
OF THE CENTENNIAL OFFICE BUILDING GENERAL
INFORMATIONST. PAUL, MINNESOTA 55155 612/296^117
INFORMATION BULLETIN #79-11 April 20, 1979
TO: Chairperson, County Welfare Board
Attn: Welfare Director
Chairperson, Human Service Board
Attn: Director
SUBJECT: Benefit Recovery Unit
The Benefit Recovery Unit was established in accordance with federal regulations
to recover financially liable third party resources available for payment of
medical care costs incurred by Medical Assistance recipients. These resources
include: Worker's Compensation, No-Fault Auto, Health Insurance, and tort liability.
During our first three years, we have noted several problem areas. At this time,
we would like to reiterate the procedures that must be followed which will aid
the unit in recovering taxpayer dollars spent in the Title XIX Program.
I. Recovery Checks
All recovery checks sent from the county to DPW must include the following:
1. Type of recovery; i.e. estate, excess income, etc.
2. Full and correct MA ID # for each recipient. (If the client either presently
does not have an MA ID # or has never previously been a recipient of MA,
the money should not be sent to the Benefit Recovery Unit).
3. State the correct amount of money to be applied against each individual
recipient account.
II. Worker's Compensation
The Worker's Compensation Commission services county agencies with a Notice
to Intervene concerning Title XIX recipients attempting to file for Worker's
Compensation benefits. These notices are to inform the county/state that
if medical expenses related to the work injury have been paid by Title XIX, the
county/state has a right to intervene to recoup such expenses should an award
be made in the recipient's favor. The individuals filing the petitions may
either be currently receiving aasistance or have previously received assistance.
A copy of each Notice to Intervene must be forwarded to the Benefit Recovery
Unit immediately. The one exception is if your county attorney is willing to
AN EQUAL OPPORTUNir/' EMPLOYERDPW-825 (8-77)
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Exhibit IV-8
(continued)
Page 2
file the intervention on behalf of the State, and perfomi all necessary
follow up work to facilitate recovery. Receipt by the Benefit Recovery
Unit of the Notice to Intervene is imperative in order to obtain reim-
bursement of Medical Assistance expenses. Timeliness in forwarding these
notices is crucial in that the state is usually given only a specified
amount of time (usually 15 days) in which to initiate recovery efforts.
It is also requested that the county telephone the Benefit Recovery Unit
upon receipt of the intervention so that recovery steps may be initiated
by the unit prior to actual receipt of the Intervention. The Benefit
Recovery Unit will then be able to handle all Worker's Compensation
interventions on behalf of the counties for recovery of medical expenses.
The Benefit Recovery Unit encourages county agencies to inform the unit of
all instances wherein a third party payor may exist. Any available infor-
mation relative to an accident or injury should be conveyed to the unit via
written memorandum or telephone. The unit will then further investigate
the case to ensure proper utilization of third party resources. County
agencies should also refer all recipients and/or attorneys requestingcopies of medical expenses to the Benefit Recovery Unit so that the MA
Program's interests may be protected prior to release of the medical
documentation. The unit handles recoveries of all types including
recovery of No- Fault auto insurance benefits.
The Benefit Recovery Unit routinely notifies county agencies of recipients
who receive monetary reimbursement as a result of any third party settlement.
It is then the county's responsibility to ensure that the recipient's ongoing
eligibility is verified.
Ill Health Insurance Information Form (HI IF) DPW-192^
Please note : If a person changes from one program to another a completed
HIIF, checked original , must be sent to the Benefit Recovery
Unit . (An Assignment of Benefits must also be submitted if
the recipient is the oolicyholder. )
Section 1: (Case Identification Information) Boxes 1-4 must show the same
information for person 01 as it appears on the CI File.
Box 5: Birthdate should appear as only six digits, as opposed
to seven used on the CI File.
Section 5: (Individuals covered by policy) List only those individuals that
are both eligible for assistance and covered by the Health Insur-
ance policy. (Ex.: Needy children case in which a parent is the
policyholder but not eligible for assistance. Parent's name would
not be indicated in Section 5.)
*Section 5 must also show the recipient's relationship to the
policyholder .
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Page 3
Exhibit IV-8
(continued)
Box 38: (for County Use Only) This box must be completed.
Check one of the followinq:
1. Original: If this is the first DPW-1Q22 sent to the Benefit
Recovery Unit reqardina a soecific insurance policyfor that soecific MA ID #.
2. Update: If any of the followina has chanaed since the original
DPW-1922 was sent to the Benefit Recovery Unit:
a. Name chanoe for person listed in Section 1.
b. Name of policyholder chanqes.
c. Insurance terminates.
d. Additions to Section 5.
3. Coverage Change: If information in Section 3, Boxes 1-9 chanaes.
Ex.: The oriqinal Hllf^ shows hospital only
coverane (Box 1) and the client notifies
you that he/she now has coverage under
major medical (Box 3) also.
*When sending an undate or coverage chanoe HIIF, it is only necessary
to comolete boxes 1 through 5, 28, 38 and the boxes pertaininq to
the information being altered.
IV. Premium Payment of Cost Effective Health Insurance Policies
Premiums may be paid for health insurance policies insuring Title XIX recipients
provided the policy is cost effective . Payments must be made by the countv. The
county is then reimbursed by DP'-/ via submission of the Summary of Abstract.
The Benefit Recovery Unit reviews all policies to determine their cost effectiv-
ness. The following information must be submitted, however, for the policy
to be evaluated:
1. Copy of actual health policy.
2. Amount of premiums.
3. Premium payment schedule (i.e. quarterly, monthly).
4. Any available information on recipient's medical history (i.e. chronic
disease).
If the recipient does not have a cooy of the actual health policy, he/she should
request a duplicate policy from the insurance carrier.
Please note : Premiums for indemnity policies are not payable under Medical
Assistance.
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Exhibit IV-8
(continued)
Page 4
Further information relative to the aforementioned areas is available in
Instructional Bulletins #76-18, 77-28, 77-91 and 78-37.
If you would like more information regarding any aspect of Benefit Recovery,
please contact:
Beth Wahtera, Manager
Benefit Recovery Unit
690 North Robert Street
St Paul, Mn 55101
(612)296-6964
Yours very truly,
\Xcshk C U,rV^
Arthur E. Noot
Commissioner
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CHAPTER V
CURRENT PROCEDURES
COLLECTION OF HEALTH INSURANCE INFORMATION
Health insurance information is collected by the county
agency at intake, eligibility redetermination, and whenever a
change in status affecting health coverage occurs. The Title XIX
recipient/applicant is responsible for providing all insurance
information relative to any available health coverage. An
Assignment of Benefits is also obtained, pursuant to State law,
if the recipient/applicant is the policyholder. At the same
time, the countyis responsible for indicating the existence of
health insurance coverage on the Case Information file. A
Y indicator is used to reflect health insurance while a N
indicator is used to reflect no insurance known to be in force.
The Y indicator is also reflected on the monthly Medical Assistance
identification card under OHC {other health coverage).
The insurance information is collected via the Health Insurance
Information form (HIIF, DPW-1922; Exhibit V-1 ) for subsequent
forwarding to the Benefit Recovery Unit. The Health Insurance
Information form replaced the previously used Benefit Recovery
Information form (BRIF, DPW-1922; Exhibit V-2) as of September
1977. (See County Instructional Bulletin #77-28; Exhibit V-3.)The Health Insurance Information form was designed to facilitate
direct key entry of the insurance data for the Other Health Coverage
(OHC) file.
Prior to Statewide implementation, the form was used in a
pilot project involving three counties. As a result of the project,
revisions were subsequently made in the design of the form, prior to
finalized version. Training seminars were also conducted throughout
the State for county personnel for instruction in the proper
completion of the form. A portion of these seminars was devoted
to the participants actually completing sample Health Insurance
Information forms using various types of insurance as examples.
As of September 1977, the Benefit Recovery Information form
was no longer accepted by the Benefit Recovery Unit but instead,
was returned to the respective county worker with instructions to
resubmit using the revised form. The return of the document was
necessary to ensure compliance by the counties in using the Health
Insurance Information form.
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The keying process of the HIIFs began in August 1977. All
incoming HIIFs are batched upon receipt by the Benefit Recovery
Unit and transferred directly to the Total Data Entry (TDE) Unit
for keying.
Once a week, the keyed documents are returned to the Benefit
Recovery Unit where they are then filed in the manual Individual
Case files to facilitate insurance billing.
IDENTIFICATION AND SUBMISSION OF HEALTH INSURANCE CLAIMS
The provider is given an option in the utilization of health
insurance benefits:
(1) He/she may bill the insurance carrier in lieu of billingMedical Assistance. If the claim is denied or only
partial payment of the total medical expense is received,
the bill may then be submitted to Medical Assistance, using
the appropriate TPL code and indicating the amount of insurance
reimbursement received.
or
(2) He/she may bill Medical Assistance in lieu of billing
the insurance carrier and, by appropriate use of the
TPL field on the invoice, instruct the Benefit Recovery
Unit to pursue the insurance benefits.
(TPL Codes; Exhibit V-4)
Health Insurance Claim forms (HICFs, DPW-1848; Exhibit V-5)
are produced at point of adjudication of each invoice when the
following exists:
(1) A Y indicator exists on the Case Information file.
(2) The provider has instructed Benefit Recovery to
bill the insurance carrier by leaving the TPL field
blank .
(3) No amount from other sources exists on the invoice.
The Health Insurance Claim form contains the information submitted
on the provider's original invoice in a reformatted version for
purposes of insurance submission.
The HICFs are produced in triplicate on a weekly basis at
an average of 1500-1600 per week. Each HICF is manually matchedwith the individual Benefit Recovery Case file containing the
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Health Insurance Information form and where appropriate, the Assignment
of Benefits.
Four Medical Claims Analysts are then responsible for assigning
each HICF an individual file number and for transposing the specific
insurance information from the Health Insurance Information form
onto the Health Insurance Claim form. The file number is a seven
digit number beginning with an alpha prefix assigned to each
Medical Claims Analyst, followed by the Julian date, which serves
to indicate the day the claim was billed. The last three digits
are numeric and reflect the number of the HICF as processed thus
far that day. The Medical Claims Analyst also attaches a copy
of the completed Assignment of Benefits (Exhibit V-6) form
if the recipient is the policyholder, or the Notice of Subrogation
(Exhibit V-7).
The HICFs are billed daily with those HICFs for the ten largest
carriers being batched prior to mailing. A second notice copy of
the HICF is retained in the manual Health Insurance Case file,
while a third copy is filed in the Accounts Receivable Section for
subsequent reconciliation. (See Accounting of TPL Recoveries.)
HEALTH INSURANCE REPORTS
Two reports are also produced on a weekly basis which indicate
invoices for which the TPL code used by the provider contradicts
the insurance indicator ( Y or N ) on the Case Information file.
These reports are:
(1) Possible Insurance Coverage.
(2) Insurance Possibly No Longer in Force.
These reports are utilized in the identification of health
insurance that has not been indicated by the county and/or recipient.
They are also used to identify those providers who may be routinely
using the wrong TPL code, either knowingly or unknowingly. Follow
up by Benefit Recovery personnel is performed as appropriate.
IDENTIFICATION OF OTHER THIRD PARTY LIABILITY
The Tort Section is responsible for pursuit of all other
liability. This includes, but not limited to, the following
resources:
Worker's Conpensation
No Fault Automobile Insurance
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Tort Liability
Homeowner's Insurance
Owner, Landlord and Tenant Insurance (OL&T)
Assigned Claims Bureau
Worker's Compensation Special Fund
Crime Victims Reparation Act.
The identification of liability other than health insurance is
accomplished by the system through two methods. These are:
(1) Injury codes reflected on the invoice by the provider of
service. (See Exhibit V-8.)
(2) Trauma diagnosis edits for exception reporting.
The above data is communicated to the Benefit Recovery Unitvia weekly exception reports. (Exhibits V-9,10,11 ,12) These
reports are broken into 4 categories:
(a) Work Accidents
(b) Auto Accidents
(c) Non Specific Accidents
(d) Diagnosis Reflects Possible Tort Liability.
Upon receipt of the weekly exception reports. Tort personnel
manually obtain recipient addresses from the Case Information
file via the CRT for all recipients identified on the reports.
Accident/injury inquiries are then mailed to these recipients
(Exhibit V-13).
Due to staffing constraints, a dollar limit of $100 is presently
imposed for the identification by the system of potential Tort
cases. As a result, an average of 200 recipients are identified
per week as having required medical care as a result of an accident
or injury. Statistics do reflect, however, that in spite of the
$100 limit on initial identification of potential TPL claims, the
unit pursues 90% of the dollars identified as subject to TPL.
For casesin
which the Benefit Recovery Unit does notreceive
a response within 30 days, a second inquiry is sent. If no response
is received within 30 days to the second request, the case is referred
to the respective county agency. The county agency is then responsible
for individually contacting those recipients who have failed to provide
third party information relative to their medical care.
Upon receipt of the completed accident/injury inquiries, a
determination is made by the Benefit Recovery Unit paralegal
whether or not a potential third party exists. Those responses
for which third party liability clearly does not exist are filed
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in a No TPL file for documentation purposes. All other responses
are handled by the Tort Section personnel.
At the onset of the Benefit Recovery operation, recovery action
was not immediately initiated upon indication of potential TPL.
