Anda di halaman 1dari 146

Benefit Recovery

in the

Minnesota
Title XIX

Prosram

Intonnatton

Resource
Csnter

March 1980
Health Care Financin3 Administration

THE HEALTH CARE FINANCING ADMINISTRATION (HCFA) was established to combine health financing and quality assurance programs into a single HCFA is responsible for the Medicare program, Federal particiagency. 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 efficiency 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.

BENEFIT RECOVERY
IN THE

MINNESOTA TITLE XIX PROGRAM

MARCH 1980

BETH A. WAHTERA
MANAC2R, BENEFIT RECOVERY

DEPARTMENT OF PUBLIC WELFARE

TABLE OF CONTENTS

CHAPTER
I.

TITLE

PAGE
1

INTRODUCTION
GENERAL PROGRAM STATISTICS Program Size Program Costs Average Cost By Selected Provider Types Provider Participation Health Insured Recipients

II.

3 3
3

4 4
5 5

III.

ORGANIZATIONAL STRUCTURE Heal th Recovery Secti on Tort Liability Section Accounts Receivable Section Data Control Section
LEGISLATIVE AUTHORITY Enabling Legislation Recent Legal Devel opmen ts Decisions of the Supreme Court Legislative Analysis
CURRENT PROCEDURES Collection of Health Insurance Information Identification and Submission of Health Insurance Claims Health Insurance Reports Identification of Other Third Party Liability Uncontested Liability Contested Liability Contested Worker' s Compensation Accounting of TPL Recoveries Health Insurance Recoveries Other TPL Adj ustments
OTHER HEALTH COVERAGE (OHC) FILE Introduction Overv i ew Collection of Health Insurance Data Health Insurance Billing Collection of Other TPL Data Accounts Receivable Function OHC Input Documents Health Insurance Information Form (HIIF) Health Insurance Information Request Form (HIIRF) Insurance Adjustments and Recoveries Form (lARF). Tort Letters Closing Form (TCF) General Subsystems Desi gn Collection of Health Insurance Data Health Insurance Billing Collection of Other TPL Data Accounts Receivable Processing
SUMMARY

6
7

lY.

33 33 37 39 40

V.

47 47

48 49 49
51

52 53 54

55 56

VI.

89 89 89 89 90 90
91

91
91

92 92 92 99 99

104 105 106 133

VII.

LIST OF EXHIBITS

EXHIBIT
III-l

PAGE

Department of Public Welfare Organizational Chart


Health Care Programs Division Organizational Chart

10
11

III-2
III-3

Benefit Recovery Unit Organizational Chart


Position Description:
Position Description: Position Description: Position Description: Position Description:
Manager, Benefit Recovery

12

III-4
III-5 III-6
III-7

13-16 17-20

Administrative Assistant
Legal Technician

21-24
25-27
28-31
35 35 35

Senior Account Clerk


Medical Claims Analyst

III-8
IV-1

Minnesota Minnesota Minnesota Minnesota Minnesota

Statutes Statutes Statutes Statutes Statutes

62A.045 256B.042 256B.37 2568.06 256B.39

35
35

IV-2
IV-3

DPW Rule 47 (Third Party Liability)

36
37

DPW Rule 47 (Premium Payment)

IV-4

Minnesota Statutes 176.191


Minnesota Statutes 176.521 Vetsch vs. Schwan's Sales Enterprises (Syllabus) (283 NW 2nd 884; 1979)
Instructional Bulletin #78-37

38 38

IV-5
IV-6

39

IV-7

41-42

IV-8
V-1

Information Bulletin #79-11


Health Insurance Information Form (HIIF)

43-46
57-58
59

V-2

Benefit Recovery Information Form (BRIF)


County Instructional Bulletin #77-28
Third Party Liability (TPL) Codes

V-3
V-4

60
61

V-5

Health Insurance Claim Form (HICF)

62-63

LIST OF EXHIBITS

EXHIBIT
V-6

PAGE

Assignment of Benefits for Private Health Care Coverage


Notice of Subrogation
Injury Codes
TPL Report:
TPL Report:

64

V-7 V-8

65
66

V-9

Work Accidents

67

V-10
V-11

Auto Accidents..
Accidents
-

68 69
70

TPL Report:
TPL Report:

Possible Tort Liability

V-12

Diagnosis Reflects Possible Tort Liability....

V-13
V-14

Accident/ Injury Inquiry


TPL File Summary

71-72
73

V-15
V-16

TPL Cover Letter

74
75

Notification of Potential Interest


Assigned Claims Bureau
-

V-17
V-18

Application of Benefits

76

Medical, Surgical, Hospital Lien


Workers' Compensation Petition to Intervene

77-78

V-19
V-20
V-21

79-80
81

Daily Receipts Register

Multiple Adjustment Form


A/R Copy
-

82
83

V-22

Health Insurance Claim Form

V-23
V-24

Recipient Adjustment Form

84
85

Third Party Participation Report

V-25
V-26 V-27

Adjustment Report
Third Party Payment Analysis Report
Total Report

86
87

88

LIST OF EXHIBITS

EXHIBIT
VI-1

PAGE

Health Insurance Information Form

93-94
95-96
97

VI-2

Health Insurance Information Request Form


Insurance Adjustments and Recoveries Form

VI-3 VI-4
VI-5 VI-6

Tort Letters Closing Entries Form


Health Insurance Claim Form Purged Cases Listing

98
107

Insurance Adjustments and Recoveries Form/Health Insurance Claim Form Match Data Report Insurance Adjustments and Recoveries Form/Health Insurance Claim Form Match Exceptions Listing Insurance Adjustments and Recoveries Form/Excess Recoveries Listing

108

VI-7

109

VI-8

110

VI-9

Other Health Coverage/Case Information Match Data Report

Ill

VI -10

Worker Message Listing


Possible Insurance Coverage Listing
Insurance Possibly No Longer In Force

112

VI-11

113 114 115

VI-12
VI-1 3

Adjustments Requested to Insured Claims

VI-14

Other Health Coverage/Adjudicated Claims File Match Data


Medical Assistance Identification Number/File Number Cross Reference Listing

116

VI -15

117

VI-16

File Number/Medical Assistance Identification Number Cross Reference Listing

118
119
120

VI-17

Recipient Name/File Number Cross Reference Microfiche


Potential Tort Liability Claims Listing

VI-18
VI -19

New Tort Claims File/Tort History File Match Data

121

VI-20

Tort Claims Reference Microfiche

122

LIST OF EXHIBITS

EXHIBIT
VI-21

PAGE

Tort Claims Accident/Injury Inquiry


Age of Health Insurance Claim Form Records
Awai ti ng Resol uti on

123-124

VI-22

25

YI-22a
VI-23

(Carrier Specific)
Age of Health Insurance Claim Form Records at Time of Denial (Carrier Specific)

126

VI-23a
VI-24

127 128

VI-24a
Vl-25

Age of Health Insurance Claim Form Records at Time of Collection (Carrier Speci f ic )

129 30

Health Insurance Claim Form Accounts Receivable Case Microfiche


Health Insurance Claim Form Accounts Recei vabl e Summary Report

131

VI-26

32

CHAPTER

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 utilization 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 reimbursement 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.

(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 aspects of third party as contained herein.

(3)

Provide detail and description of the present status of the activity, specifically the implementation of the OHC file.

CHAPTER

II

GENERAL PROGRAM STATISTICS

PROGRAM SIZE
Fiscal Year 1978
Fiscal Year 1979

MA eligible individuals

(monthly average) 206,808

(monthly average) 200,813


117,761

Cases

118,737

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
This reflects
a

461,615,000

13.3% increase in fiscal year 1979 as compared (In addition to all Federally required services, Minnesota also provides coverage for all additional services for which Federal financial participation is received.)
to fiscal year 1978.

AVERAGE COST BY SELECTED PROVIDER TYPES


Fiscal Year 1978
Fiscal Year 1979

Inpatient hospital
(per day)

155.41

166.79

Physician (per visit or service)


Dental (per visit or service)

15.25

16.15

13.59

14.87

Outpatient hospital
(per visit)

16.90

17.58

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
Hospitals Physicians Dentists Nursing Homes Optometrists Chiropractor Pharmacy

Participation Rate
100% 90% 84% 98% 100% 90% 100%

HEALTH INSURED RECIPIENTS


In December 1979, 13.30% of the recipients in Minnesota were identified as being insured by some type of health policy.

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:
Medical Claims Analyst Supervisor Medical Claims Analyst Senior 3 Medical Claims Analysts
1 1

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. Obtain additional information as needed by the insurance carriers for the processing of claims.

(2)

(3)

Visually identify whenever possible those health insurance claims that are not insurance reimbursable.
Ensure that the health file is correctly updated from responses received by insurance carriers. Ensure that the county is notified of any changes in insurance coverage which would require Case Information (CI) file updates.

(4)

(5)

(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 costeffectiveness when submitted for premium payment consideration.
Ensure that all billable Health Insurance Claim forms are submitted correctly and in a timely manner.

(8)

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

1
1

Legal Technician (Supervisor) Medical Claims Analyst 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.


Obtain all Title XIX medical payment documentation as needed.

(4)

(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.

(2)

Obtain additional information as needed from appropriate sources to enable accurate identification of TPL.
Identify all

(3)

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.
Ensure that accurate reimbursement due the Department is obtained.
Refer to the Legal Technician all cases of nature and/or requiring legal expertise.
a

(7)

(8)

difficult

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.


Provide guidance, supervision and legal expertise to Tort Section personnel.

(3)

(4)

Report to the Manager on the status of settlement negotiations, legal decisions, etc.
Refer all

(5)

settlement offers to the Manager for approval.

ACCOUNTS RECEIVABLE SECTION


Staffing:
1

2
1

Account Clerk Senior (Supervisor) Account Clerks Clerk II

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. Ensure that all deposit slips/checks have been properly recorded by the Accounting Division.

(3)

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.


Obtain additional information as necessary to properly identify checks/denials.

(2)

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. 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.
To report to the Manager on the status of the Accounts Receivable Section.

(2)

(3)

DATA CONTROL SECTION


Staffing:

Administrative Assistant (Supervisor) 1 Clerk Typist Intermediate 2 Clerk Typists 2 Student Workers (as needed)

This section is primarily responsible for performing all support activities related to the unit. It is the responsibility of the section to:
(1

Properly maintain the health insurance files.

(2 (3

Disseminate all
Perform all

incoming mail.

typing.

(4

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.

(5

(6

Communicate with county personnel as necessary.

It is the responsibility of the Administrative Assistant to:


(1

Ensure that effective and efficient procedures are maintained within the Data Control Section and between all interfacing sections, divisions, local agencies.

(2

Analyze third party statistics from monthly financial reports and compile reports from such data. Perform research and compile reports as assigned.

(3 (4

Assist in and/or conduct training seminars as needed.


s

Thi
(1

chapter also includes examples of position descriptions for:


Manager, Benefit Recovery
-

(Exhibit III-4)

(2

Administrative Assistant
Legal

(Exhibit III-5)

(3

Technician

(Exhibit III-6)
-

(4

Senior Account Clerk

(Exhibit III-7)
-

(5

Medical Claims Analyst

(Exhibit III-8)

Exhibit III-l

n o
o z z z < -I

SI
luO > r-J
.

l| -J%
<f! * IIlO
0- k-*^
0.

S5I

<5 KB
IL U.

*^6
s

-1;
1
a

UQ

<

S
"t

z
UJ

z o i
J.? U.Q

z < >

<<
UI

s c S.S

O
I zQ

zS 2S

0 lu
I Q

?l
5,

2Q Wo
o
3

<nS
ui
,

-J

<

21
a.

S.n

Ot * t| t
<

> Sz" Zio US OOttl - - < 5 UJ 5 q| e^ 5q z>-s


IL

UJ^ te
J;

1^

E;

<
J lU

U
z

CO

3 a. Z UJ <

25 2*
St'

CO

2
ft)

ii 5I

it

<

10

Ejdiibit III-2

en
(1)

()

H
-P
cn 0)

t)
to
4-)

H -P

c9^

1
r-l

-P

8 i
'^'-^

w D D

p
UJ

g M
CO CO

w u W M Cm > Q P^
di CO

CO

11

Ejdiibit III-3

g
04

i
Co

55

2 O H

SQ

11

12

Exhibit III-4
EMPLOYEE'S NAME
State of Minnesota

POSITION DESCRIPTION
AGENCY/DIVISION

A
ACTIVITY

Public Welfare/Incone Maintenance


CLASSIFICATION TITLE

Benefit Recovery
WORKING TITLE
(if

different)

POSITION

CONTROL NUMBER

Medical Payment Recovery Supervisor


PREPARED BY

Manager
PREVIOUS INCUMBENT
APPRAISAL PERIOD
(this position

to

accurately reflects

EMPLOYEE'S SIGNATURE (this position my current iob>

description

DATE

SUPERVISOR'S SIGNATURE
reflects the

description

DATE

employee's current job)

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, Senior Account 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:

$283,378

Clientele:

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.

PE-00042-02

(3-78)

WH ITS:

Employee

YELLOW:

Supervisor

BLUE: Agency

personnel office

SALMON:

Dept. of Personnel

13

Exhibit III-4 (continued)

POSITION DESCRIPTION
Resp
No.

D D

EMPLOYEE'S NAME

POSITION

CONTROL NUMBER

596200

PRINCIPAL RESPONSIBILITIES, TASKS AND PERFORMANCE INDICATORS


It is my responsibility tc ensure that existing recovery procedures are 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 party
3.

Priority

%of
Time

Discretion

1.

25%

4.

5.

6.
2.

liability situations. Maintain procedures for adequate investigation and determination of liable party. 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. Maintain procedures to ensure that satisfactory reimbursement to the Department of Public Welfare is achieved through negotiations, etc. Promote payrrant of cost effective health insurance policies.
15%

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. Report to MA Director on a monthly basis. 6.
It is my responsibility to ensure that the Department is in compliance 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 directly 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.

3.

15%

4.

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. Conduct training seminars for county personnel. 1. Determine cost-effectiveness of health insurance policies. 2. Compose Policy and Instructional Bulletins to reiterate 3. procedure/policy and/or advise parties of new procedures/policy. Maintain ongoing communications with third party liability 4. personnel at federal level and in other states. Keep apprised of activities within Invoice Processing, Policy, 5. etc. which may impace the BR operation.

15%

PE-00042-02

(3-78)

WHITE: employee

YELLOW:

Supervisor

BLUE: Agency personnel office

SALMON: Dept

of Personnel

14

Exhibit I I 1-4 (continued)

POSITION DESCRIPTION
Resp.

n D

EMPLOYEE'S NAME

POSITION

CONTROL NUMBER

596200
Priority

No

PRINCIPAL RESPONSIBILITIES, TASKS AND PERFORMANCE INDICATORS

of

Discretion

Time

5.

It 1s my responsibility to ensure that the OHC File is successfully implemented so that maximum recoveries may be realized through its
use.
1.

15%

2. 3.

Plan and establish ongoing procedures necessary for full implementation of the system. Provide specifications for the system to support systems liason person. 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. Evaluate the ongoing activities of each unit on a weekly basis. 2. Provide assistance and direction to BR staff. 3. 4. Ensure that adequate training needs for staff members are met. 5. Administer and monitor the functions of the unit. Maintain both full staff and supervisor meetings on a scheduled 6. basis or as needed.

15%

PE00042-02

(3-78)

WHITS: Employee

YELLOW:

Supervisor

BLUE: Agency personnel

office

SALMON:

Dept. of Personnel

15

Exhibit III-4 (continued)

POSITION DESCRIPTION
NATURE AND SCOPE

C L

EMPLOYEE'S NAME

POSITION CONTROL

NUMBER

596200
and

(relationships; knowledges, skills


:

abilities;

problem solving and

creativity;

and freedom to

act.)

Nature and Scope Comnunicate verbally and in writing with all appropriate parties involRelationships: ved in third party function. This includes writing policy, provider and instructional bulletins as well as conducting training seminars and preparing and compiling training materials 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 Requires verbal and written communitypes of insurance and other liability situations. Requires ability to exercise cation skills and adeptness in human relation techniques. good judgement as well as supervisory abilities.
:

Insurance background is vital to effectively determine and pursue utilization of Insurance knowledge is required in establishing procedures and policies with various insurance carriers amenable to all parties to facilitate reimbursement 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.
assailable benefits.

