Common use of Third Party Liability Clause in Contracts

Third Party Liability. By law, Medicaid is the payer of last resort and as a result shall be used as a source of payment for Covered Services only after all other sources of payment have been exhausted. If an Enrollee has resources available for payment of expenses associated with the provision of Covered Services, other than those which are exempt under Title XIX of the Social Security Act, such resources are primary to the coverage provided by the Contractor, pursuant to this Contract, and must be exhausted prior to payment by the Contractor. The Capitation Rate set forth in this Contract has been adjusted to account for the primary liability of third parties to pay such expenses. The Contractor shall be responsible for determining the legal liability of third parties to pay for services rendered to Enrollees pursuant to this Contract. The Contractor shall maintain a current TPL Resource File which contains the Enrollee’s current TPL information including coverage that has ended for the Enrollee. The Contractor shall share TPL information with Subcontractors that are responsible for payment of Covered Services for Enrollees. The Contractor shall also provide TPL information to the Department on a monthly file. All funds recovered by the Contractor from Third Party Resources shall be treated as income to the Contractor to be used for eligible expenses under this Contract. Except as provided in Section 41, the Contractor and all Providers in the Contractor’s Network are prohibited from directly receiving payment or any type of compensation from the Enrollee, except for Enrollee co-pays or deductibles from Enrollees for providing Covered Services. Enrollee co-payments, co-insurance or deductible amounts cannot exceed amounts specified in 907 KAR 1:604. Co-payments, co-insurance or deductible amounts may be increased only with the approval of the Department.

Appears in 5 contracts

Samples: Medicaid Managed Care Contract, Medicaid Managed Care Contract, Medicaid Managed Care Contract

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Third Party Liability. By law, Medicaid is the payer of last resort and as a result shall be used as a source of payment for Covered Services covered services only after all other sources of payment have been exhausted. If an Enrollee a Member has resources available for payment of expenses associated with the provision of Covered Services, other than those which are exempt under Title XIX of the Social Security Act, such resources are primary to the coverage provided by the Contractor, pursuant to this Contract, and must be exhausted prior to payment by the Contractor. The Capitation Rate set forth in this Contract has been adjusted to account for the primary liability of third parties to pay such expenses. The Contractor shall be responsible for determining the legal liability of third parties to pay for services rendered to Enrollees Members pursuant to this Contract. The Contractor shall maintain a current TPL Resource File which contains the EnrolleeMember’s current TPL information including coverage that has ended for the Enrollee. The Contractor shall share TPL information with Subcontractors that are responsible for payment of Covered Services for Enrollees. The Contractor shall also provide TPL information to the Department on a monthly fileMember. All funds recovered by the Contractor from Third Party Resources shall be treated as income to the Contractor to be used for eligible expenses under this Contract. Except as provided in Section 41, the The Contractor and all Providers in the Contractor’s Network are prohibited from directly receiving payment or any type of compensation from the EnrolleeMember, except for Enrollee Member co-pays or deductibles from Enrollees Members for providing Covered Services. Enrollee Member co-paymentspay, co-insurance or deductible amounts cannot exceed amounts specified in 907 KAR 1:604. Co-paymentsCo- pays, co-insurance or deductible amounts may be increased only with the approval of the DepartmentXxxxxxxxxx. 00 XXX 433.138 requires that as a condition of Medicaid eligibility each Member will be required to: A. Assign, in writing, his/her rights to the Contractor for any medical support or other Third Party Payments for medical services provided by the Contractor; and B. Cooperate in identifying and providing information to assist the Contractor in pursuing third parties that may be liable to pay for care and services provided by the Xxxxxxxxxx. 00 XXX 433.138 requires the Contractor be responsible for actively seeking and identifying third party resources, i.e. health or casualty insurance, liability insurance and attorneys retained for tort action, through contact with the Members, participating providers, and the Medicaid Agency.