Rather, medical expenses were accumulated for a period of time
and reimbursement was subsequently pursued, using a much lengthier
time frame. It has since become obvious that timing is of utmost
importance in pursuing reimbursement. Accordingly, several years
ago, the Tort procedures were changed to enable more timely noti-
fication to the appropriate third party, thereby substantially
reducing the likelihood that any available monies would be distributed
to the recipient in lieu of reimbursement to the Department.
Upon determination of a potential third party, a file is estab-
lished and a separate file log is started. All subsequent activityregarding the case is reflected in the Tort file and is summarized
in the file log (Exhibit V-14). Medical claims payment histories
are obtained as soon as it is established that a potential TPL
resource may exist. Those claims relating to the specific injury/
accident are then visually identified by Tort Section personnel.
At this point, the recovery actions differ according to type of
resource being pursued. These actions are briefly described below.
Uncontested Liability
The procedures for uncontested liability involve the initial
identification by Tort Section personnel of all claims related to
the specific accident or injury. Actual copies of the providers'
original invoices are obtained from microfilm and submitted to the
appropriate insurance carrier with a cover letter detailing the
requested reimbursement (Exhibit V-15) . The financially responsible
third party is advised that additional claims may also be submitted
in the future and follow up histories are obtained to identify
those claims paid by the Medical Assistance program subsequent to
the initial reimbursement request. Reimbursement is subsequently
adjusted so as to reflect on Master History. (See Chapter VI,
Accounts Receivable Function.)
In a vast majority of cases the above described procedures are
sufficient for reimbursement. The unit has experienced difficulty,
however, with one major no fault carrier who has strictly enforced
their time requirement for initial notification of an accident.
For this reason, a special notification letter is now sent in all
no fault cases (Exhibit V-16). While this special notification
does not reflect actual payments made by Medical Assistance, it
does serve to put the insurance carrier on notice, therefore, the
claim filing requirement is satisfied or met.
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The aforementioned procedures are utilized in recouping benefits
under any insurance policy other than health in cases for which
such insurance is determined to be in effect at the time of the
accident or injury and liability is not being contested.
The same procedures are also followed in seeking reimbursement
from the Assigned Claims Bureau, although recipient assistance is
required. The Assigned Claims Bureau is established from funds
contributed by all Minnesota no fault carriers. It is intended
to provide coverage for those individuals who are injured by
uninsured vehicles and who do not own automobiles themselves for
which insurance coverage would be available under the Personal
Injury Protection (PIP) portion of their coverage.
After Tort personnel have verified that insurance coverage
does not exist, using both the response from the accident/injury
inquiry as well as Motor Vehicle accident records when necessary,
the recipient is mailed the Application of Benefits form
(Exhibit V-17). This form, upon completion, is then forwarded
by the Tort Section personnel with a cover letter to the Assigned
Claims Bureau.
The Assigned Claims Bureau subsequently notifies the Benefit
Recovery Unit of the insurance processing carrier to which the claim
has been assigned. Reimbursement is subsequently received by the
Department and adjusted so as to reflect on Master History.
The Worker's Compensation Special Fund is operated on the samebasis as the Assigned Claims Bureau; however, payment from this fund
may be made only by a court order. The fund is comprised of
contributions from Minnesota Worker's Compensation carriers and is
intended to provide coverage for employees injured while working
for uninsured employers. The Special Fund is also intended to
pay a portion of the applicable benefits for an injured employee
whose disability is the result of a pre-existing handicap. The
Benefit Recovery Unit pursues recoupment from the Special Fund
as well, using the same means of identification and payment docu-
mentation previously mentioned.
Contested Liability
As in uncontested liability, all claims relative to the specific
accident or injury are visually identified from the medical claims
payment history. Excluding Worker's Compensation, a medical, surgical
hospital lien is filed against the cause of action (Exhibit V-18).
The actual filing of the lien is done by county personnel in the
county of financial responsibility, from a draft version prepared
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by the Benefit Recovery Tort Section personnel. The lien is served
on all interested parties, including the recipient, the recipient's
attorney, and the defendant. A copy is returned to the Benefit
Recovery Unit for verification purposes where it is then retained
in the individual's Tort file. All Tort liability files are keptin one manual filing system within the Tort Section.
Subsequent to the lien being filed, the recipient's attorney
is provided copies of the medical expenses and an agreement is entered
into in which she/he agrees to also represent the Department's
interests. Periodically thereafter, histories are ordered to verify
additional related medical expenses. The attorney is notified
whenever medical expenses significantly increase and she/he is
queried every six months on the status of the case. The lien itself
is required to be updated on an annual basis.
In settlement negotiations, assistance is available upon request
from the Assistant Attorney General assigned to the Benefit Recovery
Unit. Compromise settlements occur although various factors are considered
in compromising. These factors are:
(1) The extent and nature of the injury.
(2) The likelihood of continuous or ongoing medical care
and/or assistance.
(3) The total amount of the settlement.
(4) Whether or not a portion of the recipient's settlement
proceeds will be used for future medical expenses or
related expenses.
Upon the acceptance of any settlement, the county is informed,
for eligibility purposes, of the amount of the proceeds, if any,
received by the recipient.
The amount recovered by the Department is subsequently adjusted
against that recipient's medical payments history. (See Chapter VI,
Accounts Receivable Function.)
Contested Worker's Compensation
Identification of potential Worker's Compensation cases is
made by the system edits previously described, using the injury
codes as well as exception reporting for trauma diagnosis. The
unit also routinely receives from the Department of Labor and Industry
copies of the Worker's Compensation pre-trial dockets. The matching
of the Social Security numbers from the Case Information file against
the Worker's Compensation pre-trial dockets are used as a back-up
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to the identification made by the system. As a result of this
match, a consistent average of 26% of the individuals listed
on the Worker's Compensation pre-trial dockets are being identified
as Medical Assistance eligibles. Additionally, the unit/county
may receive a Notice to Intervene from the Worker's CompensationDivision subsequent to the filing of the employee's claim petition.
An intervention (Exhibit V-19) is subsequently filed by the unit
with the signature of the Attorney General's staff. If the inter-
vention is filed prior to the pre-trial, the Benefit Recovery
paralegal attends the pre-trial in an effort to obtain a stipulation
from the employer's attorney. If the intervention is filed subsequent
to the pre-trial and/or the employer's attorney does not agree
to stipulate, further efforts are made prior to the initiation
of the final hearing to obtain a stipulation. The stipulation
asks for two admissions:
(1) That the medical expenses contained in the Department's
Petition to Intervene were paid by the Department.
(2) That such expenses are the result of the alleged injury
on which the employee bases his/her claim.
Recent legislation discussed in the previous chapter has
strengthened the Department's basis for recovery in these cases.
ACCOUNTING OF TPL RECOVERIES
All third party checks are initially received by the Accounting
Division of the Department of Public Welfare. The checks are
divided into the following categories:
(a) Health Insurance Recovery
(b) Tort Recovery (all other third party recoveries)
(c) Recipient Recoveries.
The checks are then assigned, by the Accounting Division,
individual consecutive deposit codes within each recovery type.
These deposit codes are recorded on a Daily Receipts Register.
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Copies of the checks are made with the copies being attached to the
respective register and the original check being deposited. The
Accounting Division then determines and adjusts the amount of the
Federal, State and local shares. The Daily Receipts Register
(Exhibit V-20) and the check copies are then delivered to the AccountsReceivable Section of Benefit Recovery for processing. The checks
are then further divided by Benefit Recovery Accounts Receivable
personnel
HEALTH INSURANCE RECOVERIES
All health insurance checks containing the specific file
number of the Health Insurance Claim forms are separated and matched
with the Accounts Receivable copy of the HICF for immediate adjustment.
The health insurance checks which do not contain the seven digit
number but which may identify the recipient by name, social security
number, etc., are kept separately for further research. The checks
are researched to identify the specific recipient and the specific
HICF from the information provided by the insurance carrier. If the
check cannot be identified by the information available, a telephone
call will be made or a letter will be sent to the insurance carrier
requesting the specific HICF file number.
Health Insurance recoveries are adjusted on a claim - specific
basis by entering the following information on a Multiple Adjustment
form (Exhibit V-21):
Deposit Code
Amount of Insurance Reimbursement
Medical Assistance Identification Number
Original Claim Control Number
(from provider's paid invoice)
Reason Code
Status Code
Remittor
Initials of Individual Completing Transaction.
At the same time, the Accounts Receivable copy of the HICF
(Exhibit V-22) is updated to reflect the claim payment information.
This copy is subsequently refiled in the individual health insurance
file. The Multiple Adjustment forms are completed daily and are
processed through the normal processing stream. Reconciled adjust-
ments are reflected on the recipient's individual Master History
as relating to the specific claim.
Denials from health insurance carriers are presently manually
recorded on the Accounts Receivable copy of the Health Insurance
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Claim form and tallied weekly for Federal reporting purposes.
The Accounts Receivable copy of the denied HICF is also refiled
in the individual Health Insurance file.
OTHER TPL ADJUSTMENTS
Recipient Adjustment forms (Exhibit V-23) are used for many Tort
liability recoveries. In cases where more than ten individual
invoices relate to the recovery, a recipient adjustment will be
done. This adjustment is then reflected on the recipient's individual
Master History but does not relate to specific claims. A visual
determination, however, can usually be made. The Recipient Adjustment
form requires the following information:
Deposit CodeAmount of TPL Reimbursement
Medical Assistance Identification Number
Reason Code
Status Code
Dates through which Medical Expenses were Paid
Initials of Individual Completing Transaction.
All adjustments are reflected on Master History and the monthly
county remittance advice as well as annual payment summary. The
Benefit Recovery Unit also handles the adjustment of recoveries
from such resources as excess assets, estate recoveries and IV-D
medical -related expenses.
The Benefit Recovery Unit receives three MARS reports on a
monthly basis for accounting purposes. These are:
(1) Third Party Participation Report (Exhibit V-24) identifies
all recoveries made as relating to specific type of
provider.
(2) Adjustment Report (Exhibit V-25) identifies recoveries
made by the providers as well as the Benefit Recovery
Unit and provider breakdown by type of resource.
(3) Third Party Payment Analysis Report (Exhibit V-26)
identifies recoveries made by the provider prior to
billing Title XIX.
These reports in addition to the Deposit Records retained
in the Accounting Division, the weekly Benefit Recovery Total
Report (Exhibit V-27), and the manual accounting provide the data
necessary for completion of the quarterly HCFA 64.9a report.
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Ejdiibit V-1
HEALTH INSURANCE INFORMATION FORM DPW 1922
(6-77)
Recipient Last Name 01 First Name 02
MA Identification Case Number 04
iT
Completion instructions can be
found on the bock of this form.
Date of Birth 05 ''*^' mtofmolior, requeiled 0-> h.i torm ,i <ollected to delermme whether you hove ony other health mior-
program purport it authorized by Chapter 247 of iKe I97S Mir%newto Setiion lowi The information
(olletled will be cloilitied oi pnvote ond will only be ihored with county pfogrom Hoff, Deportment of
Publk Weltore Medical Atwilonce ttoK ond ipecrtied mwronce corriert. No other uve of this inlormotion will
be mode without your priorwritten :ipprovol You are under no legal compuliion to supply, the mformotion on
Ihiilorrr., however foilure to lupply oil Ihe 'equCilci inlormolion rnoy moke you ineligible lo receive Med-
10
Name of Insurance Company 06
^_Address of Insurance Claims Office 07 City 08 State 09 ZIP Code 1
1
1 1
1
I 1
1
Check ALL Of The Coverage Types Which Apply Only To The Policy Indicated On This Form 11
r.1 1 Basic Hospital Insurance
I I2 Medical - Surgical Insurance
l.J 3 Major Medical Insurance
LJ 4 Dental Insurance
Lj 5 Vision Insuronce
I I 6 Nursing Home Policy
n 7 Indemnity Policy
n 8 CHAMPUS
I I 9 Health Maintenance Organization (HMO) Insurance
I ICourt Ordered Coverage / Absent Parent
Is the indicated recipient also policyholder? 1 'ZI YES 2 D NOj
12
If 'YES', go to 4-B. If 'NO', complete the following:
Policyholder Lost Name 13 First Name 1 4 Ml 15
i
1
i
1 i
Address of Policyholder 16 City 171
L ._
State 18 ZIP Code 19
Type of Policy? 1 I I Individual 2 I I Group
If INDIVIDUAL', go to 4-C. If 'GROUP', complete the following:
20
Name Of Employer Or Group Under Wh ch Coverage Is Maintained 21
1
i1 1
Address of Employer./Group 22 City 23 State 24 ZIP Code 1
1
Enter
Group Number^^n 1
11
26 Where are your claims submitted?
1 [J Insurance Company 2 D Employer
27
Contract Or Policy Number 28
Ins. Stort Date 29 Ins. Term Date 30
Indicate ALL Individuals Covered Under Above Listed Policy And Relationship To Policyholder
First Name Of Covered Individual;
CI* Self| |
Spouse I| Child
| [Y^^^ j
Other (Specify)
D
1'
i
1 ' 1
1 i 1
i
1
1
1
1
J n
n
D
D
D
n
n
^ n
D nn
D n
n DD
a
D
D
n
nn
31
^ 32
FOR COUNTY USE ONLY 38
Wkr. Name|
| 1
| |
Wkr. Number{ | | | | | |
Entry Dote|
| | M 1
1 n Original
2 D Update
3 D Coverage Change
Service Cty. |
| j
Responsible Cty.| j |
33
34
35
36
FOR STATE USE ONLY 39 1
1 D Assignment
2 n Subrogate
3 D Suspend
Check If Continued 37D57
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Exhibit V-1
(continued)
Health Insurance Information Form
Instructions for Completion:
This form must be completed for any insurance policy which covers you and/or your dependents.