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. Problems relating to computer support system. 2. 3. Problems relating to legislation involving the third party function. 4. Problems relating to county interaction with Benefit Recovery. Problems relating to BR's interface with other operations within the Department. 5. 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: Problems relating to conflicting interpretaion of legislative intent would be 1. referred to Attorney General's office. Problems relating to Benefit Recovery's interface with other divisions would be 2. 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 Creativity can also be used in problem-solving matters. changes.
:

Reports
Program.
PE-00042-02

Freedom to Act , ^ ^ ^ ^ ^ and repor-qs to MA Director on a monthly basis via written monthly status reports, requiring his on a written or verbal basis as needed on other matters which may arise attention, approval, etc. . ^ ^ ^ ^^ *u the Freedom to act is bounded by the federal regulations and state laws defining responsibilities and authorities of the Benefit Recovery operation within the Title XIX
:
,
,

-,

~~

"

'

(3-78)

WHITE: Smployee

YELLOW:

Supervisor

BLUE: Agency personnel

office

SALMON:

Depl. of Personnel

16

Exhibit III-5
EMPLOYEE'S NAME
Scate of Minnesota

POSITION DESCRIPTION
AGENCY
DIVISION'

A
ACTIVITY

Public Wei fare /Incone Maintenance


CLASSIFICATION TITLE

Benefit Recovery Unit


(if

WORKING TITLE

different)

POSITION CONTROL

NUMBER

Executive I
PREPARED BY

Administrative Assistant
PREVIOUS INCUMBENT
APPRAISAL PERIOD
(this position

to

accurately reflects

EMPLOYEE'S SIGNATURE (this position my current job)

description

DATE

SUPERVISOR'S SIGNATURE
reflects the

description

DATE

employee's current job)

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.
2
1

Clerk Typists Clerk Typists Clerk II Student Workers

DIMENSIONS
Budget:

Clientele:

220,000 Title XIX Recipients 87 Counties 10,000 Medical Providers

PE-00042-02

(3-78)

WHITE: Employee

YELLOW:

Supervisor

BLUE: Agency personnel office

PINK

Dept. of Personnel

17

Ebdiibit III-5

(continued)

n POSITION DESCRIPTION D
Resp.

EMPLOYEE'S NAME

POSITION CONTROL

NUMBER

PRINCIPAL RESPONSIBILITIES, TASKS AND PERFORMANCE INDICATORS


.It is

Priority

Discretion

No.

Time

1.

my responsibility to supervise and coordinate Data Control activities anong clerk/clerk typists to ensure an accurate and current status. To meet with staff on weekly basis to discuss and correct proa. cedures and problems. To evaluate and reassign responsibilities among staff as the b. need arises. To evaluate staff during probationary periods and/ or as needed. c.
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. To report to Manager vjhen problems arise that I am unable to a. solve or v^en I feel she shouM becone involved. To deliver a written v^ekly report to Manager on Fridays. b. To rreet with other Benefit Recovery Unit supervisors as needed c. 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. To research and conpile recovery reports as requested by Manager b. To cctipile monthly statistics fron all available resources indic. cating ratios of recovery. To effectively reconrend changes in collection of statistical d.

10

2.

10

3.

20

data.
4.

It is my responsibility to provide training as necessary so that all involved parties remain updated as to Benefit Recovery operation. To effectively recoimend v^en training for county personnel, a. insurance carriers, providers of health care is necessary. To prepare or provide for appropriate training material. b. To conduct and/or assist in training seminars. c. To ensxare that participants are properly registered and adequate d. training accaiiTBdations are provided. To sutmit written evaluation on all aspects of training seminars e. 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 developed and utilized to the fullest extent. To obtain staff develcpnent information from available resources a. b. To inform individuals of available staff training courses. To ensure that probationary evaluations and annual evaluations c. are rrade by the appropriate supervisor for all Benefit Recovery personnel on a timely basis.

10

5.

10

PE-00042-02

(3-78)

WHITE: Employee

YELLOW:

Supervisor

BLUE: Agency personnel

office

PINK Deot. ofPrtonn0l

18

Ejdiibit III-5

(continued)

POSITION DESCRIPTION
ResD No.

B D

EMPLOYEE'S NAME

POSITION CONTROL

NUMBER

PRINCIPAL RESPONSIBILITIES, TASKS AND PERFORMANCE INDICATORS

Prioritv

erf

Discretion

Time

6.

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. To ensure that loading of manual files into conputer file is don^ a. efficiently and accurately. To ensure that all Benefit Recovery staff menbers are full inb. formed and understand the steps if inplementation prior to the actual iirpleirentation date. To effectively recanmend changes in procedures which would assis-^ c. all involved parties during the transition.

10

7.

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. To effectively recornrend changes v^ich would increase effectivea. ness and be beneficial to the Unit. To request inirediate assistance from Manager for difficult b. problem areas. To collect data, meet with other personnel in order to report to c. Manager
It is my responsibility to handle special projects as assigned so that projects are conpleted accurately and effeciently. To research and obtain information as requested from Feder-ala. Govenment, Departnent of Public Welfare personnel, other states, etc. To make effective recormendations from data corrpiled for b. special reports.

10

8.

10

9.

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. To meet with Systems personnel as needed for supplying data a. necessary for effective ccrrputer enhancements. b. To meet with Systems personnel as necessary for obtaining technical assistance. To effectively recoimend technical system changes v^iich v^Duld c. enhance coolection efforts. To meet with Systems personnel to determine feasibility of d. irtplementing such changes.

10

PE-00042-02

(3-78)

WHITE: Employee

YELLOW:

Supervisor

BLUE: Agency pertortnel office

PINK Dept of Pertortnel


.

19

Exhibit III-5 (continued)

POSITION DESCRIPTION
NATURE AND SCOPE
:

EMPLOYEE'S NAME

POSITION CONTROL NUMBER

C
(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 personnel in order to elicit support and cooperation in obtaining and disseminating information 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.

PE-00042-02

(3-78)

WHITE: Employee

YELLOW:

Supervisor

BLUE:

Ager)cy personrtel office

PINK Dept of Personnel


:

20

Bdiibit

1 1 1-6

EMPLOYEE'S NAME
State of Minnesota

POSITION DESCRIPTIO
AGENCY/DIVISION

nA
ACTIVITY

Public Welfare/Inccare Maintenance


CLASSIFICATION TITLE
'''C"=!KING

Benefit pggQvery
TITLE
(If

different

POSITION

CONTROL NUMBER

Legal Technician
PREPARED BY
PREN'IOUS INCUMBENT

APPRAISAL PERIOD
(this position description

accurately reflects

EMPLOYEE'S SIGNATURE (this position my current job)

description

DATE

SUPERVISOR'S SIGNATURE
reflects the

DATE

employee's current job)

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 recoupment 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:

Not applicable

Clientele:

Title XIX recipients r 87 counties Liability carriers thro ghout the country Worker's Compensation carriers Attorneys representing Title XIX recipients Medical Providers

PE-00042-02

(3-78)

WHITE: Employee

YELLOW:

Supervisor

BLUE: Agency personnel

office

SALMON:

Dept. of Personnel

21

Exhibit III-6
(continiif^d)

POSITION DESCRIPTION
Resp
No.

EMPLOYEE'S NAME

POSITION CONTROL

NUMBER

090950
Priority

PRINCIPAL RESPONSIBILITIES, TASKS AND PERFORMANCE INDICATORS

of

Discretion

Time

It is my responsibil-lty to determine the existence of a potential third party payor so that utilization of the financially liable resource 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.

25

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. 2. To file the medical-surgical lien in a timely manner where appropriate. To file an Intervention as appropriate in Worker's Compensation cases. 4. To communicate directly with attorneys representing recipients. 5. To communicate directly with liability insurers for reimbursement. To provide all appropriate parties with complete documentation 6. to substantiate the Department's interest. 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. To consult with the BR manager and/or Attorney General's staff, 1. on a case by case basis, to determine the dollar amount that would be satisfactory in compromised settlements. To negotiate with private attorney's, insurers, etc. to obtain 2. the most equitable recovery amount. 3. To obtain final approval of the compromised recovery amount from the Benefit Recovery manager.

25

25

It is my responsibility to provide technical assistance so that the Benefit Recovery procedures operate within the constraints established by law. To keep apprised of areas of law directly or indirectly 1. impacting the Benefit Recovery operation. To provide the legal basis and clarification of Benefit Recovery 2. procedures to county personnel, insurance carriers. Benefit Recovery personnel , etc. as needed. To do legal research for special projects as assigned by the 3. Benefit Recovery Manager. To consult with Attorney General's office as required. 4.

PE-00042-02

(3-78)

WHITE: Employee

YELLOW:

Supervisor

BL UE: Agency personnel office

SALMON:

Dept. of Personnel

22

Exhibit III-6 (continued)

POSITION DESCRIPTION
Resp.

n D

EMPLOYEE'S NAME

POSITION

CONTROL NUMBER

090950
Priority

No

PRINCIPAL RESPONSIBILITIES, TASKS AND PERFORMANCE INDICATORS

of

Discretion

Time

To provide supervision to the tort section personnel so that the section operates efficiently and effectively. 1. To provide technical assistance and guidance In problem cases Involving third party liability. 2. To review on an ongoing basis the status and progress of the tort section. 3. To apprise the Benefit Recovery manager of the status of the section via a written report on a weekly basis. 4. To obtain and review daily work sheets from tort personnel. 5. To consult with Benefit Recovery manager on problem cases or areas as required. 6. To make recommendations regarding procedural and/or policy changes when necessary. To delegate assignments, etc. as needed. 7.

20

PE-00042-02

(3-78)

WHITE: Employee

YELLOW:

Supervisor

BLUE: Agency personnel

office

SALMON:

Dept. of Personnel

23

Exhibit III-6 (continued)

POSITION DESCRIPTION
NATURE AND SCOPE
;

r L

EMPLOYEE'S NAME

POSITION

CONTROL NUMBER

090950
and
abilities;

(relationships; knowledges, skills

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.
Problems may arise in the failure of a recipient and/or his/her attorney PROBLEM AREAS This position has the authority in providing the information necessary for DPW recovery. 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 ineligible for Medical Assistance.
:

Problems may also arise in the reluctance of an attorney or insurer to agree to a settlement 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 appropriate legislation thereby facilitating reimbursement. Any matters of a questionable or more difficult nature are referred to or discussed with the Benefit Recovery Manager. This position reports to the Benefit Recovery manager on the status of FREEDOM TO ACT 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.

PE00042-02

(3-78)

WHITE: Employee

YELLOW:

Supervisor

BLUE: Agency personnel

office

SALMON:

Dept. of Personnel

24

Exhibit III-7
EMPLOYEE'S NAME
State of Minnesota

POSITION DESCRIPTION
AGENCY/DIVISION

A
ACTIVITY

Public Wei fare /Income Maintenance


CLASSIFICATION TITLE

Benefit Recovery
(if

WORKING TITLE

different)

POSITION

CONTROL NUMBER

Senicr Account Clerk


PREPARED BY
PREVIOUS INCUMBENT
APPRAISAL PERIOD
(this position

to

accurately reflects

EMPLOYEE'S SIGNATURE (this position my current job)

description

DATE

SUPERVISOR'S SIGNATURE
reflects the

description

DATE

employee's current job)

POSITION PURPOSE
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.

To

REPORTABILITY
Reports
to:

Recovery Coordination Supervisor

Supervises:

NO One

DIMENSIONS
Budget:

Clientele:

10,000 Health Care Providers


87 Minnesota Counties

220,000 Title XIX Recipients Insurance conpanies throughout the United States insuring Medicaid recipients.

PE-00042-02

(3-78)

WHITE:

YCLLOKIf: Supervisor

BLUE: Agency personnel offlet

PINK

Dept. of Personnel

25

Exhibit III-7 (continued)

POSITION DESCRIPTION
Resu No.

EMPLOYEE'S NAME

POSITION CONTROL

NUMBER

D
AND PERFORMANCE INDICATORS
Priority

PRINCIPAL RESPONSIBILITIES, TASKS


It is

%crf

Discretion

Time

1.

m/ responsibility to na in tain written and verbal camunication^ A with all involved parties so that additional information may be gained on documents in need of such information. To cormunicate as needed with Health Care Providers on any recovery a. 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 B accounts are maintained within technical program requirements. To conplete adjustirent invoices conpling concise data which updalfes a. both provider and DPW technical records. To assure proper reimbursement of insurance paynents exceeding b. DFW allowances.
i

30

2.

30

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. To establish procedures' betv,^en Accounts Receivable and the a. remaining sections of Benefit Recovery. To establish working relations with the DFW Accounting Section b. to assure proper handling and distribution of incoming recover ie^. To maintain conrrunication with Health Insurance COnpanies tterebjc. 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.
4.

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. To sort checks according to the type of recovery they represent, a. To cotplete the proper Mjustment Form on any type of recovery. b. To maintain a file for all recoveries submitted by health care c. providers, counties and recipients. To obtain necessary information vtere necessary through use of d. 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. To gain correct information through the use of recipient record a. files, microfilm copies, and recipient payment histories. To carplete Error Correction Forms and submit them to be entered b. into the system.
(3-78)

30

5.

PE-00042-02

WH/TE: Employee

YELLOW:

Supervifor

BLUE: Agency personnel office

PINK Dept. of Personnel


:

26

Ebdiibit III-7

(continued)

POSITION DESCRIPTION

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 If are'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: Problems arising due to insufficient data necessary for the adjustrtei^t a. of recoveries. Problems originating from the Error Correction Forms generated. b. Problems arising from requests for refunds. c.

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 an insurance conpany, county or medical provider making a payment to the Department in error.
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.

PE-00O42-02

(3-78)

WHITE: Employee

YELLOW:

Supervitor

BLUE: Agency personnel office

PINK Dept of Personnel


:

27

Ejdiibit III-8
EMPLOYEE'S NAME
State of Minnesota

POSITION DESCRIPTION
AGENCY/DIVISION

A
ACTIVITY

CLASSIFICATION TITLE

WORKING TITLE

(if

different)

POSITION

CONTROL NUMBER

Mpfiical Claims Analyst


PREPARED BY
PREVIOUS INCUMBENT
APPRAISAL PERIOD
(this position description

to

accurately reflects

EMPLOYEE'S SIGNATURE (this position my current job)

description

DATE

SUPERVISOR'S SIGNATURE
reflects the

DATE

employee's current job)

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^cipients


87 counties

i^prCKimately 10,000 ivtedicaid Providers Insurance conpanies throughout the United States, insuring I^dicaid recipients

PE-00042-02

(3-78)

WHITE: Employee

YELLOW:

Supervisor

BLUE:

Agertcy personnel office

PINK

Dept. of Personnel

28

Ejdiibit III-8

(continued)

POSITION DESCRIPTION
Resp. No.

EMPLOYEE'S NAME

POSITION CONTROL

NUMBER

D
Priority

PRINCIPAL RESPONSIBILITIES.TASKS AND PERFORMANCE INDICATORS

Discretion

Time

1.

It is m^' responsibility to naintain the current procedures of the B Recovery coordination section so that efficient and proper collectioifi of benefits nay be made. To collect benefits on behalf of Medi:;al Assistance recipients a. from responsible third parties through assignitent of benefits cr subrogation. To exercise DIW right of subrogation to collect insurance proceec: b. en behalf of Medical Assistance dependent children vten the absent parent is required to provide nedical care for the children. To identify and refer to the Tort Unit all cases vtere other thiijd c. party resources are potentially available, i.e. Workers' Corpensation, Auto, etc. To investigate possible insurance coverage vtere benefits have d. not been previously utilized.

2.

