06/24/1991 39660

THIRD PARTY LIABILITY PROGRAM TECHNICIAN

DEFINITION:

This is technical and administrative work in the collection, review and analysis of medical assistance claims and other information used to identify and resolve third party liability for medical assistance program service related claims that should be paid by Medicare, private insurers or other resources.

Employees in this class perform technical work reviewing claims submitted by medical assistance program service providers and evaluating other information in order to identify claims that are liable for payment by Medicare, legally responsible relatives or commercial health care insurers. Work involves applying medical assistance, Medicare, Blue Cross/Blue Shield and major medical or commercial health care insurance carrier eligibility provisions in the performance of third party liability cost recovery activities; searching insurance, medical, and county assistance office and court records; reviewing claim referrals and claim invoices submitted by medical assistance program service providers; extracting records from the automated data base files and identify and comparing data; verifying information; identifying liable third party resources; inputting new data into the automated system; processing claims; relaying information to medical assistance service providers; generating correspondence in cost recovery efforts; performing data matches from data exchange materials supplied by commercial health care insurance companies; and processing claim adjustments to reconcile automated provider accounts. Work includes contact with medical assistance service providers, county assistance offices, domestic relations offices, commercial health care insurers, the Social Security Administration, and employers to verify, obtain and provide information relating to third party liability for services provided to eligible medical assistance clients. Work is guided by established policies and procedures and it is performed independently under the general supervision of a TPL Program Technician Supervisor. Completed work is reviewed for adherence to program policies and objectives, through conferences and reports, and by an evaluation of results obtained.

EXAMPLES OF WORK:

Analyzes medical assistance claims by collecting and reviewing information on individual claims, and identifying if Medicare, legally responsible relatives or a commercial health care insurer is liable for the payment of medical assistance services provided to eligible clients.

Researches claims for payment for services provided by accessing MAMIS and TPL data base files and by contacting applicable sources to obtain or verify information for claim resolution.

Contacts medical assistance service providers, county assistance offices, domestic relations offices, court officials, commercial health care insurance companies and employers, to determine why a claim was denied by other resources, to verify dates of service provided or payment by third party resources, and to clarify health care coverage provisions and eligibility criteria/status, responds to inquiries and provides assistance and instructions in the proper completion of forms necessary for compliance with the federally mandated third party liability program.

Reviews pending claims generated by the on line Pending Resolution System of the MAMIS automated system, compares invoices and data base records, identifies and resolves discrepancies, and determines if a third party is liable for payment of claim referrals. Applies appropriate coding for the on line Pending Resolution System to resolve the claim.

Researches, interprets, and applies applicable reference manuals and the governing regulations and policies and confers with other staff and with outside sources where claim resolutions are not clearly defined.

Updates the MAMIS and TPL data bases by inputting new and/or revised information into the system.

Interprets laws and explains governing policies regarding medical assistance claims for resolution of costs for services provided to debtors, public officials, legally responsible individuals, medical assistance service providers, commercial health care insurance companies and others, and cooperates with county welfare officials in the analysis and settlement of medical assistance claims.

Processes group recoveries generated by the Unified Recovery System (URS) and generating correspondence to providers to request additional information; reviews statements forwarded by service providers, compares data against paid claims listing and MAMIS/TPL file information and determines if recovery is warranted, if billing procedures are correct, and if deductibles were paid properly; then, inputs appropriate codes into the URS.

Reviews responses to the data exchange compliance notices from county Domestic Relations Sections (DRS), which determines whether the DRS has taken appropriate action regarding enforcement of medical support for Aid to Families with Dependent Children (AFDC) children/clients.

Processes gross adjustment requests from service providers for overpayment by reviewing invoice and claim payment files, verifying information, making calculations to verify or determine the correct amount owed, completing forms with appropriate claim amounts and forwarding for MAMIS input. Generates a notification form letter to the appropriate provider upon completing the gross adjustment.

Responds to general inquiries from medical assistance program service providers and other state and federal agencies concerning the TPL identification and recovery program; provides instructions and explanations on TPL processing, procedures and requirements as needed.

Participates on special projects as required, which includes such activities as reviewing, comparing, matching and verifying data against reports and file histories; examining invoices and statements and identifying billing and procedural errors; generating informational and notification correspondence; processing claim adjustments; inputting data in the automated systems; and identifying and reporting claims processing problems and keypunch errors made by the MAMIS front-end processing contractor.

Performs quality assurance and miscellaneous reviews for segments of the Office of Medical Assistance Programs, which entails obtaining and comparing information from MAMIS/TPL files against claim data, verifying information, identifying if a liable third party exists, inputting new and updated information into the system, and notifying OMAP of new information.

Compiles statistics and prepares status reports which describe the numbers of resolved and pending claims.

Performs related work as required.

REQUIRED KNOWLEDGES, SKILLS, AND ABILITIES:

Knowledge of sources of information to resolve patient claims submitted by health care providers.

Ability to request and explain information requested by or required from the various health care service providers, commercial health care insurers and other interested parties.

Ability to apply program regulations, policies and procedures in identifying legally liable third party resources for payment for health care services provided to eligible medical assistance program recipients.

Ability to exercise judgement and to make sound decisions which are in compliance with applicable program mandates.

Ability to maintain effective working relationships with medical assistance program service providers, associates, public and private officials, county assistance office staff, domestic relations office personnel, court officials, health care insurance companies, federal and state agencies and the public.

Ability to communicate effectively by expressing ideas orally and in writing in order to respond to telephone and mail inquiries related to program regulations and procedures.

MINIMUM EXPERIENCE AND TRAINING:

Three years of para-technical experience in the identification and processing of Health Care claims or resolution of third party liability issues in the Health Care Claims processing field.

or

Any equivalent combination of experience and training.