If you are covered under more than one policy, a separate form for each policy must be completed. Additional forms
are available from your county worker.
All information must be complete and accurate. If you are unsure of specific information, it is your responsibility as a
Recipient to obtain the accurate information.
The boxes must be completed by beginning from the left. Common abbreviations may be used.
When supplying new information for an Update or Coverage Change , only Boxes 1-5 and Box 28 must be com-
pleted.
All information must be typed or printed.
1. Complete your last name, first name, and middle initial; your 16 digit Medical Assistance Identification number,
and your birthdate in the boxes provided. (#1-5) This information must be identical to that appearing on your
Medical Assistance Identification Cord and county records.
2. Complete the full name of your insurance company and the full address of the claims office handling your health
claims. (Boxes #6-10)
3. Indicate the type(s) of coverage provided by this policy. Following are descriptions of the coverages listed (Box
11):
1. Basic Hospital-covers room and board, x-rays, laboratory tests and other hospital charges while you are con-
fined as an in-patient in a hospital.
2. Medicol-Surgical-covers lab, x-ray, and surgery provided by a doctor or clinic.
3. Major Medical-usually has a deductible amount; covers office visits, prescription drugs, ambulance, supplies.
4. Dental-covers specified dental core.
5. Vision-covers optometrist/opthalmology services.
6. Nursing Home-covers room and board while confined to a nursing home.
7. Indemnity policy (income policy)-allows a predetermined dollar amount on a daily or weekly basis while you are
confined to a hospital.
8. Champus (Civilian Health & Medical Program for Uniformed Services)-covers dependents of individuals on active
duty or retired from the military.
9. Health Maintenance Orgonization (HMO)-prepoic' health cere for f reotment/services received at c specified
clinic, (This does no; include HMO coverage mainioined by iho. Stole vo; c Recipienl in lieu o( AAedicci Assir-
tance)
0. Court Ordered Insurance-lf a court order exists mandating an absent parent to maintain coverage, and de-
tails of the policy are unknown, or if no policy exists, check Box O and provide name and address of ab-
sent parent in 4-A. If insurance information is complete, and policy is court ordered, types of coverage (#1-9)
and Box O should be checked.
. Indicate whether you (the recipient) ore the policyholder. (Box #12)
If not, complete the policyholder's full name and address. (Boxes # 13-19) If the address is unknown, indicate UNK .
If you are the policyholder, you need not complete the policyholder name and address boxes.
Indicate if this policy is a Group policy (Example: through employment) or if it is an Individual policy (Box #20).
If Group insurance, complete in full the place of employment and address of employment (Boxes 21-25).In Box 26, indicate your Group number.
In Box 27, indicate whether your claims ore sent to the insurance company or whether the place of employment
maintains a claims office.
In Box 28, complete in full your contract/policy Number.
In Box 29, indicate the effective date of your coverage, if it went into force after your eligibility for Medical Assis-
tance.
Disregard Box 30 (Coverage Termination Dote.)
5. Complete the first name of all individuals receiving Medical Assistance who are covered under the policy. If you are
covered, you must complete your name also. Also, indicate the C number (last two digits of the Medical Assistance
Number) and the relationship to the policyholder of each individual listed.
If there are more than 6 individuals covered under the policy, place a check mark in the Continuation Box at the
lower right corner. Each additional individual should be listed on a second form. However, for the second form, you
need only complete Boxes 1-5 and Box 28 and attach it to the first form.
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- . LL. - _ L.
DPW-1922
(5-75)
BENEFIT RECOVERY INFORMATION FORM
OF INSURANCE
Insurance (In-Patient - Out-Patient care)
Insurance (Surgery — In-Hospital Medical — X-Ray — Lab, etc.
Medical Insurance (Dr. office visits, prescription drugs, ambulance, etc.)
insurance — Accidental Death and Dismemberment
Administration Benefits
(provides benefits to armed forces personnel)
Owners
Name:
Address:
MA — Identification No.
of Insurance Company
Address
of Insurance (use number(s) listed above)
Name (Employer)
contracts will not be assigned group names)
Number
(policy) number
of Policy Holder
date of policy (if known)
Name
FAMILY MEMBERS COVERED
Relationship Address
Reverse Side of Form for Secondary Carrier Information)
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Exhibit V-3
STATE OF MINNESOTADEPARTMENT OF PUBLIC WELFARE
OF THE CENTENNIAL OFFICE BUILDING general
^_ „.... ...»..,.- -^» « .. ^ ^ . „ INFORMATIONST . PAU ,
M I N NESOTA 551 55 6,2/296-«n7
BULLETIN #77-28 June 2, 1977
Chairperson, County Welfare Board
Attention: Welfare Director
Chairperson, Human Services Board
Attention: Director
Revised Benefit Recovery Information Form
Benefit Recovery Unit will be implementing a mechanized health insurance billing
in November. This mechanization is necessitated due to the large dollar volume
potential health recoveries. The new system will greatly enhance the Unit's collection
as well as reduce the manual work presently required for submission of claims to
health insurance carriers.
preparation for the upcoming mechanization, the Benefit Recovery Information Form
has been revised to allow direct key entry of all health insurance information
the computer file. The purpose of the revised Benefit Recovery Information Form
to collect uniform and accurate health insurance data on insured Medical Assistance
ecipients. The Revised Benefit Recovery Information Form will also be required forGeneral Assistance Medical Care Recipients in those counties which have elected
use the Centralized Disbursement System. This form will be available from Centennial
after August 20, 1977.
of September 1, 1977, all health insurance data must be submitted on the Revised
Recovery Information Form . An Assignment of Benefits (DPW-1933) will still be
to accompany a Benefit Recovery Information Form in those cases where the
is the policyholder.
information presently maintained within the Benefit Recovery Unit will be manually
by the Unit staff onto the revised form. Therefore, it is not necessary to
a Revised Benefit Recovery Information Form for those cases where insurancehas previously been submitted.
questions regarding this bulletin should be directed to:
Beth Wahtera, Acting Manager
Benefit Recovery Unit
P.O. Box 30199
690 North Robert Street
St. Paul, Minnesota 55175
Ve/y truly yours,
Vera ^ Li Kins
1^^ EQUAL opportunity employer Commissioner
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Exhibit V-4
THIRD PARTY LIABILITY (TPL) CODES
1. No insurance conpany indicated on Medical Assistance identification
card.
2. One or more insurance companies billed.
3. Patient's insurance coipany billed, but no amount was received as
deductible amount had not been met.
4. Patient's known insurance policies do not cover any part of
claim.
5. Patient's known insurance benefits applicable to this claim are
exhausted
6 Patient ' s known insurance no longer in force
7. Insurance conpany reject - reason unknown.
8. Provider unable to secure necessary papers and/or signaturefrom recipient to allow claim filing.
9. No insurance corrpany indicated on Medical Assistance identifi-cation card, but provider feels insurance coverage may exist.
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Ebdiibit V-5
HEALTH INSURANCE CLAIM FORM - BENEFIT RECOVERY - DEPT. OF PUBLIC WELFARE dpw-,848
PATIENTS NAME DATE OF BIRTH SE_X (10-77)
DPATIENTS MEDICAL ASSISTANCE N UMBER relationship ADMISSION DAT E
i I D I I
DISCHARGE DATE
FILE NUMBER
PLEASE INCLUDE F'LE NUMBER ON CORRESPONDENCE
REFER TO ATTACHMENTS FOR FURTHER INFORMATION ON THE INSURED
ID» REFERRING PHYSICIAN I NSU R ANCE 1 N FORM AT ION
PRIMARY DIAGNOSIS
SECONDARY DIAGNOSIS
SERVICE DATE IS)
I^TOI
PLACE PROCEDURE
DPROCEDURE DESCRIPTION OR DRUG'SUPPLY NAME
SERVICE DATE (S1
I^T0[
PLACE PROCEDURE
2 P
DROCEDURE DESCRIPTION OR DRUG/SUPPLY NAME
SERVICE DATE(S)
I^Tof
PLACE PROCEDUREUNUSUALSERVICE
DPROCEDURE DESCRIPTION OR DRUG'SUPPLY NAME
PLACE PROCEDUREERVICE D ATEIS)
4 PROCEDURE DESCRIPTION OR DRUG SUPPLY NAME
UNUSUALSERVICE
D
SERVICE DATE IS)
I^Tof
PLACE PROCEDUREUNUSUALSERVICE
DPROCEDURE DESCRIPTION OR DRUG/SUPPLY NAME
SERVICE DATEIS)
I^TOI
PLACE PROCEDURE
D
UNUSUALSERVICE
PROCEDURE DESCRIPTION OR DRUG SUPPLY NAME
INQUIRIES ON CLAIMMAY BE DIRECTED TO:
Department of Public Welfare
Benefit Recovery Unit
Box 30199
St. Paul, Mn. 55175
Phone; 612-296-
UNUSU ALSERVICE UNITS DAYS DIAGNOSIS CHARGE
UNUSUALSERVICE UNITS DAYS DIAGNOSIS CHARGE
UNITS, DAYS DIAGNOSIS CHARGE
UNITS'DAYS DIAGNOSIS CHARGE
UNITS'DAYS DIAGNOSIS CHARGE
UNITS DAYS DIAGNOSIS CHARGE
SERVICE DATEIS)
I^TOI
PLACE PROCEDURE
DPROCEDURE DESCRIPTION OR DRUG SUPPLY NAME
UNUSUALSERVICE
SERVICE DATEIS) PLACE PROCEDUREUNUSUALSERVICE
DPROCEDURE DESCRIPTION OR DRUG/SUPPLY NAME
INSTRUCTIONS, CODE
DESCRIPTIONS ON BACK
T I MA
D D n
UNITS'DAYS DIAGNOSIS CHARGE
UNITS DAYS DIAGNOSIS CHARGE
PAGEI I
OFI
I PAGES
AMOUNT RECEIVEDTOTAL CHARGES FROM OTHER SOURCES
CONTROL NUMBER RESOURCES
AMOUNT PD. BY MA
PROVIDERCERTIFICATION STATEMENTTH:s 15 TO CERTIFY THAT THIS CLAIM CONSTITUTES A
REQUEST FOR INSURANCE BENEFITS FOR SERVICES PROV DEDFOR AND PAID FQR ON BEHALF OF YOUR INSURED, UNDER THETITLE XIX MEDICAL ASSISTANCE PROGRAM, DEPARTMENT OFPUBLIC WELFARE. STATE OF MINNESOTA. COLLECTION 1 S
PURSUANT TO AUTHORITY ESTABLISHED BY MINNESOTASTATUTE CHAPTER 247.
X
SIGNATURE
SEND REMITTANCE TO:
Department of Public Welfa e
Fourth Floor Centenn al Bu Id ng
ATTN: Cashier
St. Pau 1, MN 55155
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Ebdiibit V-5
(continued)
THIS FORM, AND THE ACCOMPANYING ASSIGNMENT OF BENEFITS FORM AND INSTRUCTION SHEET, CON-
STITUTE A CLAIM FOR INSURANCE BENEFITS ON BEHALF OF THE NAMED RECIPIENT, (YOUR INSURED
OR- DEPENDENT OF YOUR INSURED), FOR MEDICAL SERVICES RECEIVED.
WHEN PROCESSING THIS CLAIM, THE FOLLOWING GUIDELINES SHOULD BE OBSERVED:
1. All correspondence or telephone inquiries, (address and telephone number listed
on reverse side), must refer to the File Number, (found in top right-hand corner of
claim.
2. All drafts or disallowances must include the File Number, (found in top right-hand
corner of claim).
3. All drafts should be made payable to the Department of Public Welfare.
THE FOLLQHING IS AN EXPLANATION OF CODES USED TO BESCRIBE SERVICES RENDERED:
1. ALL DIAGNOSIS CODES ARE FROM THE H-ICDA CODE SERIES.
2. PLACE COOES.
^- Place Codes , (all services except I.
Medical Transportation). -•
Destination Codes , (Medical Trans-
portation Only).
l=Office
2=Home
3=In-Patient Hosp.
4=0ut-Patient Hosp,
5=Public Clinic
6=Nursing Home
7=Ind. Lab.
8=0ther
l=Patients Home
2=In-Patient Hosp.
3=0ut-Patient Hosp.
4=Nursing Home
5=Ind.Lab/X-Ray Serv,
6=Clinic/Phy.0ff.
7=Dental Office
8=0ther Prac.Off.
9=0ther
3. UNUSUAL SERVICE CODES.
Practitioner Services.
=Prof. Comp.
=Reduced Service
=Unusual Service
Drawn Lab
=Blood Drawn Bedside
strati on Charge
=Reference to Outside Lab.
=Multiple Physicians
=Repeat Procedure Same Phy.
=Repeat Proced.-Diff . Phy.
=Anesthesia
=Anesthesia by Surgeon
K =Multiple Procedures
L =Fonow-up Only
M =Two Surgeons
N =Co-SurgGons
Q =Assistant Surgeon
S =Complications
V =Early Periodic Screening
W =Far,ily Planning
Z =MuUiple Modifiers
1 =Restorative Services
2 =Preventative Services
CODES FOUND IN UNITS BLOCK.