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. To send Health Insurance Claim Forms with assignnent of subrogation a. 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. To sutmit second notices ^/tien appropriate to follow up on c. collection of benefits. It is rry responsibility to naintain current and accurate insurance B information so that expedient claims processing is achieved. To request that counties forward to Benefit Reccveiry Unit initia]. a. and annually updated assignment of benefits. To request that counties secure initial and on-going recipient b. insurance information by obtaining Benefit Recovery Information Forms at point of intake and redetermination. To request prortpt up-dates ty counties of Case Information File c. 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. To authorize DHV paynent of those claims that are- not insxaranoe a. payable or v^iere no other third party liability exists. b. To authorize reduced DR-J payment resulting from investigstion of other health cover zge and third party liability. c. To establish procedures within the framework of claims prooessinc to assure providers of minimum claim handling and delays.

85

3.

4.

PE-00042-02

(3-78)

WHITE: Employee

YELLOW:

Supervisor

BLUE:

Agertey pertonnel office

PINK: Oapt. ofPertor^nel

29

Exhibit I I 1-8 (continued)

POSITION DESCRIPTION
Reso No.

EMPLOYEE'S NAME

POSITION CONTROL

NUMBER

D
AND PERFORMANCE INDICATORS
Priority

PRINCIPAL RESPONSIBILITIES, TASKS

Discretion

Time

5.

It is ny respcnsibility to provide on-going training and assistance 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. To conduct or participate in training seminars throughout the a.
state.
b.

c.

To travel as necessary to those counties to provide additional training vten requested. To cortminicate with health insurance carriers to insure efficient handling of Benefit Recovery Health Insurance Claim Forms.

6.

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. To inperpet benefits payable under those policies submitted to a. 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. To transpose insxarance data onto the revised Benefit Recovery a. Information Form for all cases presently maintaired within Benefit Recovery. To ensure that incoming Benefit Recovery Information Forms are b. accurately ccnpleted.

7.

8.

It is my responsibility to be responsible for an assigned section of counties (Block System) as divided amongst Ptecovery Coordination Staff. So that effective cortitunications exist between county workers and the Benefit Recovery Unit. To act as liason person for county personnel to provide on-going a. assistance and training in Benefit Recovery procedures for that specific block of counties. To handle apjaropr lately and specific and/ or foreseeable problem b. areas. c. To handle accordingly and health claims within those coanties requiring additional information or verification, etc. To provide on-going review of interfacing activities, involving d. 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. To establish and maintain procedures as necessary for health a. insurance claims v^Aiich cannot be directly suhmitted ty the mechanized system.

9.

PE-OOO42-02

(3-78)

WHITE: Employee

YELLOW:

Supervisor

BLUE: Agency personnel office

PINK

Dept. of Personnel

30

Exhibit III-8 (continued)

POSITION DESCRIPTION
NATURE AND SCOPE

p L

EMPLOYEE'S NAME

POSITION CONTROL

NUMBER

(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 that correct and proper action is executed 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 cinf ines 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 demands a 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: Problems arising due to the variety of other payment resources. 1. Problems arising due to insufficient data necessary for the 2. insurance carriers processing needs, Problems arising frccB a lack of cooperation by insurance carriers, 3. Problems arising fron a lack of uniformity of invoice codeing 4. procedures by health care providers. Problems arising from a lack of cooperation by recipient and/ or 5. absent parent in providing necessary insurance data.

PE-00042-02

(3-761

WHITE: Employee

YELLOW:

Supervitor

BLUE: Agency personnel

office

PINK : Dept of Personnel

31

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 of actions 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 Prior to this from the date last item of medical care was furnished. 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.

33

(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 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 Medical Assistance. 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 eliminate insurance 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.

34

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
r

eligible for or receiving

medical assistance pursuant to chapter 256B

1975 c 247 s I]

THIRD PARTY UABIUTY. Subdivision 1. When the state agency 256B.042 provides, 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 necessitated the medical care.
Subd. 2. The state agency may perfect and enforce its lien by following the procedures 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 contain the following: the name and address of the person to whom medical care was furnished, 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]
[

PRIVATE INSURANCE POUCIES. Subdivision 1. Upon furnishing 25<&37 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
may be
him or
(11) his

ELIGIBILITY REQUIREMENTSw Subdivision

1.

Medical assistance

paid for any person:

has applied or agrees to apply all proceeds received or receivable by spouse from automobile accident coverage and private health care coverage agency to the costs of medical care for himself, his spouse, and children. The state 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 assigned shall be applied against the cost of medical care paid for under this chapter.

Who

2SmJ39
warded

AVOIDANCE OF DUPUCATE PAYMENTS.

Billing

statements

for-

to recipients of medical assistance by vendors seeking payment for medical care rendered shall clearly state that reimbursement from the state agency is contemplated.
[

1975

c247s8]

35

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 programs 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 determining eligibility for Medical Assistance. A trust fund is a resource of hrst recourse.

a.

The
(1)

local welfare

agency

shall:

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 statements within one year from the date the last item of medical care was furnished.
lien

b.

The
(1)

state

agency

shall:

Seek recovery of

all

third-party liability

lieneftls;

(2) Distinguish between third-party liability which is a current resource and one which is not current, based on the following considerations:

(a)

Current

liability consists

limited to,

known amounts

of but is not 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


last

one

year from the date the


furnished;

item of medical care was

and

half of an otherwise eiigihie recipient


liability

Refrain from withholding payment on bew hen third party cannot be readily determined or collected.
(4)

36

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 determined 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) on a buy-in basis for eligible recipients covered under Title

XVIII of the Social Security Act.


(3)

Such other insurancrprograms as thr^t^te


eligible-recipients.

eency

may approvefor

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) (2) (3)

Copy of actual health policy.


Amount of premiums.

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

37

plus 127o interest for any medical expenses paid by Title XIX which are subsequently found canpensable by the Worker's Conpensation insurer

Minnesota Statutes 176.191


Exhibit IV-4
IS
If

the

8mrl0ii!'s see ica

sxpenges Tor

personal
L

19
20

injury sr= pa id pursuant tc any sragran

sdc in

st er ad

ay the

cosaissioner of public welfare and


dstarainad that the injury
is

it

cs

subsequently

21

cospensabie pursuant to this


insurer snail

22
23

snaptar, the workers' conpensation


the
coT.sTi

reisburs*
expenses

33

oner

of

public welfare for the nac:cal


to

2^
25

pais ana attributable

the

personal
a

injury*

including

interest at

rate of 12 percent

year.

Also, in 1979, Minnesota Statutes 176.521 was amended to provide that stipulated settlements of claims are valid only if executed in writing and signed by the parties and intervenors:

Exhibit IV-5

176.32L [ScTTLcMEfiT Q? CLAIMS^! Sabdl


[YtLl3ITY.I in acreefaent between an
dapendartt snc
wftichtrte

si an

1.

sflipla:/s

or hit

enrploysr ar

Insurer to settle sn^ ctsicr


trte
i

is not upGO appeal

before

workers' ccnpansatian
is.

court of appeafsr for


valid wners
I

conipfljnsat

on undar this crrapte-r

It has been executad in wr:trna and signed by

the partres* and intarverrors In the aatter> and the

Z
3
i,

division has approved the ssttlenrerrt and nade an award

thereon*

If the

natter Is upon appeal before the workers*

compensation court of appeals, the workers* compensation


court of appeals
is-

the approving body,-

38

'

DECISIONS OF THE SUPREME COURT


Two recent Minnesota Supreme Court (278 NW 2nd 310; 1979) and Enterprises (283 NW 2nd 884; 1979) have ri^ts, and therefore, the Department's Caipensation cases.
decisions, Myles Brooks Vetsch vs. Schwan's Sales strengthened intervenors rights in Worker's

vs. AMF Inc.

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 In consideration that the the recipient/employee's cooperation. his/her claim, obtaining his/her had settled recipient /employee cooperation would be difficult at best.

39

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 Brooks is not forthcoming for the medical expenses incurred. 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.
Given that Title XIX is "payor of last resort", it is in the identical position as health insurers in that payment from Title XIX funds should not be made when reimbursement is subsequently available through the Worker's Compensation carrier.
If the health insurers are excluded from the settlement negotiations, they are entitled to full reimbursement with interest.

(2)

(3)

(4)

Accordingly, then. Title XIX should also be reimbursed in full with interest.

40

Exhibit IV-7

STATE OF MINNESOTA
OFFICE OF THE COMMISSIONER
612/296-2701

DEPARTMENT OF PUBLIC WELFARE CENTENNIAL OFFICE BUILDING ST, PAUL, MINNESOTA 55155
May 15, 1978

GENERAL INFORMATION
612/296-6117

Instructional Bulletin #78-37

TO:

Chairperson, County Welfare Board Attention: Director


Chairperson, Human Service Board Attention: Director

SUBJECT:

Premium Payment for Cost-Effective Irsurance Policies

The new DPW Rule 47 (12 MCAP 2.047) now enables payment of insurance premiums for cost-effective health insurance policies maintained by Title XIX recipients age 65 and over.
For those over age 65, Rule 47 covers
1.)
:

2.)

Private health insurance policies which provide benefits supplemental to Medicare coverage. Private health insurance policies for recipients not enrolled in Medicare.

For those under age 65, premium payment may be made for health insurance policies that are determined to be cost-effective. The Benefit Recovery staff assists county personnel in determining the cost-effectiveness of health policies. A copy of the actual policy should be submitted to the Benefit Recovery Unit with the following information: Recipient Name 1. ) Premium Amount 2.) Premium Payment Interval (i.e. annually, monthly,) 3.)
In addition, any information regarding the recipient's past or current medical status should be indicated when available.

The premium amount should initially be made from county funds and then be Indicated on the Summary of Abstract, Line #14.

Payment of insurance premiums for cost-effective policies is economically beneficial and every effort should be made to ensure that such policies are maintained when the recipient is financially unable to do so.

AN EQUAL OPPORTUNITY EMPLOYER

41

Exhibit IV-7 (continued)

Questions regarding this bulletin should be addressed to:

Beth Wahtera, Manager Benefit Recovery Unit (612) 296-6964

Beth Lehman MA Policy Unit (612) 296-2274

Sincerely,

Edward J. Dirkswager, Jr. Commissioner

EJD:par

42

Exhibit IV-8

STATE OF MINNESOTA
OFFICE OF THE COMMISSIONER
612/296-2701

DEPARTMENT OF PUBLIC WELFARE CENTENNIAL OFFICE BUILDING ST. PAUL, MINNESOTA 55155
April 20, 1979

GENERAL INFORMATION
612/296^117

INFORMATION BULLETIN #79-11

TO:

Attn:

Chairperson, County Welfare Board Welfare Director


Chairperson, Human Service Board Director

Attn:

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
1.

recovery checks sent from the county to DPW must include the following:
Type of recovery; i.e. estate, excess income, etc. (If the client either presently Full and correct MA ID # for each recipient. 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). State the correct amount of money to be applied against each individual recipient account.

2.

3.

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 The one exception is if your county attorney is willing to Unit immediately.

AN EQUAL OPPORTUNir/' EMPLOYER


DPW-825
43
(8-77)

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 reimbursement 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 instances wherein a third party payor may exist. Any available information 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 requesting copies 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.
all

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:

Boxes 1-4 must show the same (Case Identification Information) 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 Insurance 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


.

44

Page

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 policy for that soecific MA ID #.
If any of the followina has chanaed since the original DPW-1922 was sent to the Benefit Recovery Unit:
a. b.

2.

Update:

c. d.
3.

Name chanoe for person listed in Section Name of policyholder chanqes. Insurance terminates. Additions to Section 5.

1.

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 The Payments must be made by the countv. provided the policy is cost effective of Summary of Abstract. DP'-/ submission the reimbursed by via county is then
.

The Benefit Recovery Unit reviews all policies to determine their cost effectivThe following information must be submitted, however, for the policy ness. to be evaluated:
1.

2. 3.

4.

Copy of actual health policy. Amount of premiums. Premium payment schedule (i.e. quarterly, monthly). 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.

45

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 55101 St Paul, Mn (612)296-6964

Yours very truly,

\Xcshk C U,rV^
Arthur E. Noot Commissioner

46

CHAPTER

CURRENT PROCEDURES

COLLECTION OF HEALTH INSURANCE INFORMATION


Health insurance information is collected by the county agency at intake, eligibility redetermination, and whenever a The Title XIX change in status affecting health coverage occurs. recipient/applicant is responsible for providing all insurance An information relative to any available health coverage. Assignment of Benefits is also obtained, pursuant to State law, At the same if the recipient/applicant is the policyholder. time, the county is responsible for indicating the existence of A health insurance coverage on the Case Information file. "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 for subsequent Information form (HIIF, DPW-1922; Exhibit V-1 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.

47

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 billing Medical 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) (2)

A "Y" indicator exists on the Case Information file.

The provider has instructed Benefit Recovery to bill the insurance carrier by leaving the TPL field "blank".
No "amount from other sources" exists on the invoice.

(3)

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 matched

with the individual Benefit Recovery Case file containing the

48

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)
(2)

Possible Insurance Coverage.

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

49

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 Unit via weekly exception reports. (Exhibits V-9,10,11 ,12) These reports are broken into 4 categories:
(a) (b) (c) (d)

Work Accidents Auto Accidents Non Specific Accidents 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 cases in which the Benefit Recovery Unit does not receive If no response a response within 30 days, a second inquiry is sent. 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

50

in a "No TPL" file for documentation purposes. are handled by the Tort Section personnel.

All

other responses

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 notification 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 established and a separate file log is started. All subsequent activity regarding the case is reflected in the Tort file and is summarized (Exhibit V-14). Medical claims payment histories in the file log are obtained as soon as it is established that a potential TPL Those claims relating to the specific injury/ resource may exist. 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 Reimbursement is subsequently the initial reimbursement request. 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.

51

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 same basis 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 documentation 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 (Exhibit V-18). hospital lien is filed against the cause of action The actual filing of the lien is done by county personnel in the county of financial responsibility, from a draft version prepared

52

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 kept in 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)
(2)

The extent and nature of the injury.

The likelihood of continuous or ongoing medical and/or assistance.

care

(3) (4)

The total amount of the settlement.

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 (See Chapter VI, against that recipient's medical payments history. 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 The codes as well as exception reporting for trauma diagnosis. 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

53

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 Additionally, the unit/county as Medical Assistance eligibles. may receive a "Notice to Intervene" from the Worker's Compensation Division subsequent to the filing of the employee's claim petition.

An intervention (Exhibit V-19) is subsequently filed by the unit If the interwith the signature of the Attorney General's staff. vention is filed prior to the pre-trial, the Benefit Recovery paralegal attends the pre-trial in an effort to obtain a stipulation If the intervention is filed subsequent from the employer's attorney. to the pre-trial and/or the employer's attorney does not agree to stipulate, further efforts are made prior to the initiation The stipulation of the final hearing to obtain a 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) (b)
(c)

Health Insurance Recovery Tort Recovery (all other third party recoveries) 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.

54

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 Accounts Receivable 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 adjustments 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

55

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 Code Amount 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.
Third Party Payment Analysis Report (Exhibit V-26) identifies recoveries made by the provider prior to billing Title XIX.

(3)

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.

56

Ejdiibit V-1
HEALTH INSURANCE INFORMATION FORM
Recipient Last

DPW

1922

(6-77)

Name

01

First

Name

02
Completion instructions can be found on the bock of this form.

MA

Identification

Case Number

04

Date of

Birth

!05

''*^'

mtofmolior,

requeiled
it

0->

"h.i

torm

,i

<ollected

to

delermme whether you hove ony other health mior-

iT
Name
of Insurance

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 prior written :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-

program purport

Company

06

Address of Insurance Claims Office


1 1 1

07

City
1

08

State 09

^_ Code
ZIP

10

Check ALL Of The Coverage Types Which Apply Only To The Policy Indicated
r.1
1

On

This

Form
Policy

11

Basic Hospital Insurance


-

6 Nursing

Home

2 Medical
3

Surgical Insurance

l.

Major Medical Insurance

n n
I

7 Indemnity Policy
8

CHAMPUS
(HMO)
Insurance

LJ 4 Dental Insurance Lj 5 Vision Insuronce

9 Health Maintenance Organization

Court Ordered Coverage

Absent Parent

Is

the indicated recipient also policyholder?