Appears in 2 contracts

Samples: Medicaid Managed Care Contract, Medicaid Managed Care Contract

Third Party Liability. By law, Medicaid is the payer of last resort and as a result shall be used as a source of payment for Covered Services covered services only after all other sources of payment have been exhausted. If an Enrollee a Member has resources available for payment of expenses associated with the provision of Covered Services, other than those which are exempt under Title XIX of the Social Security Act, such resources are primary to the coverage provided by the Contractor, pursuant to this Contract, and must be exhausted prior to payment by the Contractor. The Capitation Rate set forth in this Contract has been adjusted to account for the primary liability of third parties to pay such expenses. The Contractor shall be responsible for determining the legal liability of third parties to pay for services rendered to Enrollees Members pursuant to this Contract. The Contractor shall maintain a current TPL Resource File which contains the EnrolleeMember’s current TPL information including coverage that has ended for the Enrollee. The Contractor shall share TPL information with Subcontractors that are responsible for payment of Covered Services for Enrollees. The Contractor shall also provide TPL information to the Department on a monthly fileMember. All funds recovered by the Contractor from Third Party Resources shall be treated as income to the Contractor to be used for eligible expenses under this Contract. Except as provided in Section 41, the The Contractor and all Providers in the Contractor’s Network are prohibited from directly receiving payment or any type of compensation from the EnrolleeMember, except for Enrollee Member co-pays or deductibles from Enrollees Members for providing Covered Services. Enrollee Member co-paymentspay, co-insurance or deductible amounts cannot exceed amounts specified in 907 KAR 1:604. Co-paymentspays, co-insurance or deductible amounts may be increased only with the approval of the DepartmentXxxxxxxxxx. 00 XXX 433.138 requires that as a condition of Medicaid eligibility each Member will be required to: A. Assign, in writing, his/her rights to the Contractor for any medical support or other Third Party Payments for medical services provided by the Contractor; and B. Cooperate in identifying and providing information to assist the Contractor in pursuing third parties that may be liable to pay for care and services provided by the Xxxxxxxxxx. 00 XXX 433.138 requires the Contractor be responsible for actively seeking and identifying third party resources, i.e. health or casualty insurance, liability insurance and attorneys retained for tort action, through contact with the Members, participating providers, and the Medicaid Agency.

Appears in 2 contracts

Samples: Medicaid Managed Care Contract, Medicaid Managed Care Contract

Third Party Liability. By law, Medicaid is the payer of last resort and as a result shall be used as a source of payment for Covered Services only after all other sources of payment have been exhausted. If an Enrollee has resources available for payment of expenses associated with the provision of Covered Services, other than those which are exempt under Title XIX of the Social Security Act, such resources are primary to the coverage provided by the Contractor, pursuant to this t his Contract, and must be exhausted prior to payment by the Contractor. The Capitation Rate set forth in this Contract has been adjusted to account for the primary liability of third parties to pay such expenses. The Contractor shall be responsible for determining the legal liability of third parties to pay for services rendered to Enrollees pursuant to this Contract. The Contractor shall maintain a current TPL Resource File which contains the Enrollee’s current TPL information including coverage that has ended for the Enrollee. The Contractor shall share TPL information with Subcontractors that are responsible for payment of Covered Services for Enrollees. The Contractor shall also provide TPL information to the Department on a monthly file. All funds recovered by the Contractor from Third Party Resources shall be treated as income to the Contractor to be used for eligible expenses under this Contract. Except as provided in Section 41, the theThe Contractor and all Providers in the Contractor’s Network are prohibited from directly receiving payment or any type of compensation from the Enrollee, except for Enrollee co-pays or deductibles from Enrollees for providing Covered Services. Enrollee co-payments, co-insurance or deductible amounts cannot exceed amounts specified in 907 KAR 1:604. Co-payments, co-co- insurance or deductible amounts may be increased only with the approval of the Department.

Appears in 1 contract

Samples: Medicaid Managed Care Contract

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Third Party Liability. By law, Medicaid is the payer of last resort and as a result shall be used as a source of payment for Covered Services only after all other sources of payment have been exhausted. If an Enrollee has resources available for payment of expenses associated with the provision of Covered Services, other than those which are exempt under Title XIX of the Social Security Act, such resources are primary to the coverage provided by the Contractor, pursuant to this Contract, and must be exhausted prior to payment by the Contractor. The Capitation Rate set forth in this Contract has been adjusted to account for the primary liability of third parties to pay such expenses. The Contractor shall be responsible for determining the legal liability of third parties to pay for services rendered to Enrollees pursuant to this Contract. The Contractor shall maintain a current TPL Resource File which contains the Enrollee’s current TPL information including coverage that has ended for the Enrollee. The Contractor shall share TPL information with Subcontractors that are responsible for payment of Covered Services for Enrollees. The Contractor shall also provide TPL information to the Department on a monthly file. All funds recovered by the Contractor from Third Party Resources shall be treated as income to the Contractor to be used for eligible expenses under this Contract. Except as provided in Section 41, the The Contractor and all Providers in the Contractor’s Network are prohibited from directly receiving payment or any type of compensation from the Enrollee, except for Enrollee co-pays or deductibles from Enrollees for providing Covered Services. Enrollee co-payments, co-insurance or deductible amounts cannot exceed amounts specified in 907 KAR 1:604. Co-payments, co-insurance or deductible amounts may be increased only with the approval of the Department.

Appears in 1 contract

Samples: Medicaid Managed Care Contract

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