1. Anesthesia: one unit = 15 minutes.
2. Blood: one unit = 1 pint.
3. Miles: one unit = 1 mile.
4. Days: one unit = 1 day.
5. Visits: one unit = 1 visitor.
6. Psych. Care: one unit = 1 hour.
RELATIONSHIP TO INSURED.
1. Self
2. Spouse
3. Daughter
4. Son
Other
B. Medical Transportation .
l=Emergency Land Vehicle.
2=Non-emergency Land Vehicle.
3=Emergency Air Vehicle.
4=Non-emergency Air Vehicle.
5=Emergency Water Vehicle.
6=Non-emergency Water Vehicle.
C. Dental Services : All Codes for
dental services show the American
Dental Association, (ADA), Tooth
Code. See chart below.
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Exhibit V-6
ASSIGNMENT OF BENEFITS FOR PRIVATE HEALTH CARE COVERAGE
I, the undersigned, wish to qualify for Medical Assistance for myself and/or my dependents from the
Minnesota Department of Public Welfare under its Medical Assistance Program (the Program). I understand
that, to the extent of such assistance provided, Minnesota Law gives the Department all of my rights to
benefits under the terms of any private health care coverage which I have or may have. I also understand
that the Commissioner of Public Welfare is empowered to accept from me an assignment of my rights under
such private health care coverage.
Therefore, in consideration of any such assistance received by myself and/or any of my dependents
listed below and including any unborn children, I, the undersigned, hereby assign and transfer to the
Commissioner any and all rights to benefits accruing to me and/or such dependents during a period of one
year, measured from the date below, under any private health care coverage which I have or may have, to the
extent of the cost of care paid under the Program.
I hereby authorize payment to the Commissioner of any such benefits to which I may become
entitled during such period of one year from any provider of such private health care benefits, to the extent
of the cost of care paid under the Program.
I further authorize any person, physician, or other practitioner of the healing arts, hospital, clinic, or
other medically-related facility, insurance company, employer, or other organization, business, or
governmental agency to furnish upon request any and all records, data, and information regarding myhealth (including all treatment) and employment, and that of my spouse and children, to the Department
and the provider of private health care benefits named below by the Department. A copy of this
authorization shall be as valid as the original.
Medical and employment data obtained by the Department of Public Welfare for payment for any
and all medical care shall be utilized only for the purpose of collecting your private health care benefits.
Utilization of such data shall be effective November 1, 1975. This assignment shall terminate and become
invalid upon termination of your Medical Assistance.
I further agree to indemnify and hold any person or entity making payment pursuant to this
assignment harmless against all liabilities, cost, or expenses incurred as a result of such payment.
Date Signature
Address
DPW use only
Provider of health care benefits:
Medical Assistance ID number
Dependents:
64
PZ-01933-01
DPW-1933
(3-76)
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Exhibit V-
STATE OF MINNESOTADEPARTMENT OF PUBLIC WELFARE
CENTENNIAL OFFICE BUILDING
ST. PAUL, MINNESOTA 55155
Claims Processor
the 1975 legislative session, the Department of Public Welfare secured legislation, (Chapter 247), which
assignment of health insurance proceeds to which an insured recipient is entitled. Additionally, the
allows the Depiirtment the right of subrogation when the insured is not the recipient ... such as in cases
the absent parent is required to provide hospital/medical insurance on behalf of his/her dependent children.
enactment of such legislation provides the statutory authority for the Department of Public Welfare,
Recovery Unit), to administer a Benefit Recovery Program, whereby the Department of Public Welfare
the insurance company on behalf of the recipient, thus assuring reimbursement to the Department of Public
Additionally, this program will assure that the Department of Public Welfare is the payor of last
... subsequently reducing tax dollars expended.
VIRTUE OF THIS LETTER, THE DEPARTMENT OF PUBLIC WELFARE IS HEREBY EXERCISING ITS
OF SUBROGATION FOR BENEFITS DUE THE RECIPIENT NAMED ON THE ATTACHED BILLING
UNDER THE CONTRACT HELD BY YOUR INSURED ,
SERVICES ENUMERATED ON THE ATTACHED STATEMENT.
you for your assistance and cooperation. If you have any questions, or require additional information,
se write or call the Benefit Recovery Unit.
Request of Payment Instructions
A check or draft covering benefits payable with an explanation of what is being paid. Checks should be
made payable to the Department of Public Welfare.
Notices indicating no benefits payable because (a) No coverage for services rendered, or (b) Deductible not
met, etc.
A notice that benefits have already been paid. This should include the name of the person(s) paid and the
amount.
A notice that the recipient is not your insured.
drafts or disallowances must include the file number listed on the top right-hand corner of the billing form.
STATE DEPARTMENT OF PUBLIC WELFAREBENEFIT RECOVERY UNIT
690 North Robert Street
P.O. Box 43170
St. Paul, Minnesota 55164
AN EQUAL OPPORTUNITY EMPLOYER
PZ-02323-01
DPW-2323 (9-78),
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Ejdiibit V-8
INJURY
The Injury Code most accurately describing the reason for treatment,
must be included on all claims submitted to Medical Assistance for
payment
Injury Codes
1. ^Problem not related to accident or employment.
2. Work related accident or disease.
3 Accident
4. Auto accident.
5. Auto accident occurring after January 1, 1975, for viMch
incurred expenses exceed $20,000 or contractual liability.
6. -Billing frcxn Pathologists, Radiologists and Anesthesiologists.
(New code effective September 1, 1975.)
* Injury Code Numbers 1 and 6 are only necessary to assure that
the Injury Code field on the invoice is not blank.
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Ebdiibit V-9
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Exhibit V-10
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3 t- • . > • • ' • i • • • • •
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Ejdiibit V-11
's~s'? ? si
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Ebdiibit V-12
Z Q
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Exhibit V-13
OFFICE OF THE
COMMISSIONER612/296-2701
STATE OF MINNESOTADEPARTMENT OF PUBLIC WELFARE
CENTENNIAL OFFICE BUILDINGST. PAUL, MINNESOTA 55155
GENERALINFORMATION612/296-6117
r nMedical Service Date:
This form must be returned
within 14 days.
1_ J
We have received information which indicates you MAY have sustained an accident. (If you have not sustained an
an accident, please read question number 1 ). The following information is needed in order to process your
medical bill, and to determine whether a third party might also be responsible for payment of the bill. Please
answer all questions which apply to you. If a question is not applicable, please indicate N.A. (i.e., not applicable).
1) Is your injury the result of an accident? If yes, please give a brief description of how and where the accident
happened. (IF YOUR INJURY IS DUE TO NATURAL CAUSES, AN ILLNESS, OR ANYTHING OTHERTHAN AN ACCIDENT, PLEASE STATE SO HERE, AND IT WILL NOT BE NECESSARY TO COMPLETETHE REST OF THIS QUESTIONNAIRE.)
2) On what date did your accident occur?
3) What pharmaceutical drugs, if any, have you received?
4) Do you feel the accident was caused by or due to someone else? If so, who?
5) If your accident occurred at work, please answer the following:
a) who is your employer and what is your employer's address and telephone number?
6) Please give the telephone number where you can be reached.
AN EQUAL OPPORTUNITY EMPLOYER
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Exhibit V-13
(continued)
7) If your accident involved an automobile, please answer the following:
a) Were you a passenger, driver or pedestrian?
b) Do you or any relative living in your household carry No-fault insurance coverage? Please give the name,
address, policy and claim number of the insurance company, indicate in whose name the policy is in and
your relationship to the policyholder.
c) If your were a pedestrian or a passenger in the automobile, please give the name of the driver(s). Please
also state if the driver(s) had No-fault insurance, and the name, address, policy and claim number of
the insurance carrier.
d) If more than one auto was involved in the accident, please give the name of the driver(s) of the other
auto(s). Please also state if they have No-fault insurance, and the name, address, policy and claim
number of their insurance carrier.
e) Please state if you have turned in your claim to a No-fault insurance carrier. If so, which carrier, and
have they paid anything on the claim?
8) If your accident occurred on someone else's property (e.g. at school, at a store, at a neighbor's home, etc.),
please answer the following:
a) Does the school, store, neighbor, etc. carry any homeowner's liability, or school insurance? If so, please
give the name, address, policy and claim number of the insurance company, and in whose name thepolicy is in.
b) Have you turned in a claim to the insurance company?
9) Do you plan to bring legal action against anyone for your accident? Please state the name and address of the
person(s) you will be bringing suit against. Has a date been set for the trial? If an attorney will be representing
you, please give his/her name and address.
The information requested on this form is collected to determine whether any available third party resources exist
which may provide medical payment in lieu of medical assistance. The collection of this information for program
purposes is authorized by Chapter 247 of the 1975 Minnesota Session Laws. The information collected will be
classified as private and will only be shared with county program staff, Department of Public Welfare Medical
Assistance staff and specified financially liable third parties. No other use of this information will be made with-
out your prior written approval.
If you do not have the information that is requested, please obtain it. Your immediate cooperation will be appre-
ciated. If you have any questions, please feel free to call us.
Thank you. This form must be returned wi thin fourteen (14) days.
Benefit Recovery Unit
(612) 296-7660 (612) 296-7855
DPW-2237 (3-79)
PZ -02237-02
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Ebdiibit V-L4
NAME
DATE FILED OPENED
DATE OF LIEN OR INTERVENTION_
HISTORIES ORDERED (DATES)
DATE OF INJURY
NUMBER (S)
INVENTORY LOG
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Ejdiibit V-15
STATE OF MINNESOTADEPARTMENT OF PUBLIC WELFARE
OFFICE OF THE CENTENNIAL OFFICE BUILDING f fil^il'^L,^K,COMMISSIONER INFORMATION
612/296-2701 ST, PAUL, MINNESOTA 55 1 55 612/296-6117
RE: Policyholder -
Injured Party -
Date of Loss -
Dear
Please be advised that the Departinent of Public Welfare has incurred
medical expenses relating to injuries sustained by
As it is indicated that your catpany has primary liability for all
medical expenses relating to this injury, reimbursement for the ex-
penses paid to date v^ich total must be made to the
Department of Public Welfare. The Department has the statutory
right to recoup these expenses frcm the financially liable third
party. If you are unable to reimburse the Department at this time
or for any reason, kindly contact me at your earliest convenience.
Following is an itemization of the expenses incurred thus far.
Should any additional expenses be incurred, appropriate documentation
will be forwarded to you. Payment should be issued to the Department
of Public Welfare and sent directly to iny attention. Kindly indicate
the reference number on your check.
Should you have any questions or should you require additional inform-
ation, please contact me.
Your anticipated cooperation is greatly appreciated.
Provider Dates of Service Amount Billed Amount Paid
Respectfully,
Legal Techician
Benefit Recovery Unit
AN EQUAL OPPORTUNITY EMPLOYERcc:
Manager, Benefit Recovery Ui^^^@DPW. 825
(R.77>
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Exhibit V-16
STATE OF MINNESOTADEPARTMENT OF PUBLIC WELFARE
OF THE CENTENNIAL OFFICE BUILDING GENERALINFORMATION
ST. PAUL, MINNESOTA 55155 612/296-6117
Date:
(Insurance Carrier Name & Mdress)
RE : Policyholder
Policy Number:
Claim Number:Injured Party:
To Whom it May Concern:
We have been informed that the above captioned individual sustained
injuries requiring medical treatment as a result of a(n) (auto, hone,
etc.) accident on . As it is indicated that your
company is the liability carrier, we are hereby advising you that the
Department of Public Welfare may have made payment for medical expenses
for which you would be financially liable. This unit is presently
obtaining complete information regarding any related amoionts expended
so that recoupment may be made. We will be providing you with such
documentation in the near future. Should you have any questions
concerning reimbursement, please feel free to contact this unit.
Sincerely,
Legal Technician
Benefit Recovery Unit
Minnesota Department of Public Welfare
AN EQUAL OPPORTUNITY EMPLOYER
®DPW.826
IB. 77)
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Exhibit V-17
APPLICATION FOR BENEFITS
OATB Ot« POLICYHOLDCR DATE or ACCIOBIT FILE NUIWER
TO ENABLE US TO OETERMtNE IF YOU ARE ENTITLED TO BENEFITS UNOEft THE PROVISIONS OF THE MINNESOTA
NO-FAULT AUTOMOBILE INSURANCE ACT, PLEASE COMPLETE THIS APPLICATION FORM AND flETURN IT
PROMPTLY.
r n TO:
MINNESOTA AUTOMOBILE ASSIGNED
CLAIMS BUREAU
Room 2250 — Dam TowerMinneapolis, Minnesota 55402
L JAPPLICANTS NAME
YOUR AOORESS (NO., STREET, CITY OR TOWN, STATE AND ZIP CODE) DATE OF 8IRTH
/ /
SOCIAL SECURITY NO.
DATE AND TIME OF ACCIDENT
/ /
PLACE OF ACCIDENT (STREET, CITY OR TOWN AND STATE)
BRIEF DESCRIPTION Of ACCIDENT
OWNER OF VEHICLE
RIDING IN OR STRUCK BVTtn LICENSE PLATE NO.
ESCRIBE AUTOMOBILES OWNED BY YOU OR ANY MEMBER OF YOUR FAMILY RESIDINQ IN THE SAME HOUSEHOLD.