'YES',

'ZI

YES

NO

12

If

go

to 4-B.

If

'NO', complete the following:

Policyholder Lost

Name
1

13

First

Name
i

Ml

15

Address of Policyholder

16

City

17
1

State 18

ZIP

Code

19

L
Type of Policy?
If
1
I I

._
2
I I

Individual

Group

20

INDIVIDUAL', go

to 4-C.

If

'GROUP', complete the following:

Name Of
1

Employer Or Group Under

Wh ch

Coverage

Is

Maintained

21

Address of Employer./Group
1

22

City

23

State 24

ZIP

Code

Enter

Group Number

^n ^
Number

26
1 1

Where are your


1

claims submitted?

27

[J Insurance Company

Employer

Contract Or Policy

28

Ins.

Stort Date

29

Ins.

Term Date 30

FOR COUNTY USE ONLY 38


Wkr.

Name

| | !

Wkr. Number
{ |
| |

Entry Dote
Indicate ALL Individuals
First

| |
| !

Covered Under Above


;

Listed Policy

And
Child

Relationship To Policyholder

Name Of Covered

Individual

CI*

Self

Spouse

[Y^^^

Other
j

(Specify)

J
' 1

D n n D

D D n n n

' i

1 1

1 1

D n D n D
57

n n D

a D D n n n

n D D

Original

Update
Coverage Change
| |
j

31

Service Cty.

Responsible Cty.

32

FOR STATE USE ONLY


33
1

39

34

D n D

Assignment

Subrogate

Suspend

35

36

Check

If

Continued

37

Exhibit V-1 (continued)

Health Insurance Information Form


Instructions for Completion:

This form must be


If

completed for any insurance policy which covers you and/or your dependents.
policy, a separate

you are covered under more than one are available from your county worker.
All

form for each policy must be completed. Additional forms


specific information,

information must be complete and accurate.

If

you are unsure of


left.

it

is

your responsibility as a

Recipient to obtain the accurate information.

The boxes must be completed by beginning from the

Common

abbreviations

may be

used.

When
pleted.
All

supplying

new information

for

an "Update" or "Coverage Change", only Boxes 1-5 and Box 28 must be com-

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
claims.

full

name

of your insurance

company and

the

full

address of the claims office handling your health

(Boxes #6-10)

3.

Indicate the type(s) of coverage provided by this policy. Following are descriptions of the coverages listed
11):
1.

(Box

Basic Hospital-covers

room and board,


in

x-rays, laboratory tests

and other

hospital charges while you are con-

fined as an in-patient
2.

a hospital.
drugs,

3. 4.

Medicol-Surgical-covers lab, x-ray, and surgery provided by a doctor or clinic. Major Medical-usually has a deductible amount; covers office visits, prescription Dental-covers specified dental core.
Vision-covers optometrist/opthalmology services.

ambulance, supplies.

5.

6.
7.

8.

9.

Nursing Home-covers room and board while confined to a nursing home. Indemnity policy (income policy)-allows a predetermined dollar amount on a daily or weekly basis while you are confined to a hospital. Champus (Civilian Health & Medical Program for Uniformed Services)-covers dependents of individuals on active duty or retired from the military. Health Maintenance Orgonization (HMO)-prepoic' health cere for reotment/services received at c specified clinic, (This does no; include HMO coverage mainioined by iho. Stole vo; c Recipienl in lieu o( AAedicci Assirf

tance)
0.

Court Ordered Insurance-lf a court order exists mandating an absent parent to maintain coverage, and dethe policy are unknown, or if no policy exists, check Box "O" and provide name and address of absent 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.
tails of

4-A. Indicate whether you (the recipient) ore the


If If

policyholder. (Box #12) complete the policyholder's full name and address. (Boxes # 13-19) If the address is unknown, indicate "UNK". you are the policyholder, you need not complete the policyholder name and address boxes.
not,
if

4-B. Indicate
If

this policy

is

Group
in

policy (Example: through


full

Group

insurance, complete

the place of

employment) or if employment and address

it

is

of

an Individual policy (Box #20). employment (Boxes 21-25).

In In

Box 26, indicate your Group number. 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,
tance.

if

it

went

into force after

your

eligibility for

Medical

Assis-

Disregard Box 30 (Coverage Termination Dote.)


5.

Complete the

first

name

of

all

individuals receiving Medical Assistance

who

are covered under the policy.


(last

covered, you must complete your

name

also.

Also, indicate the C!

number

two

digits of the

If you are Medical Assistance

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.

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

58

J-LfU. LL.

UX-

l_

L.

DPW-1922
(5-75)

BENEFIT RECOVERY INFORMATION FORM


TYPi OF INSURANCE
1.

Hospital Insurance (In-Patient

Out-Patient care)

2. 3.

Medical-Surgical Insurance (Surgery

In-Hospital Medical

X-Ray

Lab, etc.

Major Medical Insurance (Dr. office


Dental
Vision

visits,

prescription drugs, ambulance, etc.)

4. 5. 6.

Auto
insurance

7. Life

Accidental Death and

Dismemberment

8. Veteran's Administration Benefits

9.

CHAMPUS
Other

(provides benefits to

armed forces personnel)

10.
1 1

Home Owners

Recipient

Name:

Recipient Address:

Recipient

MA

Identification No.

Name

of Insurance

Company
Address

Type of Insurance

(use number(s) listed above)

Group Name (Employer)


(Individual contracts will not be assigned

group names)

Group Number
Contract (policy) number

Name

of Policy Holder

Effective date of policy

(if

known)

FAMILY MEMBERS COVERED


Name
Relationship

Address

(Use Reverse Side of

Form

for

"Secondary Carrier" Information)

59

Exhibit V-3

STATE OF MINNESOTA
OFFICE OF THE COMMISSIONER
6,2/296-2701

DEPARTMENT OF PUBLIC WELFARE CENTENNIAL OFFICE BUILDING .....,.- -^ ^_ .... ^ . P AU M N N ESOT A 551 55 ST
..

general
INFORMATION
6,2/296-n7

INSTRUCTIONAL BULLETIN #77-28

June 2, 1977

TO:

Chairperson, County Welfare Board Attention: Welfare Director


Chairperson, Human Services Board Attention: Director

SUBJECT:

Revised Benefit Recovery Information Form

The Benefit Recovery Unit will be implementing a mechanized health insurance billing system in November. This mechanization is necessitated due to the large dollar volume of potential health recoveries. The new system will greatly enhance the Unit's collection ability as well as reduce the manual work presently required for submission of claims to the health insurance carriers.
the Benefit Recovery Information Form {DPW'1922) has been revised to allow direct key entry of all health insurance information The purpose of the revised Benefit Recovery Information Form into the computer file. is to collect uniform and accurate health insurance data on insured Medical Assistance Recipients. The Revised Benefit Recovery Information Form will also be required for insured General Assistance Medical Care Recipients in those counties which have elected to use the Centralized Disbursement System. This form will be available from Centennial Stores after August 20, 1977.
In preparation for the upcoming mechanization,

As of September 1,

1977, all health insurance data must be submitted on the Revised Benefit Recovery Information Form An Assignment of Benefits (DPW-1933) will still be required to accompany a Benefit Recovery Information Form in those cases where the Recipient is the policyholder.
.

All

information presently maintained within the Benefit Recovery Unit will be manually transposed by the Unit staff onto the revised form. Therefore, it is not necessary to submit a Revised Benefit Recovery Information Form for those cases where insurance information has previously been submitted.

Any questions regarding this bulletin should be directed to:

Beth Wahtera, Acting Manager Benefit Recovery Unit P.O. Box 30199 690 North Robert Street 55175 St. Paul, Minnesota

Ve/y truly yours,

Vera

VJL/par

1^^

EQUAL opportunity employer Commissioner


60

^/
Li Kins

Exhibit V-4

THIRD PARTY LIABILITY (TPL) CODES

1.

No insurance conpany indicated on Medical Assistance identification


card.

2. 3.

One or more insurance companies billed. Patient's insurance coipany billed, but no amount was received as deductible amount had not been met.
Patient's known insurance policies do not cover any part of claim. Patient's known insurance benefits applicable to this claim are exhausted
Patient
'

4.

5.

6
7. 8.

known insurance no longer in force

Insurance conpany reject - reason unknown.

Provider unable to secure necessary papers and/or signature from recipient to allow claim filing.

9.

No insurance corrpany indicated on Medical Assistance identification card, but provider feels insurance coverage may exist.

61

Ebdiibit V-5

HEALTH INSURANCE CLAIM FORM


PATIENTS NAME PATIENTS MEDICAL ASSISTANCE
i

BENEFIT RECOVERY
DATE OF BIRTH

DEPT.

OF PUBLIC WELFARE
FILE

dpw-,848
(10-77)

SE_X

D
N UMBER
I

NUMBER

relationship

ADMI SSION DAT E


I I

DISCHARGE DATE
PLEASE INCLUDE F'LE NUMBER ON CORRESPONDENCE

REFER TO ATTACHMENTS FOR FURTHER INFORMATION ON THE INSURED


ID

REFERRING PHYSICIAN

NSU R ANCE N FORM AT ION


1

INQUIRIES ON CLAIM MAY BE DIRECTED TO:


Department of Public Welfare
Benefit Recovery Unit

PRIMARY DIAGNOSIS

SECONDARY DIAGNOSIS

Box 30199
St.

Paul, Mn. 55175

Phone; 612-296-

SERVICE DATE IS)


I

PLACE PROCEDURE

UNUSU AL SERVICE

UNITS DAYS

DIAGNOSIS

CHARGE

^TOI

D
UNUSUAL

PROCEDURE DESCRIPTION OR DRUG'SUPPLY NAME

SERVICE DATE (S1


I

PLACE

PROCEDURE

SERVICE

UNITS DAYS

DIAGNOSIS

CHARGE

^T0[

D
DRUG/SUPPLY NAME
UNUSUAL
SERVICE
UNITS, DAYS

P ROCEDURE DESCRIPTION OR

SERVICE DATE(S)
I

PLACE PROCEDURE

DIAGNOSIS

CHARGE

^Tof

D
UNUSUAL
SERVICE

PROCEDURE DESCRIPTION OR DRUG'SUPPLY NAME

SERVICE D ATEIS)
4

PLACE PROCEDURE

UNITS'DAYS

DIAGNOSIS

CHARGE

D
PROCEDURE DESCRIPTION OR DRUG SUPPLY NAME
UNUSUAL
SERVICE
UNITS'DAYS
DIAGNOSIS

SERVICE DATE IS)


I

PLACE PROCEDURE

CHARGE

^Tof

D
UNUSUAL

PROCEDURE DESCRIPTION OR DRUG/SUPPLY NAME

SERVICE DATEIS)
I

PLACE PROCEDURE

SERVICE

UNITS DAYS

DIAGNOSIS

CHARGE

^TOI

D
UNUSUAL
SERVICE
UNITS'DAYS
DIAGNOSIS

PROCEDURE DESCRIPTION OR DRUG SUPPLY NAME

SERVICE DATEIS)
I

PLACE PROCEDURE

CHARGE

^TOI

D
UNUSUAL
SERVICE
UNITS DAYS

PROCEDURE DESCRIPTION OR DRUG SUPPLY NAME

SERVICE DATEIS)

PLACE PROCEDURE

DIAGNOSIS

CHARGE

D
PROCEDURE DESCRIPTION OR DRUG/SUPPLY NAME
INSTRUCTIONS, CODE DESCRIPTIONS ON BACK
T
I

TOTAL CHARGES

AMOUNT RECEIVED FROM OTHER SOURCES

PAGE
I I

OF
I

PAGES

D D

n
1

MA

CONTROL NUMBER

RESOURCES

AMOUNT
PROVIDER
SEND REMITTANCE TO:
Department of Public Welfa
Fourth Floor Centenn
al

PD. BY MA

CERTIFICATION STATEMENT
TH:s 15 TO CERTIFY THAT THIS CLAIM CONSTITUTES A REQUEST FOR INSURANCE BENEFITS FOR SERVICES PROV DED FOR AND PAID FQR ON BEHALF OF YOUR INSURED, UNDER THE TITLE XIX MEDICAL ASSISTANCE PROGRAM, DEPARTMENT OF PUBLIC WELFARE. STATE OF MINNESOTA. COLLECTION S PURSUANT TO AUTHORITY ESTABLISHED BY MINNESOTA STATUTE CHAPTER 247.

e
Id

Bu

ng

ATTN: Cashier
St.

Pau 1,

MN

55155

SIGNATURE

62

Ebdiibit V-5

(continued)

THIS FORM, AND THE ACCOMPANYING ASSIGNMENT OF BENEFITS FORM AND INSTRUCTION SHEET, CONSTITUTE 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.
3.

All drafts or disallowances must include the File Number, (found in top right-hand

corner of claim).
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.

2.

ALL DIAGNOSIS CODES ARE FROM THE H-ICDA CODE SERIES. PLACE COOES. Place Codes , (all services except ^I.

Medical Transportation).

Destination Codes , (Medical Transportation Only).


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

l=Office 2=Home 3=In-Patient Hosp. 4=0ut-Patient Hosp,

5=Public Clinic 6=Nursing Home


7=Ind. Lab.

8=0ther

3.

UNUSUAL SERVICE CODES.


B.

Practitioner Services. A =Prof. Comp. K =Multiple Procedures B =Reduced Service L =Fonow-up Only C =Unusual Service M =Two Surgeons Ci=Blood Drawn Lab N =Co-SurgGons C2=Blood Drawn Bedside Q =Assistant Surgeon C3=Admini strati on Charge S =Complications D =Reference to Outside Lab. V =Early Periodic Screening E =Multiple Physicians W =Far,ily Planning F =Repeat Procedure Same Phy. Z =MuUiple Modifiers G =Repeat Proced.-Diff Phy. 1 =Restorative Services H =Anesthesia 2 =Preventative Services J =Anesthesia by Surgeon
.

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.
Dental dental Dental Code.
All Codes for Services services show the American Association, (ADA), Tooth See chart below.
:

C.

CODES FOUND IN UNITS BLOCK.


1. 2.
3.

4.
5.

6.

Anesthesia: one unit = 15 minutes. Blood: one unit = 1 pint. Miles: one unit = 1 mile. one unit = 1 day. Days: one unit = 1 visitor. Visits: Psych. Care: one unit = 1 hour.

RELATIONSHIP TO INSURED.
1.

2.

Self Spouse

3. 4.

Daughter Son

Other

63

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). understand that, to the extent of such assistance provided, Minnesota Law gives the Department all of my rights to have or may have. also understand benefits under the terms of any private health care coverage which that the Commissioner of Public Welfare is empowered to accept from me an assignment of my rights under
I
I

such private health care coverage.


in consideration of any such assistance received by myself and/or any of my dependents 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 have or may have, to the year, measured from the date below, under any private health care coverage which

Therefore,

listed

extent of the cost of care paid under the Program.

hereby authorize payment to the entitled during such period of one year from of the cost of care paid under the Program.
I I

Commissioner of any such benefits to which may become any provider of such private health care benefits, to the extent
I

further authorize any person, physician, or other practitioner of the healing arts, hospital, clinic, or 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 my health (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.

other

and

Medical and employment data obtained by the Department of Public Welfare for payment for any 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.
all
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:

PZ-01933-01

DPW-1933

64

(3-76)

Exhibit V-

STATE OF MINNESOTA
DEPARTMENT OF PUBLIC WELFARE CENTENNIAL OFFICE BUILDING ST. PAUL, MINNESOTA 55155
Attn:

Claims Processor

During the 1975 legislative session, the Department of Public Welfare secured legislation, (Chapter 247), which mandates assignment of health insurance proceeds to which an insured recipient is entitled. Additionally, the
legislation allows the Depiirtment the right of subrogation

when

the insured

is

not the recipient

...

such

as in cases

where the absent parent

is

required to provide hospital/medical insurance on behalf of his/her dependent children.


legislation

statutory authority for the Department of Public Welfare, Recovery Program, whereby the Department of Public Welfare bills the insurance company on behalf of the recipient, thus assuring reimbursement to the Department of Public Welfare. Additionally, this program will assure that the Department of Public Welfare is the "payor of last resort" ... subsequently reducing tax dollars expended.

The enactment of such (Benefit Recovery Unit),

provides

the

to administer a Benefit

BY VIRTUE OF THIS LETTER, THE DEPARTMENT OF PUBLIC WELFARE IS HEREBY EXERCISING ITS RIGHT OF SUBROGATION FOR BENEFITS DUE THE RECIPIENT NAMED ON THE ATTACHED BILLING STATEMENT, UNDER THE CONTRACT HELD BY YOUR INSURED FOR SERVICES ENUMERATED ON THE ATTACHED STATEMENT.
Thank you
for

your assistance and cooperation.

If

you have any questions, or

require additional information,

please write or call the Benefit Recovery Unit.

Request of Payment Instructions


1.

2.

3.

4.

check or draft covering benefits payable with an explanation of what is being paid. Checks should be 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.

made payable

All drafts or disallowances

must include the

file

number

listed

on the top right-hand corner of the

billing

form.

STATE DEPARTMENT OF PUBLIC WELFARE BENEFIT RECOVERY UNIT


P.O.

690 North Robert Box 43170


St. Paul,

Street

Minnesota

55164

AN EQUAL OPPORTUNITY EMPLOYER


PZ-02323-01

DPW-2323

(9-78),

65

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. 2.

^Problem not related to accident or employment.

Work related accident or disease.


Accident

3
4.
5.

Auto accident.

Auto accident occurring after January 1, 1975, for viMch incurred expenses exceed $20,000 or contractual liability.
-Billing frcxn Pathologists, Radiologists and Anesthesiologists. (New code effective September 1, 1975.)

6.

Injury Code Numbers 1 and 6 are only necessary to assure that the Injury Code field on the invoice is not blank.

66

Ebdiibit V-9

z o O <
SI a.

o
-H rt

I- -

z <

31

o ^

o
<

>-"

>
I/)

-<

UJ oc
(- LU

o
I

LU

EZ < oe
-t lij

<3-

(\j
sj-

U-

LA

t/1

->

rj
-

^-

t- Q.

UJ a. i:
-<

- < (J z

67

Exhibit V-10

Y'

n*B*'NBCIO
1

SlSKn

(SI'P)

10

10

N O

ft

'I

o o -

N'

n y ^

^ - N

.-

rv.

tC

r<tv.t)
i i

t-

ZQ 3 tO< E O< >


3 O
z: o: LU

in <T 1^ o. >0

o
<J-

<.c

o
{^
.

o
a!

<0 ro 9>
<ft
1

O o
>

^
rd

r^ in

o Ki

m
r^

ro to
rfl

<r

^
rt

^
(O

ro
*-

-^

CM O* -*

^T

m
eo r^

'

rj (M
*-4

o o

O o o

O O

o o

S3-

so
s> tf"

o o

*M 0

a*

in
S3-

00

*3-

CM

o ^

rH

rj

rj ru

o
CM

o
-I pH

2< => -J oo

o E 2 LU < a: O
-H

Li-

t/)

hH -) I- Q.

a.

E H < o z

H E Q. 3 " Z

68

Ejdiibit V-11

's~s'? ? si

z<
=)

-T

O
O.

-J
>-c

fSJ

U-

l^

I/)

l-l

-1

uj Q.

m 3

69

Ebdiibit V-12

Z Q O <

O x <

13 a: LU z: I-

-H

q:

70

Exhibit V-13

STATE OF MINNESOTA
DEPARTMENT OF PUBLIC WELFARE
OFFICE OF THE COMMISSIONER
612/296-2701

CENTENNIAL OFFICE BUILDING


ST. PAUL,

GENERAL

INFORMATION

MINNESOTA

55155

612/296-6117

Medical Service Date:

This form must be returned

within 14 days.

1_

We

have received information which indicates you 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

MAY

answer
1)

all

questions which apply to you.

If

question

is

not applicable, please indicate "N. A."

(i.e.,

"not applicable).
the accident

Is your injury the result of an accident? If yes, please give a brief description of happened. (IF YOUR INJURY IS DUE TO NATURAL CAUSES, AN ILLNESS,

how and where

THAN AN ACCIDENT, PLEASE STATE SO HERE, AND


THE REST OF THIS QUESTIONNAIRE.)

IT

OR ANYTHING OTHER WILL NOT BE NECESSARY TO COMPLETE

2)

On what

date did your accident occur?


drugs,
if

3)

What pharmaceutical

any, have you received?

4)

Do you

feel the

accident was caused by or due to someone else?

If so,

who?

5)

If

a)

your accident occurred at work, please answer the following: 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

71

Exhibit V-13 (continued)


7)
If

a)

your accident involved an automobile, please answer the following: Were you a passenger, driver or pedestrian?

b)

Do you

or any relative living

in

address, policy and claim

number

your household carry "No-fault" insurance coverage? Please give the name, of the insurance company, indicate in whose name the policy is in and

your relationship to the policyholder.

c)

If

your were
if

also state

a pedestrian or a passenger in the automobile, please give the name of the driver(s). Please 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


if

auto(s). Please also state

in the accident, please give the name of the driver(s) of the other 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 have they paid anything on the claim?

"No-fault" insurance

carrier.

If

so,

which

carrier,

and

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)

give the

Does the school, store, neighbor, etc. carry any homeowner's liability, or school insurance? If so, please name, address, policy and claim number of the insurance company, and in whose name the
is

policy

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

person(s)

you

will

be bringing suit against. Has

date been set for the trial?

If

name and address of the 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 without your prior written approval.

ciated.

you do not have the information that is requested, please obtain it. Your immediate cooperation If you have any questions, please feel free to call us. Thank you. This form must be returned wi t hin fourteen (14) days. Benefit Recovery Unit
If

will

be appre-

(612) 296-7660

(612) 296-7855
DPW-2237
(3-79)

PZ -02237-02

72

Ebdiibit V-L4

NAME
DATE FILED OPENED
DATE OF LIEN OR INTERVENTION_

DATE OF INJURY

NUMBER (S)

HISTORIES ORDERED (DATES)

INVENTORY

LOG

73

Ejdiibit V-15

STATE OF MINNESOTA
OFFICE OF THE

COMMISSIONER
612/296-2701

DEPARTMENT OF PUBLIC WELFARE CENTENNIAL OFFICE BUILDING ST, PAUL, MINNESOTA 55 1 55

f!fil^il'^L,^K,

INFORMATION

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 exmust be made to the penses paid to date v^ich total Department of Public Welfare. The Department has the statutory right to recoup these expenses frcm the financially liable third If you are unable to reimburse the Department at this time party. 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 information, 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 EMPLOYER


cc:

Manager, Benefit Recovery

Ui^^^@
DPW. 825
(R.77>

74

Exhibit V-16

STATE OF MINNESOTA
OFFICE OF THE

COMMISSIONER
612/296-2701

DEPARTMENT OF PUBLIC WELFARE CENTENNIAL OFFICE BUILDING ST. PAUL, MINNESOTA 55155

GENERAL INFORMATION
612/296-6117

Date:

(Insurance Carrier Name & Mdress)

RE :

Pol icyholder 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)

75

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.

n J
(NO.,

TO:

MINNESOTA AUTOMOBILE ASSIGNED CLAIMS BUREAU Room 2250 Dam Tower

Minneapolis, Minnesota 55402

L
APPLICANTS NAME

YOUR AOORESS

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

Ttn

LICENSE PLATE NO.

OR STRUCK BV

ESCRIBE AUTOMOBILES OWNED BY YOU OR ANY MEMBER OF YOUR FAMILY RESIDINQ


AUTOMOBILE

IN

OWNER

THE SAME HOUSEHOLD. INSURER

POLICY NUMBCA

AS A RESULT OF THIS ACCIDENT WERE YOU INJURED?

YES

NO

IP

YOUR ANSWER

IS

YES,

COMPLETE THE REST OF THIS FORM.

DESCRIBE YOUR INJURY

WERE YOU TREATED BY A OOCTORT DOCTOR'S NAME AND ADDRESS


YES
IF

PHONE NUMBER

NO
IN

YOU WERE TREATED

A HOSPITAL, WERE YOU

HOSPITAL'S NAME AND AOORESS

AN IN4>ATIENT7

AN OUT-PATIENT?
BILLS TO DATE

Q
WILL YOU HAVE MORE MEDICAL EXPENSE?

AMOUNT OF MEDICAL
$

AT THE TIME OF YOUR ACCIDENT WERE YOU

IN

THE COURSE

YES

NO

OF YOUR EMPLOYMENT?

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?
LIST

'^^^

~Z

'^O

NAMES AND ADDRESSES OF YOUR PRESENT EMPLOYERS AND GIVE OCCUPATION AND DATES OF EMPLOYMENT:

"EMPtOYER'ANlJ address"

OCCUPATION

-fff-

TMPiLOYE'RANirADBRESS"

"SccupatTon"

AS A RESULT OF YOUR INJURY HAVE YOU HAD ANY OTHER EXPENSES?

YES

NO

IF

YES, EXPLAIN

ON REVERSE

SIDE.

16.

SIGNATURE OF APPLICANT OR PARENT OR GUARDIAN

DATE:

IMPORTAHT:
A 3A36
(Ed.

1.

2.
1-75)

TO BE ELIGIBLE FOR BENEFITS YOU MUST COMPLETE AND SIGN THIS APPLICATION. YOU MUST ALSO SIGN ANY ATTACHED AUTHORIZATION(S).
oiv.

uNironx ^aiNTtMO au^^LV

DO NOT DETACH
AUTHORIZATION FOR MEDICAL INFORMATION AS REQUIRED BY THE MINNESOTA NO FAULT AUTOMOBILE
INS.

ACT

THIS AUTHORIZATION OR PHOTOCOPY HEREOF, WILL AUTHORIZE A PHYSICIAN, HOSPITAL, CLINIC, OR OTHER MEDICAL INSTITUTION TO FURNISH ALL INFORMATION YOU MAY HAVE REGARDING MY CONDITION WHILE

UNDER YOUR OBSERVATION OR TREATMENT. INCLUDING THE HISTORY OBTAINED, X-RAY AND PHYSICAL
FINDINGS DIAGNOSIS AND PROGNOSIS.

SIGNATURE OF APPLICANT OR PARENT OR GUARDIAN

76

Ebdiibit V-18

State of Minnesota

Medical, Surgical, Hospital Lien

County of

whose aaaress

is

represents and states:

That he/she
the

is

the Director of the

County Welfare Department. That

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

is

and who has, or

presently, a

recipient of

income maintenance under the

County Welfare Department.


was injured on or about
,
,

That

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


justly

is

Dollars;

and that there

is

due thereon, as of the date hereof, the sum of

Dollars.

To
claimed

the best of affiant's knowledge, the


said

names and addresses of


for

all

persons, firms and corporations

by

injured

person to be

liable

damages

arising

out of said injuries are as follows:

Name

Address

That pursuant to Minnesota Statute 393.10, the


Department,
in

County Welfare County and


State of Minnesota, does

and for the


lien for the value

hereby claim a

of the aforesaid medical,

sxirgical,

or hospital care provided the said


Dollars

injured person in the

amount of
on account of
said injuries.

upon any and

all

causes of

action accruing to said injured person

77

Exhibit V-18 (continued)


The amount of
the claim set forth above represents only that
at
this

amount which

is

known

and determined to be due


hospital expenses
are

time. In
to

the event that additional future medical, surgical, or


this

incurred relative

particular matter,

it

being most difficult,


is

if

not

impossible, to determine such additional expenses at this time, this claim of lien

intended to

include such additional expenses.

STATE OF MINNESOTA

)SS.

COUNTY OF

.)

being duly sworn, and


states, that

upon oath

he

is

the.

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


this

me
19.

day of

Notary Public,

.County, Minnesota

My

commission expires.

To be

served according to

MSA

514.69 on the following:

>
=

c E 3

>
cL

<3

c a

B
5
i Ik o
lU 1-

J
C i
4}

:|5

1 z
1| 5

S
3

^ O

3
,c
J

5
o

3
o

o
o
.8

1
O

c >
8

5
o

>
E

c
T3

Z 3 8

1
c

5l
78

>
fl

Exhibit V-19

STATE OF MINNESOTA DEPARTMEm' OF LABOR AND INDUSTRY WORKERS' a2?3NSATION COt-KISSION

PETITiaJ FUR LEAVE TO INTERVENE


Eitployee

VS.

File No.

Record No.
Eitployer

and

Insurer

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 character 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

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 1980 of ,

day

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

80

Exhibit V-20

OPW-215

(8-76,

-*m
Date

DO

H^AXaH. AaSlfftanCe fteaef it Recovery ir700 n Support


inri^fni
Deposit -No.
'
-

Stolo of *inneoa

department of foeuc welfare

Ooily Receipts Register


FuinJ__
1
1

35269
ir>come

Ciass.

REMITTERS MAME

CHECK, MONEY OBOES NUMBER OR DATE

DO NOT KEVPL'MCH

CHECK DO NOT KEYPUHCM


Oi=

CHn >-""" CODE - 2


1

PATIEWT
7

ACCOUNT NUMBER
:

D PLAN NO.
13
\i.

(HS
21

TRANSACTION

CODE
24

\
1

AMOUNT

'
i

23

28

29130

SsUeiS'j
i i

iieollet County

1904

11
<^l^

'

'-"'
1 1

1
1
1

yrJ

?o Op
30
ip

2Helth Support

10T78
tS2

*^
1
.

Wkt^rh-'^^s^^^ 4ri oA^ fu T


,1

X
\

,375 op
1

St.

touis County

1'

11
1

III
-l'
:j

SOfop

;
!

^exepln County
.
'

S7%9tl
660018

r-'

rH

''i

1.1
1

1
,

.S?9 op
,9 ,7

1 i

"

-t

7.

S6001?
560016
SSOfllS

:.;

*''

111111 (1111(1
1 (

6?

i %

^H!
i i i
i

111

11
1

III
1

? CO
,5

9.

^
1

"^'
1

-1

00
lOP

1
i

10.

.
.-

56061%-'^

^;
1
1

,?o
,

'

i.

"

SB01S ^
SBOOOf
.

"I--1

^('
1
1

'l

^3 op

'

.|2

^6
25

!0M
1

i
U.
IS.

568*61

" B
,

"^
,
1

II
1

II

111
1

S60l78

1,1

lilt

1 1 1

,.^0
,

op

' 1

660*77
60*76

111
1

^1
1

10 op
?5 00 V^ op
1
i i

16

17

60*75 560*7*
560U8B

4^
1
1 1

18

^
^

10 00
1

19

;s 00
t 1
1 1
1

20

560*67 "^
1 1 1

1^' op
,

i
1

21.

560*65
563*6*

'

,5 ,5

00
00

22

M "

/
1

'

^3.

560*63
!

^
"^

1
1

,
,

10 OP

^*

560t62

'

15 Op
1
,

' 1

)'
Siiomiitea bv
1

550U79 ^
Dale SiiOmmed

,1,1
Tolsl

10 00

Rece.vod

tov

Date

fKBceiveiO

CAHD COOES
A oound

81

S2 84
=

Patiem PayrTw-ni 0\he' PatTnem (Musi aiway* have insiwaoce P'an Numb^rt
etc

NSf Check,

iDeposn redocltonsf

Aci'on CoOefi

stQ" <! ifi w^is coliwrin wll post 81 cards lo i^* fiad O^bi File. see paoe 207 ol Accounts Aeci^sbie Manud' lO' explanation.