AUTOMOBILE OWNER INSURER POLICY NUMBCA
AS A RESULT OF THIS ACCIDENT WERE YOU INJURED? YES Q NO Q IP YOUR ANSWER IS YES, COMPLETE THE REST OF THIS FORM.
DESCRIBE YOUR INJURY
WERE YOU TREATED BY A OOCTORT
YES NO
DOCTOR'S NAME AND ADDRESS PHONE NUMBER
IF YOU WERE TREATED IN A HOSPITAL, WERE YOU
AN IN4>ATIENT7 Q AN OUT-PATIENT? Q
HOSPITAL'S NAME AND AOORESS
AT THE TIME OF YOUR ACCIDENT WERE YOU IN THE COURSE
OF YOUR EMPLOYMENT? YES Q NO Q
AMOUNT OF MEDICAL BILLS TO DATE
$
WILL YOU HAVE MORE MEDICAL EXPENSE?
YES NO
DATE DISABILITY FROM WORK BEGAN DATE YOU RETURNED TO WORK
HAVE YOU RECEIVED OR ARE YOU ELIGIBLE FOR ANY BENEFITS UNDER WORKMEN'S COMPENSATION? '^^^~Z
'^O G
LIST NAMES AND ADDRESSES OF YOUR PRESENT EMPLOYERS AND GIVE OCCUPATION AND DATES OF EMPLOYMENT:
EMPtOYER'ANlJ address
TMPiLOYE'RANirADBRESS
OCCUPATION
SccupatTon
-fff-
AS A RESULT OF YOUR INJURY HAVE YOU HAD ANY OTHER EXPENSES? YES Q NO Q IF YES, EXPLAIN ON REVERSE SIDE.
16. SIGNATURE OF APPLICANT OR PARENT OR GUARDIAN DATE:
IMPORTAHT: 1. TO BE ELIGIBLE FOR BENEFITS YOU MUST COMPLETE AND SIGN THIS APPLICATION.
2. YOU MUST ALSO SIGN ANY ATTACHED AUTHORIZATION(S).
A 3A36 (Ed. 1-75) uNironx ^aiNTtMO • au^^LV oiv.
DO NOT DETACH
AUTHORIZATION FOR MEDICAL INFORMATIONAS REQUIRED BY THE MINNESOTA NO FAULT AUTOMOBILE INS. ACT
THIS AUTHORIZATION OR PHOTOCOPY HEREOF, WILL AUTHORIZE A PHYSICIAN, HOSPITAL, CLINIC, OR OTHERMEDICAL INSTITUTION TO FURNISH ALL INFORMATION YOU MAY HAVE REGARDING MY CONDITION WHILEUNDER YOUR OBSERVATION OR TREATMENT. INCLUDING THE HISTORY OBTAINED, X-RAY AND PHYSICALFINDINGS DIAGNOSIS AND PROGNOSIS.
SIGNATURE OF APPLICANT OR PARENT OR GUARDIAN
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Ebdiibit V-18
State of Minnesota Medical, Surgical, Hospital Lien
County of
, whose aaaress is
, represents and states:
That he/she is the Director of the County Welfare Department. That
the County Welfare Department and the Minnesota Department of Public
Welfare has paid, and will become liable to pay for, certain medical, surgical, or hospital care rendered
to^
, whose address is
, and who has, or is presently, a
recipient of income maintenance under the County Welfare Department.
That was injured on or about,
19_ , at , and required medical,
surgical, or hospital care due to the following injury:
That such medical, surgical, or hospital care was rendered by.
,whose address is .
, on the following dates:
That the reasonable value of said care is Dollars; and that there is
justly due thereon, as of the date hereof, the sum of Dollars.
To the best of affiant's knowledge, the names and addresses of all persons, firms and corporations
claimed by said injured person to be liable for damages arising out of said injuries are as follows:
Name Address
That pursuant to Minnesota Statute 393.10, the County Welfare
Department, in and for the County and State of Minnesota, does
hereby claim a lien for the value of the aforesaid medical, sxirgical, or hospital care provided the said
injured person in the amount of Dollars upon any and all causes of
action accruing to said injured person on account of said injuries.
77
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Exhibit V-18
(continued)
The amount of the claim set forth above represents only that amount which is known
and determined to be due at this time. In the event that additional future medical, surgical, or
hospital expenses are incurred relative to this particular matter, it being most difficult, if not
impossible, to determine such additional expenses at this time, this claim of lien is intended to
include such additional expenses.
STATE OF MINNESOTA
COUNTY OF
)
)SS.
.)
states, that he is the.
being duly sworn, and upon oath
and that he did make and sign
the foregoing instrument, and that the same is true to the best of his knowledge.
Subscribed and sworn to before me
this day of 19.
Notary Public, .County, Minnesota
My commission expires.
To be served according to MSA 514.69 on the following:
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Exhibit V-19
STATE OF MINNESOTA
DEPARTMEm' OF LABOR AND INDUSTRY
WORKERS' a2«?3NSATION COt-KISSION
Eitployee
VS.
Eitployer
and
Insurer
PETITiaJ FUR LEAVE TO INTERVENE
File No.
Record No.
TO: THE WORKER'S COMPENSATION COMMISSICW OF MINNESOTA.
COMES fJCW, your Applicant, The Minnesota Departinent of Public Welfare, and states
to the Comnission as follows:
That Applicant has provided the above naired Eirployee with benefits under the program
of Medical Assistance from approximately of to the present.
II.
That the aformentioned Medical Assistance benefits consisted of medical payments
made by the Applicant to the several medical vendors -Jno treated Employee for his injury,
said injury, upon information and belief, may have arisen out of and in the course of
Eirployee 's employiient with the above named Eirployer.
III.
An itemization of Medical Expenses is attached hereto. (Appendix A) . Copies of
all bills toward which payment was made are also attached hereto. (Appendix B)
,
IV.
That Applicant has an interest in the instant proceedings by virtue of its claim for
reimbursement of the above described medical payments, said interest being of such char-acter that Applicant stands to lose by any order or decision entered in the absence of
Af^licant.
V.
That it is the desire of the Applicant to intervene in said action to assert its
claim and right to be reimbursed for its medical payments advanced on behalf of Employee.
WHEREFORE, J^plicant prays for the order of the Coimission allowing Applicant to
intervene in these proceedings and for such other and further relief as may be determined
just and equitable.
79
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Exhibit V-19
(continued)
state of Minnesota )
)
)
Ransey County )
P. Kenneth Kohnstanin, being first duly sworn upon oath, deposes and states:
that he is a Special Assistant Attorney General representing the ^4innesota Departnent
of Public Welfare; that he has read the foregoing application and knows the contents
therein; that said application is true of his own knowledge and as to those matters
that are therein stated on information and belief, he believes then to be true.
subscribed and sworn to
before ne on this day
of , 1980
WARREN SPANNUAS
Attorney General
State of Minnesota
Assistant Attorney General
by
SPECIAL ASSISTANT ATTORNEY GENERAL
4th Floor Centennial Office Building
St. Paul, Minnesota 55155
Telefiione: (612) 296-6673
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Exhibit V-20
OPW-215 (8-76, H^AXaH. AaSlfftanCe Stolo of *»inne»o»a
fteaefit Recovery ir700department of foeuc welfare
-*m DO n Support „ Ooily Receipts Register
Date • - - inri^fni Deposit -No.' -
FuinJ__ _
35269
ir>come Ciass.
CAHD COOES 81 — Patiem PayrTw-ni
S2 — 0\he' PatTnem (Musi aiway* have insiwaoce P'an Numb^rt
84 — NSf Check, etc iDeposn redocltonsf
•= A oound stQ < ifi w^is coliwrin «w«ll post 81 cards lo i^* fiad O^bi File.
* Aci'on CoOefi see paoe 207 ol Accounts Aec«i^sbie Manud' lO' explanation.
REMITTERS MAME CHECK, MONEY OBOES 1 C»HnNUMBER OR DATE
1
>-
Oi= CHECK CODE
s
PATIEWT ACCOUNT NUMBER CD
(HS TRANSACTION \PLAN NO. CODE 1
:
AMOUNT 1 'i
*
^ DO NOT KEVPL'MCH DO NOT KEYPUHCM 1 - 2 7—: : 13 \i. 21 23 24 28 29130 SsUeiS'j
i«ieollet County 1904 ^11 1 1 1 1
'
1 I 1 1
'- '1
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:
2He«lth Support 10T78 <^l^Wkt^rh-'^^s^^^4rioA^ fu ^, . 30 i»p
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Siiomiitea bv 1 Dale SiiOmmed Rece.vod tov Date fKBceiveiO Tolsl
REGISTER CLERKS COPYTEB 141980
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Exhibit V-21
MULTIPLE ADJUSTMENT FORM
DATE r~
OPW-1994(12-76)
Orig CCN
D«po»lt Amount
CLAIMS PROCESSINQ DOCUMENT CONTROL NUMBER
MAID#
Rwnlttor
RC
02Dapotit Amount MAIO# RC S
Orlg CCN
03D»potlt Amount MAIDJl
Remittor
RC S
Orlg CCN
04D«potlt Amount MAIO#
Remittor
RC
Orig CCN
05D»po»lt MA ID#
Ramlttor
RC
Orlg CCN
06 Dapotit Amount MA ID#
Ramittor
RC
Orig CCN
07Dapotit MA ID#
Ramittor
RC
Orlg CCN
08Dapotit (Amount MAIO#
Ramittor
RC
OfIg CCN
09Oapoilt MA IO#
Ramittor
RC
Orig CCN
10Oapoilt Amount MAIO#
Remittor
RC
Orlg CCN
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Exhibit V-22
HEALTH INSURANCE CLAIM FORM - BENEFIT RECOVERY - DEPT. OF PUBLIC WELFARE dpw ,848
PATIENTS NAME DATE OF BIRTH SEX (10-77)
I I I I DPATIENTS MEDICAL ASSISTANCE N UMBE R selationship ADMISSION DAT E
I I D I I
DISCHARGE DATE
FILE NUMBER
.EASE INCLUDE F'LE NUMBERON CORRESPONCENCE
REFER TO ATTACHMENTS FOR FURTHER INFORMATION ON THE INSURED
ID» REFERRING PHYSICIAN I NSU R A N CE I N FORM AT ION
PRIMARYDIAGNOSIS
SECONDARY DIAGNOSIS
SERVICE DATE(S)
IItoI
PLACE PROCEDURE
DPROCEDURE DESCRIPTION OR DRUG SUPPLY NAME
SERVICE DATE (S)
I^Tof
PLACE PROCEDURE
DPROCEDURE DESCRIPTION OR DRUG SUPPLY NAME
SERVICE DATEIS) PLACE PROCEDUREUNUSUALSERVICE
DPROCEDURE DESCRIPTION OR DRUG SUPPLY NAME
SERVICE DATE(SI PLACE PROCEDUREUNUSUALSERVICE
DPROCEDURE DESCRIPTION OR DRUG SUPPLY NAME
SERVICE DATEISI
I^TOI
PLACE PROCEDUREUNUSUALSERVICE
DPROCEDURE DESCRIPTION OR DRUGSUPPLY NAME
SERV ICE DATE(Sj
I^TOI
PLACE PROCEDURE
D
UNUSUALSERVICE
PROCEDURE DESCRIPTION OR DRUG SUPPLY NAME
SERVICE DATEISI PLACE PROCEDUREUNUSUALSERVICE
DPROCEDURE DESCRIPTION OR DRUG/SUPPLY NAME
SERVICE DATEIS)
IItoI
Place procedureUNUSUALSERVICE
DPROCEDURE DESCRIPTION OR DRUG 'SUPPLY NAME
INSTRUCTION
DESCRIPTION
S, CODES ON BACK
MA
inquiries ON CLAIMMAY BE DIRECTED TO;
Department of Public Welfare
Benefit Recovery Unit
Box 30199
St. Paul, Mn. 55175
Phone: 612-296-UNUSU ALSERVICE UNITS DAYS DIAGNOSIS CHARGE
UNUSUALSERVICE UNITS DAYS DIAGNOSIS CHARGE
UNITS/DAYS DIAGNOSIS CHARGE
UNITS/DAYS DIAGNOSIS CHARGE
REASON FORCLAIM DISALLOWANCE:
UNITS DAYS DIAGNOSIS CHARGE
DATE:
REMITTOR;
DEPOSIT CODE:
AMOUNT RECEIVED:
UNITS DAYS DIAGNOSIS CHARGE
UNITS DAYS DIAGNOSIS CHARGEAMOUNT DUEPROVIDER:
UNITS DAYS DIAGNOSIS CHARGE AMOUNT DUERECIPIENT:
PAGEI I
OFI I
PAGES
TOTAL CHARGESAMOUNT RECEIVEDFROM OTHER SOURCE
CONTROL NUMBER RESOURCES
D D n AMOUNT PD. BY MA
PROVIDER
CERTIFICATION STATEMENTTHIS IS TC CERTIFY THAT THISREQUEST FOR INSURANCE 8ENEFFOR AND PAID FQR ON BEHALF OTtTLEXlX MEDICAL ASSISTANCEPUBLIC WELFARE. STATE OF MUPURSUANT TO AUTHORITY ESTABSTATUTE CHAPTER 247.