REGISTER CLERKS COPY

TEB 141980

81

Exhibit V-21
OPW-1994

MULTIPLE ADJUSTMENT
DATE r~
Dpolt

FORM

(12-76)

CLAIMS PROCESSINQ DOCUMENT CONTROL NUMBER

Amount

MAID#

RC

Orig

CCN

Rwnlttor

02
Orlg

Dapotit

Amount

MAIO#

RC

CCN

Remittor

03
Orlg

Dpotlt

Amount

MAIDJl

RC

CCN

Remittor

04
Dpotlt

Amount

MAIO#

RC

Orig

CCN

Ramlttor

05
Orlg

Dpolt

MA

ID#

RC

CCN

Ramittor

06
Orig

Dapotit

Amount

MA

ID#

RC

CCN

Ramittor

07
Orlg

Dapotit

MA

ID#

RC

CCN

Ramittor

08
Of Ig

Dapotit

(Amount

MAIO#

RC

CCN

Ramittor

09
Orig

Oapoilt

MA

IO#

RC

CCN

Remittor

10
Orlg

Oapoilt

Amount

MAIO#

RC

CCN

82

Exhibit V-22

HEALTH INSURANCE CLAIM FORM


PATIENTS NAME
I

BENEFIT RECOVERY
DATE OF BIRTH
I I
I

DEPT.

OF PUBLIC WELFARE
FILE

dpw

,848

SEX

(10-77)

NUMBER

PATIENTS MEDICAL ASSISTANCE


I

N UMBE R
I

selationship

AD MISSION DAT E
I I

DISCHARGE DATE
.EASE INCLUDE F'LE NUMBERON CORRESPONCENCE

REFER TO ATTACHMENTS FOR FURTHER INFORMATION ON THE INSURED


ID

REFERRING PHYSICIAN

NSU R A N CE

FORM AT ION

MAY BE DIRECTED
PRIMARY DIAGNOSIS

inquiries ON CLAIM TO;


Department of Public Welfare
Benefit Recovery Unit

SECONDARY DIAGNOSIS

Box 30199
St.

Paul, Mn. 55175

Phone: 612-296-

SERVICE DATE(S)
I

PLACE PROCEDURE

UNUSU AL SERVICE

UNITS DAYS

DIAGNOSIS

CHARGE
REASON FOR
CLAIM DISALLOWANCE:

ItoI

D
UNUSUAL

PROCEDURE DESCRIPTION OR DRUG SUPPLY NAME

SERVICE DATE (S)


I

PLACE

PROCEDURE

SERVICE

UNITS DAYS

DIAGNOSIS

CHARGE

^Tof

D
UNUSUAL
SERVICE
UNITS/DAYS
DIAGNOSIS

PROCEDURE DESCRIPTION OR DRUG SUPPLY NAME

SERVICE DATEIS)

PLACE PROCEDURE

CHARGE
DATE:

D
PROCEDURE DESCRIPTION OR DRUG SUPPLY NAME
UNUSUAL
SERVICE

SERVICE DATE(SI

PLACE PROCEDURE

UNITS/DAYS

DIAGNOSIS

CHARGE
REMITTOR;

D
PROCEDURE DESCRIPTION OR DRUG SUPPLY NAME
UNUSUAL
SERVICE DATEISI
I

PLACE PROCEDURE

SERVICE

UNITS DAYS

DIAGNOSIS

CHARGE

DEPOSIT CODE:

^TOI

D
UNUSUAL

PROCEDURE DESCRIPTION OR DRUGSUPPLY NAME


AMOUNT RECEIVED:
UNITS DAYS

SERV ICE DATE(Sj


I

PLACE PROCEDURE

SERVICE

DIAGNOSIS

CHARGE

^TOI

D
UNUSUAL
SERVICE
UNITS DAYS

PROCEDURE DESCRIPTION OR DRUG SUPPLY NAME


AMOUNT DUE
DIAGNOSIS

SERVICE DATEISI

PLACE PROCEDURE

CHARGE

PROVIDER:

D
PROCEDURE DESCRIPTION OR DRUG/SUPPLY NAME
UNUSUAL
SERVICE

SERVICE DATEIS)
I

Place procedure

UNITS DAYS

DIAGNOSIS

CHARGE

AMOUNT DUE
RECIPIENT:

ItoI

PROCEDURE DESCRIPTION OR DRUG 'SUPPLY NAME


INSTRUCTION S, CODE DESCRIPTION S ON BACK MA
TOTAL CHARGES
AMOUNT RECEIVED FROM OTHER SOURCE

PAGE
I

OF
I I I

PAGES

D D

CONTROL NUMBER

RESOURCES

AMOUNT
PROVIDER
SEND REMITTANCE TO:
Departrnent o
f

PD. BY

MA

CERTIFICATION STATEMENT
THIS IS TC CERTIFY THAT THIS CLAIM CONSTITUTES A REQUEST FOR INSURANCE 8ENEF TS FOR SERVICES PROVIDED FOR AND PAID FQR ON BEHALF O F YOUR INSURED. UNDER THE TtTLEXlX MEDICAL ASSISTANCE PROGRAM. DEPARTMENT OF PUBLIC WELFARE. STATE OF MU NESOTA- COLLECTION IS PURSUANT TO AUTHORITY ESTAB HEO BY MINNESOTA STATUTE CHAPTER 247.
.'

Public Welfo e
al

Fourth Floor Centenn

Bu

Id

ng

ATTN;
St.

Cosfi ier

Pau 1,

MN

55155

SIGNATURE

83

Exhibit V-23
OPW-1994

RECIPIENT ADJUSTMENT
DATE r~
01
Deposit

;i2 -5)

FORyV\

CLAIMS PROCESSING DOCUMENT CONTROL NLMBER

77

MA

lOif

'pC

'3
I

from date

thru date

Remittor

02

! 1

77
RC

Deposit

Amour t

MA

ID*

'S

from date

thru date

Remittor

03

Deposit

Amoun

_
1

MA

ID*

PC

4
s

from date
1

thru date

i I

Remittor

04
1 1

77
I

4
s

:RC

from date

thru date
pi

!,

Remittor

05

lOeposit

Amount

MA

77
I0#

4
S

RC

from date

thru date

Remittor

1 1

06

77
i

4
'S

Deposit

Amount

MAID<

|F,C

from date

thru date

'

Remittor

07

Oeoosit

Amount

MA

ID*

77 PC

4
's

from date
I

thru date
I I I
i

08

77
Deposit
i

4
Is

IRC

from date

thru date

09
J
I:

M
i

77

4
I

'fc

:s

I
I

from date

thru date
77
I I

lioiL Deposit
I

I I

from date

thru date

Remitt-jr

84

Ebdiibit V-24

'-^

ij_g

jA-IEFmj.ft,

i^

aTl s g ; g y^^ ^ ^ g ?- s ^ a g^lilllgLS jA-CfJ]

o
I

CO

lO

rsj

ov
r\i.

K>

C0'<< ro

N- nT

o <O a. H>
1-4

OO^
in tn

ir

O
D.

to > K)
so r\j o* Ciri

<
t-<

CO

>

t- O. c: in

< O 0. X

X s
-H

x{

s X'
-(

in
I

>n in

-J 0.

<Z

l-i
ffv'

r^ CO

r<>

CO

^
*r rO

CO K> CO
>a-|

r^ *o K)

-^ r- K> in ?^ .-*

0 fO r(O <o

m^ ^

o PH ^

o<

'

CO in rvi e^ rsi CO

I'ilK* ^otl^J

^^ r^ K> to ro ps f^ r^
f<>

^
-4

a.

o^

*n

fO

tft - -

M tZ UJ X
in
I/)
I-.

i/>

in ce
_j

<

b:

< ~

U
i

UJ

=3 > _) o: UJ

< >

o
ou
CO UJ
:

tn

o.

z
>-

<
> O U
Od|.

= -> << Q tn -J -I < <J o z > UJ -J -I t- s: <-< oc H - *< in o o O. 3 H- tO O u. U. IX < o o -I X >i 1- JI- H O L>
I
i

i-i

UJ

(J

I/)

,!

Q < u. > o
1/1

^ jo: > ui o Q> CE a I0.0


0:

M
Zi
: I

Of Q.

<

(/)

I-

>-Z
cji

<
Q.

oc a: oe
U.

O
oc

'li

Q. O.

OJ >^

> ac

O
5

UJ

<r
(J

-<

I-

< tO OE o z a.
.^K_

>

Q.

< < O

"

O UJ in m o O CiZ z z Of M a. Z < 3X X -I ^ O <' < O z


t/>
I-.
I/)
; .

>- UJ oe a: UJ oJ CL l> UJ zj 1/1) C_J Q tn Z, UJ


I

> O UJ o > O O
(J UJ oc
>-.

o:

jC

m - (- O' *- < Z ui n: >- 3 X O h31 O < )- UJ o o


'^ot
I

h-l

1/1

r-

r> UJ DC en
9

t-

f-a

jrxP

85

Exhibit V-25

t-

c f ^

a r - ' '
:

c -c

>,

r*^
r--

<U
O

IS

rj o -"

r\*

f*^

-H

- CK <0 OS ro (NJ ^^ sD *a-

tn CO to sc K) < J-

II

I'

ff*

i-H

c 2 3 O E
ff^

in

r\j
v3-

CO

r^ c-

t*"

in CM ^^ -I OS

m o

* r^ c^ c^ CO CM f-4 fO

03 -< h* >o CO 1 eo iNi rj D

m o o

fs- fO fO sT sC ^^ Kl r^ CK CO >T s> rvj OS I-i ro i-i CM

cys

so
eo

rsj rsi rsj

m
o

tys

-^

CO ^

O
I

jfs.

CO e^ -J fNj in r^ ru

fO so U^ -H ^ OS fs. v^ iTi r^ fss so in f-< <n

^^O m
;

^o
I

to .^ sT ^^ to IM

rg K> to

<V

!>;

r~

m
3-

iD >r

to "J r^ (M (>- rj

>

f\J

OS OS Ki

r^ rj e^ OS C3
s>

I
'"5.

2 = O <

(-

om
t>

OS

tM tri o* OS in (0 >T CO r^ rg Ift i-i J- 4 O^ r') fO r.


1 i

o O o K

Kk

>3-

rsJ ifi

CO

^ O
f^'

in <\l V_| fH o so

*)
<a-

OS
-

sT v

IfV ff-

CO

rv iA Os CO -H rj ^^ fO CO rv GO OS sT; <NJ u^ r^ fs- so JNJ

>

^^ sb tn o^ tn in ^ so to OS ^s CO sb in in ^4 in

Dc

to _H <M

sa-

tr>

*H te CO tM CM
T

-^ CO ^ *^ IM -I sD ^^ ^ l^

a> f t

in

s^

r IUJ z => E >- o < E


Q.

<

tn in rj rj r* to (M o* <- in
eo
ir^
r--

o* r-:
F<>

o ^
f**

r^

tM

PO to <0 in

oo
;

.^

.^ sT in

CO
ITi

o* -^ vo rj
rI

OO-sS- -
0>'
esi
1 1

OS

Ifi

CO

<\J

O
1

to to s "

o tn ^<o

ll

<^ so *i& CO
J
in' Q>.

G
iTi
o*-

lit

.|l
im! e^
rs.:

..... ^ m
foi K;
I

f^ 1^ t^ e^, c >c
-

OS

ir>

m
ov

O' to t~
j"

(M OS IM

to

r)

tf

o- ru

o^

nt

Oslo

in

tM r^

so (^ 1^ sT rj osJ lo CO' <a- S3- <M u^! OS CO '^ .-1 k> im;

e rjlm OS CO -. r J <v CO rsi CO CO c- <M r* so rv)

to

3-

^^
O
-

<M in

t;

1^

CO o> IVJ
-J

<lo

o:

in Foi

stf-

tn
I

tM

set INI

CO

to

CnJ

K>

0| r*^

>!0

oo u

oj

^^ ^

p.*

r\j

K*

3"

in

^0:*iO

^3
:d

i.^H

Itn
!

CM

^-|

IS.

mi

cointocoGom^intn

'

<

> UJ o u
ce

O. UJ

ui
o.;
>-l

ui!

t-

/?

=j
UI

CO
Ui'

O o
UJ 15

o'

>> oo u a:
UJ a. UJ UJiUJ tj

ui<

^ 2 o
(t/l
I

JUJ

eel Q.1 LU
fl|

> o: = o

< cn U2 l(J (-.<:--< o O< O Z o:z: UI 0| 0- => E|U E Zlt- >- t-lh- 2 a| <) u o <j|u - -i{
I
i;

> O < u UJ 2 ae
Q.

ac UI

Om

^t
> >
a: UJ ae^

u o Z at
<
Q.

2U
m tn zz

-i

UJl

->;

a.!

E UJ O E U

M<
c o
q:
I

loe

_,_

Z E
tjj

UI
UJ -J
"-I

=> cs tn
>-<
I

Zio: <IUJ
tn

O
tj

Ol OJ

> <

o. u.

UJl

Ol

eJ

ttIO
OsIh- cni

UJ

111

111.

#^l

_i a:
I

<

O> Ui O o o O 2 < oU< UI 22Z Z (J O


ui\ a:

o:

Ck:

0 UJ Ui CK

tnlz <
at

<_>

> ., UJ

UJ Z Z - 0 UJ >-l - ^ H at >< O < Zl UI Be - at t- SIX O => O UI O ta < UJ O


(jj

u 5^x

UJ

z 2 o oe z o u o
UI

UI lU

<
(J>

>- <J

Z': UI
'

tn

3 O
ir>

UJ at

<z O UJ E > m a "


tnl
^

li-jpi.ui..,

8*

I*-

86

Ejdiibit V-26

: E :t s ; s;s R a.

C 4 t -

rJ

h i

i'

h^

B 4 6..

?i; i

O -

w;

fi

J
C^

I> o
I
I

-J

Ioe

O
z

z ui
oc
UJ(

a. 1-

> oj X <

oc z:

J<

>Jz =
lij

O*

w N -H
ISJ

ii ii Vt
-i fSl ij-

ad -

Oj Ui

o< DC -J o

It

CJ
*^.

in >- o:

OS II:

<

<
Q.

-I

>-(

r^ 80 r** CO CO so ^ in c^ f F-C CO

if^
CTs LTl

rj ov rj so

r*^

> rj t^

TN(

On nT OD

fO 00 U>

o O

r\i ft tr^ CO C^ ~ -i so CO sT CO > <M CO o r^ ry

r^

<- r*I

fsi

OI 9. CO

CK

<

UJ a. z:

CO rg

ifi

fO o*

O > < = X
UJ CD OC

<0
xjIT)

*-

CC irt in o 0 ITi CM r*. K) ON tn CG * #- in sT -H iP-l M K]

a m

m < ^
-J

_A_

87

Exhibit V-27
y^
N
1

f>

'

V)

^ c s c * z

J,

n V n *

r-

c c -

c - w r r ^' ^ p~S
fS

N N

Ti!;;;! sTf;

^ t. e c _ ' (^ X t. V t' K ? D n n < ^ ^ < 4 n ^ ^ V

e . ; c:s K ^ Ki^ K K 11

*.

i i

.z
H-<

o
in

o ""

M
oo

in in

eo ^t

zz 30 UO 3t
3t O ^
tu CD

f^ r-

M
1 i

fM l^

o
r<>

o ee ^

tn

"^
i

o w

tf

o>
.

<

*N
-4
J 1
1

pM

j
1

i
1

z
</)4/)

.v4
>4

l>-

xz ^o <o -J u u
-1 Ul CO

<0

ro
i>

r-

o
h4

(7>

tn

l>

00

Ul
t

z 3
o z <

O
h*M

<o

CO r

-M

u^
(f
9,

o o

o 00 o
(NJ

o ^
f.

m
^ ^

* m

f<v in

o <
Q.

in in in

o
<M
-

in CO

u.
i4

M fl

m
r

iM

m fM

<c IS
fvl

w X
u.

CM

m
</)

o>

Mrf

(N

0^

rg IM 14

in

m
(M

o
a>
(*>

in

I/)

a:

_i u

z < ^
u.

m*

CO * tn

If

T in o

1 1

3C

w
o

.
-1

"*
1 1 ' !

D X 11 X

i
-<
in

m4

s
4

o
M
1

s
7*
-

V-4

a u

u o

o o

u u
1

::{

a
>-

<

o u

a u

X
XI

^
u K D
U.
UJ

->

W1 a. MM
l

^ m

4 > J
i !

*J 2:

Z *"
Ul

X < z o
Q. LU

(X
.