SIGNATURE
CLAIM CONSTITUTES A
TS FOR SERVICES PROVIDEDF YOUR INSURED. UNDER THEPROGRAM. DEPARTMENT OFNESOTA- COLLECTION IS.' £HEO BY MINNESOTA
SEND REMITTANCE TO:
Departrnent o f Public Welfo e
Fourth Floor Centenn al Bu Id ng
ATTN; Cosfi ier
St. Pau 1, MN 55155
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Exhibit V-23
ECIPIENT ADJUSTMENT FORyV\
DATE r~
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01Deposit
from date
CLAIMS PROCESSING DOCUMENT CONTROL NLMBER
MA lOif
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i Remittor
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from date thru date 1 1 Remittor
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1
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from date thru date 1Remittor
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1
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i
1
4s
04
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I
I
77:RC
4s
from date thru date
1
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05lOeposit 1 Amount
pi
77 4MA I0# RC 1 S
from date thru date 1 Remittor
06Deposit Amount
i
1
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4MAID»< |F,C 'S
from date thru date 1
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11
77 1 4MA ID* PC 1 's
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I
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M 77j
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from date thru date Remitt-jr
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Ebdiibit V-24
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Exhibit V-25
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Exhibit V-27
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CHAPTER VI
OTHER HEALTH COVERAGE (OHC) FILE
INTRODUCTION
The Other Health Coverage (OHC) system is scheduled to be
implemented in early 1981. This system will mechanize the current
Benefit Recovery operation. This system can be broken down into
several functional areas or subsystems. The subsystems of the
OHC are:
(a) Collection of Health Insurance Data
(b) Health Insurance Billing(c) Collection of Other TPL Data
(d) Accounts Receivable Function.
The succeeding sections will include an overview of each of the
subsystems, followed by a section to explain the various input
documents, and finally an explanation of the subsystems general
design.
OVERVIEW
Collection of Health Insurance Data
This OHC subsystem will continue to produce reports and generate
records of health insurance information for all Medical Assistance
recipients who are known to have some type of health insurance coverage.
Two documents, previously described, are used to collect accurate
health insurance data. The first is the Health Insurance Infortnation
form (HI IF) which, as previously detailed, is completed by the county
and submitted to DPW. If there are errors on the submitted HIIF, the
county will receive a turnaround document referred to as a Health
Insurance Information Request form (HIIRF). This form will indicate
by asterisk those data fields requiring county action. The HIIRF
is corrected by the county worker and resubmitted to DPW until all
the HIIF information is successfully recorded.
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Health Insurance Billing
This OHC subsystem will generate insurance claims using insurance
data contained on the OHC file in conjunction with claim data contained
on the MMIS Invoice file. This automatic function will reduce manualintervention presently necessary for claims submittal.
The subsystem will produce on a bi-weekly basis, a completed
Health Insurance Claim form (HICF) which will be mailed directly
to the appropriate insurance carrier. All insurance identification
data printed on the HICF by the system will be extracted from the
Health Insurance Information form (HIIF). As previously mentioned,
the specific insurance information is presently manually entered
onto each HICF.
Multiple HICFs will be produced to identify for the health
carriers the existence of duplicate coverage. Each HICF willprovide the insurance policy data for the coverage concurrently
in effect so that coordination of benefits may be more effectively
handled. Those HICFs requiring special handling will be referred
to the Benefit Recovery Unit for additional processing. Special
handling cases, for example, may involve the attachment of a
claimant statement to the HICF.
The Health Insurance Claim forms produced will distinguish
the types of coverage available under the specific policy. The
existing production of HICFs is irrespective of the types of
coverage available for the individual.
The system will also produce second notice HICFs on a scheduled
basis without manual intervention.
Certain TPL billing activity not pursued at this time due to
staffing constraints will be handled in the new system. This activity
will include billing not only for services which are normally covered
under the major medical portion of coverage but also for those claims
which presently fall beneath the imposed dollar limits. While it is
not considered cost effective to pursue these claims under the present
manual processing system, the automation will ensure that all claims
subject to third party coverage will be submitted to the financially
liable party for payment consideration.
Collection of Other TPL Data
As previously described, an accident/injury inquiry is sent to
all recipients for whom paid claims reflect that the medical care
received is possibly a result of an accident or injury for which a
third party may be liable.
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In collecting third party liability information necessary for
recovery from these types of resources, the automated subsystem will:
(1) Address and prepare for mailing the accident/injury
inquiries to those recipients identified on the Tort
exception reports.
(2) Enable the unit to eliminate the present dollar limit
of $100 tor initial identification of other TPL resources.
(3) Produce second request accident/injury inquiries on a
scheduled basis.
(4) Prevent the mailing of additional accident/injury inquiries
for subsequent claims for the same recipient for which the
existence or lack of liability has been previously
establi shed.
(5) Refer to the county, for their action, those recipients
failing to respond to the accident/injury inquiries.
Accounts Receivable Function
The Accounts Receivable subsystem will provide an efficient
means of entering accounts receivable data for health payments
and denials on MMIS Master History.
Multipleresource listings used for cross-matching
ofinformationreceived on payments/denials will be produced to enable proper iaenti-
fi cation and accurate adjudication in cases where the specific file
number has not Deen indicated Dy the insurance carrier.
Tms subsystem will also produce detailed and comprehensive
third party activity reports used for management reporting. These
reports, described later in this chapter, will provide such information
as aging data, reason tor oeniais, and source of recovery.
OHC INPUT DOCUMENTS
Health Insurance Information Form (HIIF)-(Exhibi t VI-1)
Utilized by county agencies in the collection of pertinent health
insurance data relative to a specific policy. If more than one policy
exists tor the same individual (s) , additional HlIFs are required. This
form is designed to enable direct key entry of the data for OhC purposes
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An HI IF is received by the Benefit Recovery Unit first at
intake, and whenever a change occurs in the content of the infor-
mation initially submitted (e.g., policy terminates, dependent
coverage obtained, dental coverage included, etc.). An Assignment
of Benefits is submitted with the HI IF if the recipient is the
pol icyholder.
Health Insurance Information Request Form (HIIRF)-(Exhibit VI-2)
Turnaround document sent to the county which is identical
to the HIIF. It serves:
(1) To indicate to the county (by asterisks) those data fields
omitted or illegible and therefore, unacceptable for
processing.
(2) To enable the county to manually correct those exception
fields noted in (1) and resubmit using the same document.
Insurance Adjustments and Recoveries Form ( IARF)-(Exhibit VI-3)
Multi -entry preprinted form which is completed by Accounts
Receivable Section upon receipt of health insurance payment or
denial. Identifies specific claim and amount of recovery
necessary for adjustment against Master History file.
Tort Letters Closing Form (TCF)-(Exhibit VI-4)
Pre-printed multi -entry form completed by Tort Section upon
receipt of response to accident/injury inquiry. Serves to close
Tort claims from the History file so second or additional accident/
injury inquiries are not sent out. Identifies type of resource
being pursued.
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Ejdiibit VI-1
Recipient Last Nome
MA Identificotion Case NumberV?
M
HEALTH INSURANCE INFORMATION FORM DPW 1922
(6-77)
01 First Name 02
04
i
Date of Birth
03Completion instructions con be
found on the back of this form.
05 ^^ intormotio 1 requetled on ihii forrn it collected to determine whether you hove ony other heoHh insvr-
. provide medical poymenli i n l ie u ol medicol oisistance. The collection o^ thii inlormotion tor
progrom purpoiei it outhonied by Chopler 247 o) the 1975 Mmnewto Sewion lawi. The -nformotion
collected yiH be closulied os private ond will only b« shored with county progrom stoH, DeportmenI o(
Public Wellore Medical Asi.iionce StoH ond ipecitied inwronce corrieri. No other uie of thii inlormolion will
be mode without your prior written opprovol. You ore under no legol compuljion to Mipply. the informolion on
this form; however, foilure to tupply all the requested inlormolion may mohe you ineligible to receive Med-
Nome of Insurance Company 06
Address of Insurance Claims Office 07 City 08 State 09 ZIP Code 1 10
Check ALL Of The Coverage Types Which Apply Only To The Policy Indicated On This Form 11
[D 1 Basic Hospital Insurance O 6 Nursing Home Policy
1 1 2 Medical - Surgical Insurance [I] 7 Indemnity Policy
D 3 Major Medical Insurance D 8 CHAMPUS
1 14 Dental Insuronce O 9 Health Maintenance Organization (HMO) Insuronce
O5 Vision Insurance
OCourt Ordered Coverage / Absent Parent
Is the indicated recipient also policyholder? 1 I I YES
If 'YES', go to 4-B. If 'NO', complete the following:
2 n NO 12
Policyholder Last Name 13 First Name 14*IL
15
Address of Policyholder 16 City 17 State 18 ZIP Code 19
Type of Policy? 1 LJ Individual 2 I I Group
If INDIVIDUAL', go to 4-C. If 'GROUP', complete the following:
20
Name Of Employer Or Group Under Which Coverage Is Maintained 21
Address of Employer/Group 22 City 23 State 24 ZIP Code 1
_Enter
Group Number 126 Where are your claims submitted?
1 1 1 Insurance Company 2 1 1 Employer
27
25
Contract Or Policy Number 28 Ins. Start Date 29 Ins. Term Dote 30|
indicate ALL Individuals Covered Under Above Listed Policy And Relationship To Policyholder
First Name Of Covered Individual Cl# Self
I] °
~~\ n
Spouse ChildStep-
Child
D n
D D n
D D 1 1
D D 1 1
U D uD n LJ
Other (Specify)
1 1 1 1
1 1
III 1
III 1
1 1 1 1
1 1 1 1
31
32
33
34
35
36
FOR COUNTY USE ONLY 38
Wkr. Nome| | | | | |
Wkr. Number| | | | | |
Entry Dote| | | | | |
1 D Original
2 D Update
3 D Coverage Change
Service Cty.| |
Responsible Cty.| |
FOR STATE USE ONLY 39
1 D Assignment
2 D Subrogate
3 n Suspend
Check If Continued| 37
|
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Exhibit VI-1
(continued)
Health Insurance Information Form
Instructions for Completion :
This form must be completed for any insurance policy which covers you and/or your dependents.
If you are covered under more than one policy, a separate form for each policy must be completed. Additional forms
are available from your county v/orker.
All information must be complete and accurate. If you are unsure of specific information, it is your responsibility as a
Recipient to obtain the accurate information.
The boxes must be completed by beginning from the left. Common abbreviations may be used.
When supplying new information for an Update or Coverage Change , only Boxes 1-5 and Box 28 must be com-
pleted.
All information must be typed or printed.
1. Complete your last name, first name, and middle initial; your 16 digit Medical Assistance Identification number,
and your birthdate in the boxes provided. (#1-5) This information must be identical to that appearing on your
Medical Assistance Identification Card and county records.
2. Complete the full name of your insurance company and the full address of the claims office handling your health
claims. (Boxes #6-10)
3. Indicate the type(s) of coverage provided by this policy. Following are descriptions of the coverages listed (Box
11):
1. Basic Hospital-covers room and board, x-rays, laboratory tests and other hospital charges while you are con-
fined as an in-patient in a hospital.
2. Medical-Surgical-covers lab, x-ray, and surgery provided by a doctor or clinic.
3. Major Medical-usually has a deductible amount; covers office visits, prescription drugs, ambulance, supplies.
4. Dental-covers specified dental care.
5. Vision-covers optometrist/opthalmology services.
6. Nursing Home-covers room and board while confined to a nursing home.
7. Indemnity policy (income policy)-allows a predetermined dollar amount on a daily or weekly basis while you are
confined to a hospital.
8. Champus (Civilian Health & Medical Program for Uniformed Services)-covers dependents of individuals on active
duty or retired from the military.9. Health Maintenance Organization (HMO)-prepaid health care for treatment/services received at a specified
clinic. (This does not include HMO coverage maintained by the State for a Recipient in lieu of Medical Assis-
tance)
0. Court Ordered Insurance-lf a court order exists mandating an absent parent to maintain coverage, and de-
tails of the policy are unknown, or if no policy exists, check Box O and provide name and address of ab-
sent parent in 4-A. If insurance information is complete, and policy is court ordered, types of coverage (#1-9)
and Box O should be checked.
4-A. Indicate whether you (the recipient) are the policyholder. (Box # 12)
If not, complete the policyholder's full name and address. (Boxes #13-19) If the address is unknown, indicate UNK .
If you are the policyholder, you need not complete the policyholder name and address boxes.
4-B. Indicate if this policy is a Group policy (Example: through employment) or if it is an Individual policy (Box #20).
If
Groupinsurance, complete in full the place of
employment andaddress of employment (Boxes 21-25).
In Box 26, indicate your Group number.
In Box 27, indicate whether your claims are sent to the insurance company or whether the place of employment
maintains a claims office.
In Box 28, complete in full your contract/policy Number.
In Box 29, indicate the effective date of your coverage, if it went into force after your eligibility for Medical Assis-
tance .
Disregard Box 30 (Coverage Termination Date.)
5. Complete the first name of all individuals receiving Medical Assistance who are covered under the policy. If you are
covered, you must complete your name also. Also, indicate the CI number (last two digits of the Medical Assistance
Number) and the relationship to the policyholder of each individual listed.
If there are more than 6 individuals covered under the policy, place a check mark in the Continuation Box at the
lower right corner. Each additional individual should be listed on a second form. However, for the second form, you
need only complete Boxes 1-5 and Box 28 and attach it to the first form.
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Exhibit VI-2
EEALTH INSURANCE INPORMATIOJ REOUE£;T FORM DPW 1922
(6-77)
Recipient Last Name 01 First Name 02 Ml 03
MA Identification Cose Number 04
i
Date of Birth
Completion instructions can be
found on the back of this form.
05 ^^ informotion fequested on Ihij lorm is collected to determine whether you have any other heollh intur-
once whrch moy provide medicol poymonti In liflu ot medico Oiwjfonce The collection ot this intormotion for
progrom purpoiei is outhofiied by Chopter 247 o l the 1975 Minnesoto Soiiion Laws. The information
collected will be doisi'icd os pi-inote ond will only be shored with county progrom iloH, Deporlment of
be mode without your prior written oppro*ol. You ore under no legol compulsion to supply, the inforrnatioo on
this form, howe*e', foilure to supply oil the requested intormoiion moy moke you ineligible to receive Med-
Name of Insurance Company 06
Address of Insurance Claims Office 07 City 08 State 09 ZIP Code 1
Check ALL Of The Coverage Types Which Apply Only To The Policy Indicated On This Form
I I 1 Basic Hospital Insurance
I I 2 Medical - Surgical Insurance
I 1 3 Major Medico Insurance
I 4 Dental Insurance
I I 5 Vision Insurance
I I 6 Nursing Home Policy
I I 7 Indemnity Policy
D 8 CHAMPUS
I I9 Health Maintenance Organization (HMO) Insurance
I ICourt Ordered Coverage / Absent Parent
Is the indicated recipient also policyholder? 1 I I YES
If ~YES', go to 4-B. If 'NO', complete the following:
2 D NO 12
Policyholder Last Name 13 First Name 14 Ml 15
1
Address of Policyholder 16 City 17 State 18 ZIP Code 19
Type of Policy? 1 I I Individual 2 I I Group
If 'INDIVIDUAL', go to 4-C. If 'GROUP', complete the following:
20
Name Of Employer Or Group Under Which Coverage Is Maintained 21
Address of Employer/Group 22 City 23 State 24 ZIP Code 1
Enter
Group Number 126 Where ore your claims submitted?
1 LJ Insurance Company 2 U Employer
27
Contract Or Policy Number 28 Ins. Start Date 29 Ins. Term Date 30|
^
Indicate ALL Individuals Covered Under Above Listed Policy And Relationship To Policyholder
First Name Of Covered Individual Cl# Self
J] D
I] °
~J
~J
~J
'n n
Spouse ChildStep-
Child
D 1
D D
D D 1 1
n n 1 1
n D 1 1
n n
Other (Specify)
1 1 1
1 1 1
1 1 1 1
III 1
III 1
1 1 1 1
31
32
33
34
35
36
FOR COUNTY USE ONLY 38
Wkr. Name|__|_
Wkr. Number[_J_
Entry Date I I
1 D Original
2 D Update
3 D Coverage Change
Service Cty.| |
Responsible Cty.| |
FOR STATE USE ONLY 39
1 n Assignment
2 D Subrogate
3 CU Suspend
Check If Continued ] 37| [
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Exhibit VI-Z
(continued)
Health Insurance Information Form
Instructions for Completion :
This form must be completed for any insurance policy which covers you and/or your dependents.
If you are covered under more than one policy, a separate form for each policy must be completed. Additionol forms
are available from your county worker.
All information must be complete and accurate. If you are unsure of specific information, it is your responsibility as a
Recipient to obtain the accurate information.
The boxes must be completed by beginning from the left. Common abbreviations may be used.
When supplying new information for an Update or Coverage Change , only Boxes 1-5 and Box 28 must be com-
pleted.
All information must be typed or printed.
1. Complete your last name, first name, and middle initial; your 16 digit Medical Assistance Identification number,
and your birthdate in the boxes provided. (#1-5) This information must be identical to that appearing on your
Medical Assistance Identification Card and county records.
2. Complete the full name of your insurance company and the full address of the claims office handling your health
claims. (Boxes #6-10)
3. Indicate the type(s) of coverage provided by this policy. Following are descriptions of the coverages listed (Box
11):
1. Basic Hospital-covers room and board, x-rays, laboratory tests and other hospital charges while you ore con-
fined as an in-patient in a hospital.
2. Medical-Surgical-covers lab, x-ray, and surgery provided by a doctor or clinic.
3. Major Medical-usually has a deductible amount; covers office visits, prescription drugs, ambulance, supplies.
4. Dental-covers specified dental care.
5. Vision-covers optometrist/opthalmology services.
6. Nursing Home-covers room and board while confined to a nursing home.
7. Indemnity policy (income policy)-allows a predetermined dollar amount on a daily or weekly basis while you ore
confined to a hospital.
8. Champus (Civilian Health & Medical Program for Uniformed Services)-covers dependents of individuals on active
duty or retired from the military.
9. Health Maintenance Organization (HMO)-prepaid health care for treatment/services received at a specifiedclinic. (This does not include HMO coverage maintained by the State for a Recipient in lieu of Medical Assis-
tance)
0. Court Ordered Insuronce-lf a court order exists mandating an absent parent to maintain coverage, and de-
tails of the policy are unknown, or if no policy exists, check Box O and provide name and address of ab-
sent parent in 4-A. If insurance information is complete, and policy is court ordered, types of coverage (#1-9)
and Box O should be checked.
Indicate whether you (the recipient) are the policyholder. (Box # 12)
If not , complete the policyholder's full name and address. (Boxes #13-19) If the address is unknown, indicate UNK .
If you are the policyholder, you need not complete the policyholder name and address boxes.
Indicate if this policy is a Group policy (Example: through employment) or if it is an Individual policy (Box #20).
If Group insurance, complete in full the place of employment and address of employment (Boxes 21-25).
In
Box 26,indicate
your Group number.In Box 27, indicate whether your claims are sent to the insurance company or whether the place of employment
maintains a claims office.
In Box 28, complete in full your contract/policy Number.
In Box 29, indicate the effective dote of your coverage, if it went into force after your eligibility for Medical Assis-
tance .
Disregard Box 30 (Coverage Termination Date.)
5. Complete the first name of all individuals receiving Medical Assistance who are covered under the policy. If you are
covered, you must complete your name also. Also, indicate the CI number (last two digits of the Medical Assistance
Number) and the relationship to the policyholder of each individual listed.
If there are more than 6 individuals covered under the policy, place a check mark in the Continuation Box at the
lower right corner. Each additional individual should be listed on a second form. However, for the second form, you
need only complete Boxes 1-5 and Box 28 and attach it to the first form.
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Ejdiibit VI-3
irtnn m INSURANCE ADJUSTMEINTS AND RECOVERIES
Piii i^UMlJl::UmHffl
FILE NUMBER
r il In I
HILE NUMBER
ILL
jm^^NnMRgR
Fjrir| mm
TTCrOTfflT
nnn
Jr'lLk NUMBER
II Mill
1 1 IT III I iiiii yil tim tr fflCHRn^ETCTWIBNTKECEIVED I
il i I jj 1
'Mwrm^^ms
u fflOOWn^ECTTRTEP
mmAMOUNT RECEIVED
rirnmI 1 1 1 I W I I
^•DUNT RECEIVED 1
II 11
I u i I
MMm WLT^mi} jIIIII'
Tg^DUIxIT REC
rtiTTl
1\MT ^KCV.
UkUJblT
nL'tJlVlib I DEPOsr
rrarn tmraposTT
LUBETOSTT''mCHTSW
rnT^''^T
DEPOSITnDEPOSIT
rnFILE NUMBER AMOUNT RECET\^D I fUliJJr'ULjrr
liTiTiil [ TT fTfiJil mFILE M]^BER I
ANprWT RECFTA/Pp]
DEPOSI
liHiiil I TT riTLi 1 tfri
f
Frp:-n/Fn I Ee^sTt
B
B
Q
B
FJT.F NjIMBER I AMOUI-^ RECEIVED I t^k'lr^^l ' ' | | MM |
TTfTiil i 1 1 11m 1
1 Hrl ill
B
B
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Exhibit VI-4
' I i I
in
TORT LETTERS CLOSING ENTRIES
mh mi£ CAT TON Em.
nf\ nA.ln&NTJFirm |MB£REG
mmm
^TONI IVllMpFP
Edm iiFNI £i£a: UQ IMRFR
nr]KECIPJENT
i'^l^iDFNTTFTrATinKI Nl IMRPR
KECIPIENT flA IPENTIFICATinN Nl IMRFR
onRFClPIENT_m IpFNTIFTrATinN Nl IMRFRm lEDKECIPIENT m Identification Nu^EER
ni
fflffl
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GENERAL SYSTEMS DESIGN
Collection of Health Insurance Data
Document Control
The four documents described on the preceding pages make up
the input to the OHC system. These documents are:
(1) Health Insurance Information Form (HIIF).
(county initiated)
(2) Health Insurance Information Request Form (HIIRF).
(system generated; returned by county)
(3) Insurance Adjustment and Recovery Form (lARF).
(Benefit Recovery initiated)
(4) Tort Closing Form (TCF).
(Benefit Recovery initiated)
These documents are received and/or initiated by the Benefit
Recovery Unit and are regularly scheduled for keying. Prior to
key-entry, the documents, separated by record type, will be batched,
dated, assigned control numbers, and logged in by the Data Control
Section of Benefit Recovery.
These documents will be keyed to disk with simple content edits
being performed, thus creating a Total Data Transaction (TDT) file.
The documents passing the TDT content edits will be written to tape,
while the documents not acceptable for processing will be returned
to Benefit Recovery. The rejected documents are to be corrected
and prepared for the next processing schedule.
OHC File Update
The Total Data Transaction file is then sorted by Medical
Assistance identification number within record type to a temporary
disk file. This file will be used in a match process with the HealthInsurance Claim form (HICF) Master file which is already in the
correct Medical Assistance identification number sequence.
This process will match Insurance Adjustment and Recovery
form (lARF) records from the TDT file to the corresponding HICF
record on the History file. When a positive match occurs, the HICF
Master file will be updated with the accounts receivable information
from the lARF (e.g. amount collected, deposit code, reason code, file
number)
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After the update, an Adjustment Record will be constructed
from the data obtained from the Health Insurance Claim form/Insurance
Adjustment and Recovery form records match. The Adjustment Record will
be written to a tape file forsubsequent use in the medical payments
system processing. This tape file will also be reformatted and
written to a work file which will be used to produce two copies of
adjustment transaction reference microfiche. This microfiche will
be used by Benefit Recovery as a reference source and by Claims
Processing as part of a permanent audit trail.
Finally, as each HICF record is read, a check is made to
determine if the corresponding lARF has been received. If no action
has been recorded within the specific time limit, the record will be
written to a disk work file for later production of renotifi cation
HICFs.
As records are read from the sorted Total Data Transaction (TDT)
work file, all Health Insurance Information forms (HIIF), and Health
Insurance Information Request forms (HIIRF) will be written to a
Total Data Transaction disk work file without the Tort Closing form
(TCF) and lARF records. This file will be used in the next processing
sequence.
The following reports are produced as a result of the above
processing:
(1) HICF Purged Cases Listing (Exhibit VI-5) reflects all HICFs
purged from the Master file because 12 months have passedsince the last Insurance Adjustments and Recoveries form
(lARF) was received or the case is unresolved and has been
outstanding for a specified amount of time without action
being taken.
(2) lARF/HICF Match Data Report (Exhibit VI -6) provides
transaction input, processing and output counts for
purposes of monitoring and control.
(3) lARF - HICF Match Exceptions Listing (Exhibit VI -7) reflects
lARFs for which an HICF record could not be matched.
(4) lARF - Excess Recoveries Listing (Exhibit VI-8) reflects
matched lARF entries in which the total amount collected
exceeds the initial Medical Assistance provider payment
amount.
(5) Adjustment Transaction Microfiche utilized by Benefi.t
Recovery as a reference source and by Claims Processing as
an audit trail
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Case Information (CI) Match
System input transactions from the previous processing stages
are merged to fonn a single OHC work file. The OHC work filenow contains Health Insurance Information forms (HIIF), Health
Insurance Information Request forms (HIIRF), and New Tort Claim
(NTC) records. The New Tort Claim records represent cases for which
accident/ injury inquiries are to be submitted; however, at this
processing stage, the NTC records do not contain recipient address
information.
This file is matched against the MMIS - Case Information (CI)
file utilizing all open and closed eligibility cases in the match
process. This match will accomplish the following:
(1) Content edit all recently submitted HIIFs and HIIRFs.
(2) Update the present OHC file with current HIIF/HIIRF data.
(3) Upon completion of this processing, the OHC file will
be used to create a work file which, in turn, will create
the OHC file microfiche.
Upon matching the New Tort Claims against the Case Information
file, recipient address data will be extracted from the CI file
and will be written to the New Tort Claims (NTC) records.
During the same processing, the OHC file will be purged of
OHC records where the coverage termination date on the OHC records
is older than 24 months or a CI file record no longer exists. These
records are written to the OHC purged cases listing.
Additionally, the health insurance coverage indicators on the
CI file will be checked and verified and, as a result, a disk file
of worker messages will be produced. These messages will indicate
the specific inconsistencies encountered during subsystem processing
of the CI file and OHC records.
For additional data verification purposes, HIIFs and HIIRFs found
to contain errors will be written to a disk work file to subsequently
be printed to the HIIRF turnaround document used for resolution
of identified errors.