Ol

o <
QC

t> oe

UJ

> o
UJ

o z o ^o z
> -J
(X)

UJ

M ^ m
w^ -1 Hcc

u o
UJ

a M4 -J

^ u
*i

a 3

o tUJ

o UJ
-J >J

/ /

Irt

jj

o K a
tn

</)
trt

O a.

a u 3 o
I
X
M4 V7

to

*p>

t UJ

a:

1/5

o 2 < ae 3 2
UJ i^

to UJ

CO UJ
h<

z M < ^

</>

o
UJ oc
</)

o a.
u z < z *^
trt

</>

N
UJ

z
irt 1/1

f)
*

00 >

H-

Z
z
UJ

o
1/1 I/)

5 w
e o
",

*M

f-

m
3 -> Q <

3 e o
< D
\

z UJ o t^ o o <
o h3 <

z < -> o

1 J
<^
u

Ul

z
UJ N
t-

1-

^
1

z < a: 3 un
Z
-4

pg

<
UJ Q.

IS
Ul Q> tu. SJ

u
UJ a. >

a
UJ

to >-

<

X
-J

>
LI.

a V
*
u.
1-4

< O ^
u.

-4

M *
*

t^

0 -<
<N

o a

o ^

< Q
-t

i a:

a -

"1

3 a

UJ

^
1

< I

o *^
X

5
I
/>
J

u
X

u X
to
-J
V-

c
UJ
.

'%'

'-
.

y]

/'

--

.i
.^''-

'

;.

"^

o
N C

O
o

|0>

a 18

nwSSStwwSS^

^ a

o
f)

M n
ri

88

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) (b) (c) (d)

Collection of Health Insurance Data Health Insurance Billing Collection of Other TPL Data 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.

89

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 manual intervention 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 will provide 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 "Special to the Benefit Recovery Unit for additional processing. handling" cases, for example, may involve the attachment of a claimant statement to the HICF.
The Health Insurance Claim forms produced will distinguish The the types of coverage available under the specific policy. existing production of HICFs is irrespective of the types of coverage available for the individual.

The system will basis without manual

also produce "second notice" HICFs on a scheduled 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 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.
all

90

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.
Enable the unit to eliminate the present dollar limit of $100 tor initial identification of other TPL resources.

(2)

(3)

Produce second request accident/injury inquiries on 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.

Multiple resource listings used for cross-matching of information received on payments/denials will be produced to enable proper iaentifi 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 If more than one policy insurance data relative to a specific policy. This additional HlIFs are required. exists tor the same individual (s) form is designed to enable direct key entry of the data for OhC purposes
,

91

An HI IF is received by the Benefit Recovery Unit first at intake, and whenever a change occurs in the content of the information 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.
(1)

It serves:

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 Serves to close receipt of response to accident/injury inquiry. accident/ or additional History file second Tort claims from the so resource Identifies of type injury inquiries are not sent out. being pursued.

92

Ejdiibit VI-1
HEALTH INSURANCE INFORMATION FORM

DPW

1922

(6-77)

Recipient Last

Nome

01

First

Name

02

03
Completion instructions con be found on the back of this form.

MA

Identificotion

Case Number

04

Date of

Birth

05

^^

V?

M
A
Nome
of Insurance

i
Company

requetled on ihii forrn it collected to determine whether you hove ony other heoHh insvrprovide medical poymenli in lieu ol medicol oisistance. The collection o^ thii inlormotion tor 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 Medintormotio 1
.

progrom purpoiei

06

Address of Insurance Claims Office

07

City

08

State

09

ZIP

Code

10

Check ALL Of The Coverage Types Which Apply Only To The

Policy Indicated

On

This

Form
Policy

11

[D
1
1

Basic Hospital Insurance


-

O
[I]

6 Nursing

Home

2 Medical

Surgical Insurance

7 Indemnity Policy 8

D
1
1

3 Major Medical Insurance 4 Dental Insuronce


5 Vision Insurance

O
Is
If

D O O
1
I

CHAMPUS
(HMO)
Insuronce

9 Health Maintenance Organization

Court Ordered Coverage / Absent Parent

the indicated recipient also policyholder?


'YES',

YES

NO

12

go

to 4-B.

If

'NO', complete the following:

Policyholder Last

Name

13

First

Name

14

*IL

15

Address of Policyholder

16

City

17

State 18

ZIP

Code

19

Type of Policy?
If

LJ
If

Individual

Group

20

"INDIVIDUAL', go to 4-C.

'GROUP', complete the following:

Name Of

Employer Or Group Under Which Coverage

Is

Maintained

21

Address of Employer/Group

22

City

23

State

24

ZIP

Code

25

_
Enter

26

Where are your


1
1 1

claims submitted?

27
1 1

Group Number
4

1
Number
28
Ins.

Insurance

Company

Employer

Contract Or Policy

Start Date

29

Ins.

Term Dote 30
|

FOR COUNTY USE ONLY 38


Wkr.

Nome
| | | | | | | | | | | |

Wkr. Number
Entry Dote

a
First

indicate ALL Individuals

Covered Under Above

Listed Policy

And
Child

Relationship To Policyholder
StepChild

Name Of Covered

Individual

Cl#

Self

Spouse

Other

(Specify)

2
3

D D D

Original

Update
Coverage Change
| |

I]

~~\

D D D D U D

n D D D D n
93

31
1 1 1
1

Service Cty.

Responsible Cty.

n
1 1 1 1

32
1

FOR STATE USE ONLY

39

III III
1
1

33
1

34
1

D D n

Assignment

Subrogate

Suspend

u
LJ

35
1 1

36
1

Check

If

Continued

37
|

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


left.

specific information,

it

is

your responsibility as a

Recipient to obtain the accurate information.

The boxes must be completed by beginning from the

Common

abbreviations

may be

used.

When
pleted.
All

supplying

new information

for

an "Update" or "Coverage Change", only Boxes 1-5 and Box 28 must be com-

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. Complete the
claims.
full

2.

name

of your insurance

company and
by
this

the

full

address of the claims office handling your health

(Boxes #6-10)
policy. Following are descriptions of the

3.

Indicate the type(s) of coverage provided


11):
1.

coverages

listed

(Box

Basic Hospital-covers fined as

room and board,


in

x-rays, laboratory tests

and other

hospital charges while

you are con-

an in-patient

a hospital.
drugs,

2.

3. 4.

Medical-Surgical-covers lab, x-ray, and surgery provided by a doctor or clinic. Major Medical-usually has a deductible amount; covers office visits, prescription Dental-covers specified dental care.

ambulance, supplies.

5. Vision-covers 6.
7.

8.

9.

optometrist/opthalmology services. Nursing Home-covers room and board while confined to a nursing home. Indemnity policy (income policy)-allows a predetermined dollar amount on a daily or weekly basis while you are confined to a hospital. Champus (Civilian Health & Medical Program for Uniformed Services)-covers dependents of individuals on active duty or retired from the military. Health Maintenance Organization (HMO)-prepaid health care for treatment/services received at a specified clinic. (This does not include coverage maintained by the State for a Recipient in lieu of Medical Assis-

HMO

tance)
0.

Court Ordered Insurance-lf a court order exists mandating an absent parent to maintain coverage, and deof the policy are unknown, or if no policy exists, check Box "O" and provide name and address of absent 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.
tails

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

If the address is unknown, indicate "UNK". you are the policyholder, you need not complete the policyholder name and address boxes.

4-B. Indicate
If

a Group policy (Example: through employment) or if it is an Individual policy (Box #20). 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 date of your coverage, if it went into force after your eligibility for Medical Assistance Disregard Box 30 (Coverage Termination Date.)
if

this policy

is

Group

insurance, complete

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.

94

Exhibit VI-2
EEALTH INSURANCE INPORMATIOJ REOUE;T FORM
1
I I

DPW

1922

(6-77)

Recipient Last

Name

01

First

Name

02

Ml

03
Completion instructions can be found on the back of this form.

MA

Identification

Cose Number

04

Date of

Birth

05

i
Name
of Insurance

^^ informotion fequested on Ihij lorm is collected to determine whether you have any other heollh inturonce whrch moy provide medicol poymonti In liflu ot medico! Oiwjfonce The collection ot this intormotion for progrom purpoiei is outhofiied by Chopter 247 ol 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
this

prior written oppro*ol. You ore under no legol compulsion to supply, the inforrnatioo on form, howe*e', foilure to supply oil the requested intormoiion moy moke you ineligible to receive Med-

Company

06

Address of Insurance Claims Office

07

City

08

State

09

ZIP

Code

Check ALL Of The Coverage Types Which Apply Only To The


I I

Policy Indicated
I

On

This

Form
Policy

Basic Hospital Insurance


-

6 Nursing Home

2 Medical
3

Surgical Insurance

7 Indemnity Policy 8

Major Medico! Insurance

D
I
I I I

CHAMPUS
(HMO)
Insurance

4 Dental Insurance
5 Vision Insurance

9 Health Maintenance Organization


Court Ordered Coverage
/

Absent Parent

Is If

the indicated recipient also policyholder?


~YES',

YES

NO

12

go

to 4-B.

If

'NO', complete the following:

Policyholder Last

Name

13

First

Name

14

Ml

15

Address of Policyholder

16

City

17

State 18

ZIP

Code

19

Type of Policy?
If

Individual

Group

20

'INDIVIDUAL', go to 4-C.

If

'GROUP', complete the following:

Name Of

Employer Or Group Under Which Coverage

Is

Maintained

21

Address of Employer/Group

22

City

23

State 24

ZIP

Code

Enter

26

Where ore your


1

claims submitted?
2

27

Group Number
4

1
Number
28
Ins.

LJ Insurance Company

Employer

Contract Or Policy

Start Date

29

Ins.

Term Date 30
|

FOR COUNTY USE ONLY 38


Wkr.

C
^

Name

|__|_

Wkr. Number
Entry Date

[_J_
I I

Indicate ALL Individuals


First

Covered Under Above

Listed Policy

And
Child

Relationship To Policyholder
StepChild

Name Of Covered

Individual

Cl#

Self

Spouse

Other

(Specify)

2 3

J] I] ~J ~J ~J 'n

D D D n n n

D D D

Original

Update Coverage Change


| |

31
1

Service Cty.

Responsible Cty.

D D n D n
95

32
1 1
1

FOR STATE USE ONLY


33
1 1 1
1

39

2
1 1

n D

Assignment

Subrogate

III III
1 1 1

34
1

3 CU Suspend

35
1

36
1

Check

If

Continued ] 37

Exhibit VI-Z (continued)


Health Insurance Information Form
Instructions for

Completion

This
If

form must be completed for any insurance policy which covers you and/or your dependents.

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


left.

specific information,

it

is

your responsibility as a

Recipient to obtain the accurate information.

The boxes must be completed by beginning from the

Common

abbreviations

may be

used.

When
pleted.
All

supplying

new information

for

an "Update" or "Coverage Change", only Boxes 1-5 and Box 28 must be com-

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. Complete the
claims.
full

2.

name

of your insurance

company and

the

full

address of the claims office handling your health

(Boxes #6-10)

3.

Indicate the type(s) of coverage provided by this policy. Following are descriptions of the coverages listed
11):
1.

(Box

Basic Hospital-covers

room and board,


in

x-rays, laboratory tests

and other

hospital charges while

you ore con-

fined as
2. 3.

an in-patient

a hospital.
drugs,

Medical-Surgical-covers lab, x-ray, and surgery provided by a doctor or clinic. Major Medical-usually has a deductible amount; covers office visits, prescription 4. Dental-covers specified dental care.
5. Vision-covers

ambulance, supplies.

6.
7.

8.

9.

optometrist/opthalmology services. Nursing Home-covers room and board while confined to a nursing home. Indemnity policy (income policy)-allows a predetermined dollar amount on a daily or weekly basis while you ore confined to a hospital. Champus (Civilian Health & Medical Program for Uniformed Services)-covers dependents of individuals on active duty or retired from the military. Health Maintenance Organization (HMO)-prepaid health care for treatment/services received at a specified clinic. (This does not include coverage maintained by the State for a Recipient in lieu of Medical Assis-

HMO

tance)
0.

Court Ordered Insuronce-lf a court order exists mandating an absent parent to maintain coverage, and deof the policy are unknown, or if no policy exists, check Box "O" and provide name and address of absent 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.
tails

4-A. Indicate whether you (the recipient) are the policyholder. (Box
If If

# 12)
If

address. (Boxes #13-19) you are the policyholder, you need not complete the policyholder name
not complete the policyholder's
,

full

name and

the address is unknown, and address boxes.

indicate

"UNK".

4-B. Indicate
If

a Group policy (Example: through employment) or if it is an Individual policy (Box #20). 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 Assistance Disregard Box 30 (Coverage Termination Date.)
if

this policy

is

Group

insurance, complete

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.

96

1 1

Ejdiibit VI-3

irtnn
1
1

m
I

INSURANCE ADJUSTMEINTS AND RECOVERIES

IT III
i^UMlJl::U

iiiii yil
"fflCHRn^ETCTWIB JNTKECEIVED
I

tim
Uk UJblT
'

tr

Piii!

m
il

il

jj

n
I

B B

'Mwrm^^ms
L'tJlVlib

Hffl

u rrarn tm

DEPOsr

"fflOOWn^ECTTRTEP

mm
I

raposTT

FILE NUMBER
r

AMOUNT RECEIVED
I

In
ILL

rirn
I 1
1 1

m m
W u
I

LU

BETOSTT''

FILE NUMBER
I

CHTSW

rn

B
|
|

jm^^NnMRgR

^DUNT

RECEIVED
1 1 I i

"1
I

T^''^T

II
FJT.F NjIMBER
I

AMOUI-^ RECEIVED
1 1 1 1

TTfTiil
Fjrir|

t^k'lr^^l!'!'

MM

Hrl

ill

mm

MM m WLT^mi}
Tg^DUIxIT

jIIIII'

TTCrOTfflT

nnn
[
I

REC

rtiTTl
AMOUNT RECET\^D
I

FILE NUMBER

liTiTiil
FILE M]^BER

TT fTfiJil
ANprWT RECFTA/Pp
]
1

n rn m
DEPOSIT
DEPOSIT
fUliJJr'ULjrr

B B

DEPOSI

liHiiil
Jr'lLk

TT riTLi
Frp:-n/Fn 1\MT ^KCV.

tfri
I

NUMBER

Ee^sTt

II

Mill

97

Exhibit VI -4

'

m m m
i

in
I

TORT LETTERS CLOSING ENTRIES

h m i CAT TON

Em.

nf\
|MBR

A.ln&NTJFirm

EG
Ed
nr]

fflffl

mm

TONI

IVllMpFP

iiFNI ia: UQ

IMRFR

KECIPJENT

iDFNTTFTrATinKI
i'^l^

Nl

IMRPR

KECIPIENT

flA

IPENTIFICATinN

Nl

IMRFR

on
KECIPIENT

m
m

RFClPIENT_m IpFNTIFTrATinN

Nl

IMRFR

lED
Identification Nu^EER

ni
98

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) Health Insurance Information Request Form (HIIRF). (system generated; returned by county)

(2)

(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 Health Insurance 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 When a positive match occurs, the HICF record on the History file. Master file will be updated with the accounts receivable information from the lARF (e.g. amount collected, deposit code, reason code, file number)

99

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 for subsequent use in the medical payments This tape file will also be reformatted and system processing. 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 If no action determine if the corresponding lARF has been received. 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 processing:


(1)

result of the above

HICF Purged Cases Listing (Exhibit VI-5) reflects all HICFs purged from the Master file because 12 months have passed since 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.
lARF - HICF Match Exceptions Listing (Exhibit VI -7) reflects lARFs for which an HICF record could not be matched.

(3)

(4)

Excess Recoveries Listing (Exhibit VI-8) reflects matched lARF entries in which the total amount collected exceeds the initial Medical Assistance provider payment amount.
lARF
-

(5)

Adjustment Transaction Microfiche utilized by Benefi.t Recovery as a reference source and by Claims Processing as an audit trail

100

Case Information (CI) Match

System input transactions from the previous processing stages are merged to fonn a single OHC work file. The OHC work file now 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) (2) (3)

Content edit all

recently submitted HIIFs and HIIRFs.