New Tort Claims (NTC) Processing
Finally, New Tort Claims records contained on the OHC file
which do not match a CI file record will be written to a Tort-CI
match exceptions listing, while those New Tort Claim records for
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which recipient address information has been obtained via the CI/
NTC match will be written to a Tort Claim work file for later
processing.
As a result of the above processing, the following reports
are produced:
(1) Health Insurance Information Request Form (HIIRF) turn-
around document.
(2) OHC-CI Match Data Report (exhibit VI-9) reflects transactions
input, processing and output counts for monitoring and
control purposes.
(3) OHC Purged Records Listing reflects those cases purged
from the OHC file for reasons stated above.
(4) OHC File Microfiche reflects all OHC cases as they currently
exist.
(5) Tort - CI Match Exception Listing reflects New Tort records
for which a CI file record could not be matched.
(6) OHC - CI Match Exception Listing reflects those OHC
cases for which no matching CI file record was found.
The Adjudicated Claims file from the medical payment system is
merged with the OHC Suspended Adjudicated Claims file from the lastprocessing cycle of the OHC system. This results in an OHC
Adjudicated Claims file containing new and old Adjudicated Claim
records in Medical Assistance identification number sequence.
The updated OHC file is matched against the OHC adjudicated
Claims work file now containing newly paid claims as well as some
previously paid but not billed claims. This match accomplishes the
following:
(1) Identifies those provider claims which, by match definition,
are possibly covered by the type of health insurance.
Those claims for which adequate billing data exists
(via the HIIF/HIIRF) are written to the Health Insurance
Claim form (HICF) Work Print file.
(2) Those matched provider claims for which insufficient billing
data exists are written to a new generation Suspended
Adjudicated Claim tape which is subsequently merged with
the Adjudicated Claim file tape in the next processing cycle.
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(3) Case file numbers will be machine assigned for each recordwritten to the HICF work print file. (This file numbercontains eight characters of which the first character is
alpha and refers to the specific individual within BenefitRecovery's Health Recovery Section responsible for that
portion of the generated HICFs. The next six characters
are sequential and numerical with the eighth character
used as a check digit.)
(4) Coordination of benefits data will be reflected on the
appropriate HICFs in cases where two insurance policies
exist for the same claim.
(5) Records from the Adjudicated Claims work file are identified
according to specified injury and trauma diagnosis codes
and are written to a New Tort Claim file to be passedthrough further Tort processing. (See Collection of Other
TPL Data.) The claims identified in this manner are
established as other potential liability cases requiring the
submission of accident/injury inquiries.
(6) Workers' messages will be produced to reflect exceptions
related to the production of HICFs.
The following reports will be produced:
(1) Workers ' Message Listing (Exhibit VI-10)
(Presently produced)
(2) Possible Insurance Coverage Listing (Exhibit VI -11)
(Presently produced)
(3) Insurance Possibly No Longer in Force (Exhibit VI -12)
(Presently produced)
(4) Adjustments Requested to Insured Claims (Exhibit VI -13)
(Presently produced)
(5) Child Abuse Claims Report
(Presently produced but referred to another division)
(6) OHC/Adjudicated Claims File Match Data (Exhibit VI-14)
Reflects input, processing and output transaction counts
for monitoring and control.
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Health Insurance Billing
The HICF work print file will be merged with the existing HICF
Master work file, creating a new and updated generation of the HICF
Master file. The HICF work print file will also be merged with theHICF Case Follow Up file creating a file containing both newly
processed HICFs and HICFs for which second notices are to be
generated.
This file, referenced as the HICF Print Process file, will be
randomly matched against the Provider file of the medical payments
system. On a match, provider name and address data will be extracted
from the Provider file and written to the HICF Print Process file.
The HICF Print Process file is then randomly matched against
the Medical Procedure Description file of the medical payments
system. Medical procedure data will be extracted and written to
the HICF Print Process file.
The HICF Print Process file in Case file number sequence, is
processed to:
(1) Print the file number/Medical Assistance identification
number cross reference listing
and
(2) Produce a work tape which will be used to create the
HICF Case file microfiche.
The HICF print process file is resorted by print sequence
producing the HICF print forms file utilized in printing the actual
data onto the HICF document. The final sort sequence will divide
HICF records into a more specialized grouping determined by the
type of manual special handling required. It will also further
sort the HICFs by carrier/codes for mailing purposes. The
following reports are produced:
(1) HICF .
(2) HICF Case File Microfiche .
(3) Medical Assistance Identification Number - File Number
Cross Reference Listing . {Exhibit VI -15)~
(4) File Number - Medical Assistance Identification Number
Cross Reference Listing . {Exhibit VI -16)
(5) Recipient Name - File Number Cross Reference Microfiche .
TTxhibit VI-17)
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Collection of Other TPL Data
The Tort Processing work file containing Tort Closing forms are
sorted to temporary disks in Medical Assistance identification number
sequence and the latter is matched against the current generation
of the Tort Claims History file. This processing will accomplish
the following:
(1) On a positive match, the Tort Closing form will cause
the corresponding record on the Tort History file to be
closed, thus eliminating the production of subsequent
accident/injury inquiries.
(2) The Tort Closing forms not matching a record will be
written to a Torts-Tort History file match exception
listing.
(3) A county notification of overdue Tort Claims inquiries
listing is produced giving those outstanding Tort inquiries
for which a response has not been received within the
specified time limit.
(4) All resolved inquiries will be purged from the Tort History
file and written to a Tort inquiry purged cases listing.
The result of this processing is a new but temporary version of
the Tort History file. The following reports are produced as aresult of this processing.
(1 ) County Notification of Overdue Tort Claims Inquiries
sent to respective counties for further investigation.
(2) Tort History Purged Cases Listing .
(3) Torts-Tort History Match Data reflects input, processing,
and output transaction counts for monitoring and control
purposes.
(4) Torts-Tort History Match Exceptions Listing - the New TortClaims file which address data is matched against the Tort
History file.
Newly identified potential Torts are matched against the Tort
Master file. This match will accomplish the following:
(1) A positive match indicates that a Tort claim for the same
recipient already exists on the Tort History file and
consequently, an accident/injury has previously been sent
to that recipient.
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(2) All Tort records for which an accident/injury inquiry
will be produced are written to a temporary work file which
will input to the print program to produce these letters.
(3) The Tort History file is updated with the appropriate New
Tort records and a new generation of that file is produced
and used as input in the next cycle processing.
(4) The updated Tort History file will be used to create a
work file from which the Tort Claims reference microfiche
is produced.
(5) Any record carried on the New Tort Claims file and selected
for the generation of a Tort letter will be used in the
preparation of a potential Tort Liability Claims listing.
The following reports are produced:
(1) Potential Tort Liability Claims Listing (Exhibit VI-18)
(2) New Tort Claims File - Tort History File Match Data (Exhibit VI-19)
reflects input processing, output transactions for control
end monitoring purposes.
(3) Tort Claims Reference Microfiche (Exhibit VI -20)
(4) Tort Claims Accident/Injury Inquiry (Exhibit VI -21) mailed
to recipients.
Accounts Receivable Processing
The purpose of this subsystem is to produce five reports containing
Accounts/Receivable summary data. This is scheduled to run on a
monthly basis. The only input to this subsystem is the HICF
Master file which produces the following reports.
(1) Age of HICF Records Awaiting Resolution (Exhibit VI-22)
(2) Age of HICF Records at Time of Denial (Exhibit VI -23)
(3) Age of HICF Records at Time of Collection (Exhibit VI-24)
(4) HICF Accounts Receivable Case Microfiche (Exhibit VI-25)
(5) HICF Accounts Receivable Summary Report (Exhibit VI -26)
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Ejdiibit VI-5
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Erfilbit VI-19
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Exhibit VI-20
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E5diibit VI-21
STATE OF MINNESOTADEPARTMENT OF PUBLIC WELFARE
9^L'S.h?^rJ^l CENTENNIAL OFFICE BUILDING generalCOMMISSIONER '^
INFORMATION612/296-2701 ST. PAUL, MINNESOTA 55155 612/296-6117
Medical Service Date:
This form must be returned
within 14 days.
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We have received information which indicates you MAY have sustained an accident. (If you have not sustained an
an accident, please read question number 1 ). The following information is needed in order to process your
medical bill, and to determine whether a third party might also be responsible for payment of the bill. Please
answer all questions which apply to you. If a question is not applicable, please indicate N.A. (i.e., not applicable).
1) Is your injury the result of an accident? If yes, please give a brief description of how and where the accident
happened. (IF YOUR INJURY IS DUE TO NATURAL CAUSES, AN ILLNESS, OR ANYTHING OTHERTHAN AN ACCIDENT, PLEASE STATE SO HERE, AND IT WILL NOT BE NECESSARY TO COMPLETE
THE REST OF THIS QUESTIONNAIRE.)
2) On what date did your accident occur?
3) What pharmaceutical drugs, if any, have you received?
4) Do you feel the accident was caused by or due to someone else? If so, who?
5) If your accident occurred at work, please answer the following:
a) who is your employer and what is your employer's address and telephone number?
6) Please give the telephone number where you can be reached.
AN EQUAL OPPORTUNITY EMPLOYER
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Exhibit VI-21
(continued)
7) If your accident involved an automobile, please answer the following:
a) Were you a passenger, driver or pedestrian?
b) Do you or any relative living in your household carry No-fault insurance coverage? Please give the name,
address, policy and claim number of the insurance company, indicate in whose name the policy is in and
your relationship to the policyholder.
c) If your were a pedestrian or a passenger in the automobile, please give the name of the driver(s). Please
also state if the driver(s) had No-fault insurance, and the name, address, policy and claim number of
the insurance carrier.
d) If more than one auto was involved in the accident, please give the name of the driver(s) of the other
auto(s). Please also state if they have No-fault insurance, and the name, address, policy and claim
number of their insurance carrier.
e) Please state if you have turned in your claim to a No-fault insurance carrier. If so, which carrier, and
have they paid anything on the claim?
8) If your accident occurred on someone else's property (e.g. at school, at a store, at a neighbor's home, etc.),
please answer the following:
a) Does the school, store, neighbor, etc. carry any homeowner's liability, or school insurance? If so, please
give the name, address, policy and claim number of the insurance company, and in whose name the
policy is in.
b) Have you turned in a claim to the insurance company?
9) Do you plan to bring legal action against anyone for your accident? Please state the name and address of the
person(s) you will be bringing suit against. Has a date been set for the trial? If an attorney will be representing
you, please give his/her name and address.
The information requested on this form is collected to determine whether any available third party resources exist
which may provide medical payment in lieu of medical assistance. The collection of this information for program
purposes is authorized by Chapter 247 of the 1975 Minnesota Session Laws. The information collected will be
classified as private and will only be shared with county program staff. Department of Public Welfare Medical
Assistance staff and specified financially liable third parties. No other use of this information will be made with-
out your prior written approval.
If you do not have the information that is requested, please obtain it. Your immediate cooperation will be appre-
ciated. If you have any questions, please feel free to call us.
Thank you. This form must be returned within fourteen (14) days.
Benefit Recovery Unit
(612) 296-7660 (612) 296-7855
DPW-2237 (3-79)PZ -02237-02
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Exhibit VI-22
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Exhibit VI-22a
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Ejdiibit VI-23
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Exhibit VI-23a
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COX Exhibit VI-26
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CHAPTER VII
SUMMARY
There are several factors contributing to the viability of the
Minnesota Benefit Recovery operation. Of primary significance is
that the operation is based on sound legislative authority obtained
in the developmental stage. There is no doubt that without this
legislative basis, the operation would suffer in attempting to
obtain direct reimbursement from third party resources.
Another critical factor is the education received by the
county workers inasmuch as the unit depends on them to identify
insurance and to provide the insurance information to the unit.
Training has consisted of emphasizing the significance of their
efforts as opposed to merely providing instruction in the completion
of the forms. The county workers have been cooperative as well as
receptive.
Provider education is of equal importance in that the unit
depends on the provider as well to identify potential TPL . By
assuming the TPL billing on their behalf, the provider has become
more responsive to alerting the unit to TPL not only through the
use of the TPL and injury codes reflected on the invoices but
through written and verbal communication.
The cooperation received from the insurance industry has been
of great significance to the Benefit Recovery Unit. The assistance
provided by the HIAA and Blue Cross/Blue Shield of Minnesota has
been instrumental to the viability of the operation.
Minnesota has an inherent advantage over some other States in
that It IS not a 1634 State, i.e., SSI individuals must meet the
specific eligibility standards for Title XIX. Thus, the State can
require the cooperation of the SSI population in identifying available
resources to the county and in assigning available benefits.
There are numerous reasons why Minnesota took this approach
to TPL utilization. Among these is the fact that providers frequently
cannot secure the complete insurance infonnation from the recipient
due to various factors. Additionally, the provider has little, if
any, incentive to pursue all available resources in that oftentimes
it results in double billing and may delay his/her cash flow.
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We believe that post payment provides for a more controlled
situation in which the likelihood of the recipient receiving any
insurance proceeds is reduced. It provides for the maximization
of all available resources. Additionally, it provides for a
monitoring system for those providers who may bill an insurance
carrier but may fail to report the insurance proceeds to the MA
program.
Some post payment recovery is necessary in each State to
ensure utilization of those resources not readily identifiable
nor available (e.g. Tort liability). In consideration of this, as
well as the aforementioned factors, Minnesota chose to include all
third party resources in its post payment recovery activity.
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CMS LIBRARY
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