Update the present OHC file with current HIIF/HIIRF data.


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 These is older than 24 months or a CI file record no longer exists. records are written to the OHC purged cases listing.

CI

Additionally, the health insurance coverage indicators on the be checked and verified and, as a result, a disk file These messages will indicate of worker messages will be produced. during subsystem processing inconsistencies encountered the specific records. file of the CI and OHC
file will

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

101

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) turnaround document.


OHC-CI Match Data Report (exhibit VI-9) reflects transactions input, processing and output counts for monitoring and control purposes.
OHC Purged Records Listing reflects those cases purged from the OHC file for reasons stated above. OHC File Microfiche reflects all OHC cases as they currently exist.

(2)

(3)

(4)

(5)

Tort

CI

for which a CI
(6)

Match Exception Listing reflects New Tort records file record could not be matched.

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 last processing 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. 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.

(2)

102

(3)

Case file numbers will be machine assigned for each record written to the HICF work print file. (This file number contains eight characters of which the first character is alpha and refers to the specific individual within Benefit Recovery'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.
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 passed through 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.
Workers' messages will be produced to reflect exceptions related to the production of HICFs.
be produced:

(5)

(6)

The following reports will


(1)
'

Workers Message Listing (Exhibit VI-10) (Presently produced)


Possible Insurance Coverage Listing (Exhibit VI -11) (Presently produced)
Insurance Possibly No Longer in Force (Exhibit VI -12) (Presently produced)

(2)

(3)

(4)

Adjustments Requested to Insured Claims (Exhibit VI -13) (Presently produced)


Child Abuse Claims Report (Presently produced but referred to another division)

(5)

(6)

OHC/Adjudicated Claims File Match Data (Exhibit VI-14) Reflects input, processing and output transaction counts for monitoring and control.

103

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 the HICF 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 Medical procedure data will be extracted and written to system. 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) (2)

HICF

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)

Re cipient Name - File Number Cross Reference Microfiche TTxhibit VI-17)

104

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 This processing will accomplish of the Tort Claims History file. 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.
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.
All

(3)

(4)

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 a result of this processing.
(1
)

County Notification of Overdue Tort Claims Inquiries sent to respective counties for further investigation.

(2)
(3)

Tort History Purged Cases Listing

Torts-Tort History Match Data reflects input, processing, and output transaction counts for monitoring and control purposes. Torts-Tort History Match Exceptions Listing - the New Tort Claims file which address data is matched against the Tort History file.

(4)

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.

105

(2)

All

will will
(3)

Tort records for which an accident/injury inquiry be produced are written to a temporary work file which input to the print program to produce these letters.

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.
The updated Tort History file will be used to create a work file from which the Tort Claims reference microfiche is produced.

(4)

(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)


New Tort Claims File - Tort History File Match Data (Exhibit VI-19) reflects input processing, output transactions for control end monitoring purposes.

(2)

(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)
(2)

Age of HICF Records Awaiting Resolution (Exhibit VI-22) Age of HICF Records at Time of Denial

(Exhibit VI -23)

(3)
(4)

Age of HICF Records at Time of Collection (Exhibit VI-24)

HICF Accounts Receivable Case Microfiche (Exhibit VI-25) HICF Accounts Receivable Summary Report (Exhibit VI -26)

(5)

106

Ejdiibit VI-5
:X

M D
I

en

X
1^

Z O

o O ui

107

E5diibit VI-6

^
Q)

tv
(T3

(\>

-p

C^

fO

in

o
6

r^

r\

r^

^ ^ ^

?N

?S

Ps

a
4->

fC

a I
H p
-p

I
H

I w
en

2
en

I
6 H S
fe

I
b H S b H S

<

CQ

<

CQ

<

CQ

H S

M
H

H H

X H

X!

M X

108

OS

Exhibit VI-7

X
(h

&:

in

in

o o

in

VD O o
Pi

Q
&5

1X4

X X

CO

CO CO

CO

b H
vo
I

00
CM CN (N

CO

O O

CO

X
CO CO

CO

b ^

rH

O o o

CNJ

O o o

CO

O o o

109

x:

Exhibit VI-8

i
g

O o

p
Eh

S5

M
CO

CO CO

n
oi

E-i

CO

VD
CO

^
CO

2
CO

X
cc;

s M
CO CO

Cv
CO

g
110

Exhibit VI-9

00

o
o

^ r^
4J

tS

r'S

r^

tS t^

>^

Pi
fd

CO
ill

(0
4-)

Q)

fO

M u

-P

13
i4

u
CO

^
^8
CO CO CD CO CO o;

+J

tx
0)

TO 0)

CO

CO

CO ^^

s
CO

CO

u o

O O
CO
(T3

^
CO QJ
rr-

O
CO CO 0)

^
CO q;

a M U
- H H

re

0)

to
J-i

8
4-!

M M
a:

-H

u
en

I
CM

O
>
C

u D
H M

W
CO

2
CQ

2 Q

%
fO

a
CO

u H M

H
M M

CQ

u M M
H

111

Exhibit VI-10

13

O c
I

00 a.

>
LU

<

> o u < a: 3 Z "


o <
(-0 I/)

IX LU

z z
^^

LU

X
lo

/>

o
<
LU

UJ

lU -J so LO
I/)

OJ

o a

< z
LU 00

< Q^ <
1/)

<

u
(X

O z
0.

LU
ta^

z
o
1/5

^
UJ ct

o z
oo

o z
I

OC LU

a
(

O
1 1

ro

o z

O^

o o o o o

o o o o
I

CO
I

o
rr,

OC O -i Z <

112

'

>

Exhibit VI-11
5cJ
z>

c
--

c
r

C| c'
cr

c o
c

ic
r^

o
(V

ed

C
C
ir

'

C
ir

d
C
r-

C c
r^

u-

f^

c
>c IT

C
r\.

rr

_
."^

^^

C C
C

C c c
f^

IT

ci

r'

CC

~
L.

ClI u.'

IT

P^

C
(V

c c c
c
r-.

o c c

2
z: -J' i_

c c
-^

c
>--

nO

(V

0-

c ^

c
rv

c
c

c c
-r

Ow

C C C

o
a

c
rr\

c
c
<\

c.

c
St
N?"

c
r-'

c c
r^ sO

o
rv

c
ir

o
c

c
cc
r*-

C
IT

e
r~
f*"

c
r^

C
-r

1
IT

sC

^
L'

c c c
^^

c
IT

C
C
rr

C
(\

f-

f^

C C

c c
c

^i

a
fcr

c
r^

o-

cr

C
r~
r^

c-

f^

P~

hr.

rrj

c"f^

cr^

V
p-

cf-

c-

OC

f^

f^

C" f

P-

<r

t^

C^ r-

ch-

cr "^

e-

C
f^

C
f^

0-

r
f~

c-

C
>*"

p^

r'

r-

>
LI

or;

r^

<:

c
or
LL-

ro

C
>'

^
c
IT

r-

c
r"

o
cr

O O ^ f^ C c c
<
rr cr

f~ (^
or

o
c-

C
(V'

.^
f^.

o
CC

c
(V.

a
(M sC

a-

- -^

PSJ

c
c

r^

c c

CC c-

c
_J
r-

nC

<r

c
f<(S.

O
oc pr
J-

h^

C
^*-

c
f^ c

ec

ccr T
r--

c
ar^

IT c-

o
o ^ ^ ^ ^ o
ir>
N?*

r c
c c

c^

IN
r-

C
f<-

c
or

O
c-

C
o-

t.-

C
r

cr

C
>r o
U"

c
f\i

c,

/r^

^
p^

_
>*-

_
r^

w ~

-C'
J-'

>

Oi
'

c
(V

o
(N

C C C
vC
r-i

c c c
-c r-

C
c

c
r-

r C C C
sC r-

^
K-

c ^*
c<c
f*".

C C C O
r*^

_ IT w
c o ^
f^

o
(M
f^
r^
rr\

c c
y

c-

r
n<r
n-

cc-

c
>p^

C
hL-

c
CC ucr

p~
li'

P c c c

in
u-

o
fs.

<

f^

rv
a:

M #^

C
fV

C O
rv
ec

c c
f\J

(M

or

o o c r. C

in
f*-.

c c
rj
er

a
tr>

c c c

cr C^

^
U'

^ -^

*r r-

c:
a:

o
fc

c
cr.

^
r-

1^-

(V

r"

^
cr

C C^ c

c
Uo;

i_
(."

LJ'
I.;.

<
ct U->
l_"

c c
1

c(-

C
r*
1

C c
1

c
1

c-

c
c
1

c
1

c
a:
e'-

c
c
1

c ^
1

c
K(

^ z L. < Cl;
?

c
cr
p^

(V
0tr 0-

r-

r^

r
p^

C
CC 0-

IT <y
C.

^^

0ccr

in
IT

c
or c-

c c ^
1

c c
1

c
c
1

c
c
1

c
c
1

C C
1

C c
1

c
c
1

o
c
1

c
c
1

C ^
1

cr

^
-r
ir-

L* r^

IT

CC C^
rr-

r-

er
cr-

^>
l.'^

ir

*^
ec

^
l_

U."

r
f^
c-

at:_'

C -M
^M (V
r^

c
l^ t>r
i_

c c
^H
p^
cr

1. ;^^

ir c^r^'

c
o-

c
0-

c-

,
rv

^rs.

^ M
rx'

c
c-

0-

e
C
7*

^ c
cr
(VI

c;
1

^-

^^ fV

CC (M
rsj

cr 0>t
r>

C
c-

C" -
r\'

C c o
IT
(N

(^
^m,

^
L~

r
c

f\

IV

<
O
ir
.

*.

c
2-

C
7"

c-

c-

C ^ m IN O

f^

'

C r ^
L'

^^ t^
ri

r-.

,m4

0or

IT

CC IT

r a c
1

C /~
(

c c
1

IN.'

r*-

^ ^ c
1

c
c
1

c c
1

c
c
1

c
c
1

o
vC r.
o-

\f c>c If
Ts.

cr p^

O
p^
tr
Pv >
-

C" m^

cr

r r^

r-,

.^ V*

Lf V*

(^

r^

V
^

-^

*?

C
1^
ir (V

C
c
p.

r
TT

c o o rj C 2
rv

c
_rf

c
:^ f\
c-

cr

CC

c^

X c
^vC

^.
cr

K
^-

^
rr
N^
r.

>r

%c
r.

C-~

c
^,

^
(N.

sC
r.

fv

c-

c
p"

C
i."

rr

cr

c
&'

2^ ^- 5-

Z
^^^

r
^

^
0-

T
c-

;?

^
p-

T
C

>
L-

e
'"

e
CC

"^

2
-"

i'

^
cr

ir

2
fV

z
-"

~
^
y

*;.

>'

_
t- C

>
L-'

Z
C

'^

c-

r <
<:

a
r-

J-

cr

s?-

"

X*

L'~

L"

l_

X
1/

LU

s^

>

J
o

i;.

q:

i
^-

<i

C
2: ;

< * _
_f _j

te~

Ll

V-

_J

h-

>
IL.

c
L^

<; 2.

^ < c

^
c_
I.

I.

cr =

c
<:
's.

>
^ <
l_'

\-.

J
L^
^^

U <
Q. u_

I
L. ^
Li.

:r

ZT

ii
L.
l_"Z,

w. ^

f^ ^^

1^

^
..'

2.
l_'

U-

Lu

<r -3

^-

*;

*-

>

h^

Ci-

u
s:

- <r

r
i^
=.

r
C-

r >

i^

o
L_

C >-

< r

c >

^ -

^ a

r
<r o2"
u.

T*

r^

f^ r-

r
I

c
I

c~
I

c r

c
tr

c:

'c

c c

r c c

rr-

C
a.

o
c
CL

c
c-

<-

o
c
ec

c
oc
r--

r-

.-

c r c
r-

(-

c
rv.

^ C
'^
(N.

c c c
u-

r c
(\

^
c-

c~

c
<v

c
a-

?\

c c a
C7

c
c ^
IN,

c
cr

r-

c
r-

c
c
f^
1^

O' c:
u. r^

C c
1

c-

r
1

C
c c
1

r~

f\J

IN
f^

C.

CL

C C a
1

r c

<-

c
a.
*f^

c c
fVi Pk'

rr>..

p^
.}

(M

V^

p^

r-

p^
CSi

P^
;s

r*

tr

a
.2X3.

--

^^i-^k

1?

rfvj

f^
w

^-

*_

J-

f-^

113

E5<hibit VI -12
IC
I"-

<I 2: Q.1

a.
liJ

2
r
C

_i c;

f^

>C

'C

c
-

tr

tc

c o >
Lj a: tr\;
I

^-

^w

C;

o
(\j

er u.

O o > o

I/;

10

c
c
r

o
c

c
C

iC

J-

:C

o
or
O.

z e
. -

o
7-

nr

C O
C
e.

C o
I

c
I

C C
I

a
ir
ir.

u_

L"

o o

c-

c
fM

> O

I'"

p^

r^

r~

z
>_

C <

r
C

or.

'

<
cc

21/

u
c

^
C_ 5.

r-

^
^~
7

tr

u >
<
u

7
^~
7"

<r

LL

or

^ i~
_j

tT)

^-

c
X
1

LJ
1

tj
(_

V
1

c
(>1

<r

^U.

!_

^ O
_
1

<*

^^

c
(NJ
fh.
1

c
1

_
1
1

^
1
1

^
1

_
1

< c
1 1

2 ^ c
r^
1

z*

__'

^ i
<

z < X
0:

^
(.^

<r

( t <
5:

,^

c
c
31 1

^
1 1

_,

r*
1

c
1 1

c
rv

9^
1

^
!?
U".

f*-

^.
a.

<
1

cr
(N

X
1

a
1

LT

-*

p*-

f^
r\)

N.
>c
^-*

c
c
c
r1

U
f^
r-1

>i;

cv
IT f^
1

c r

1-

c
t__

C
1

^
r
1

a
1

^
(^.
1

1^

*^
<**

._-

r.
r^.

c
J
1

IT

r^
1

f
_l_

r^i

^^

a
.
r.

cr ^

f^ r"

u-

< 1^
t

rv

^
r^

^
c;

r1

C
1

r-

c
1

C C
1

r.

c
^-

C"
1

^ f~ c
1 1

ir

rvj

rv

c c
I

C
1

c
c
1

C c
1

c
cr
t

IOf

c
1

^ c
r-
1

c
1 1

tr

c.

c
1

c c
1

<r
1

c-

c
1

c c
1

c
(

C r
1

r c
rs;
1

p^

c
t 1

IT.

r\j p>-

(M
1

r\.

ir
1

cc
-

<N,
1

(\l
1

0-

0-

3
Cl

r-

_.C
-J ";

.^

-^ fV

-fNiLr..
'1.

rw
"^
-'

rs,' :;;

C*.-Jr

0,
-l'^-

^
ec
r

a
^_ec...... '...
_

K
_,
.

""',

j*^_

"

'.

L .%- ^ ~l

T-^

;-"

>
<i
r."

__.

114

Exhibit VI-I3
H-

Z Q =1 c c E < <. r

o o

o o

o o

ir cr

r^

O
(V

y-

2 o rs uj C VZ
t/1

O o

o.

O o

in
c^
.^^

1^ rj

r-

UJ

o M

D <

-)

o
LU
QC

=)

^ oz o3
ae QC aM

(/

o o o

o o o

*-<

ri

c > o ^-

UJ

'

UJ LU q:
i->

- n o UJ UJ Of o a. c o 0^

t CC
Q.

o
UJ
U.

u
1/)

Ol

o>

*1

<r N.
1

<tl

r~
1

a o
a.
LLI

r <

<^

UJ
4/)

o 3

-J UJ

oe

LU

z o
f. a. UJ

a 3 uo Z

^ < o

u >
ai

(M

<M
1

^^ ri
1

n
1

o a z UJ
1

(T\

O
<r

CD

o
c
r-

o
1

UJ
v/l

r-

oo f^
rsi

CO *^
<T -J

U.

^
<SJ
1

^
(VJ
1

IM
\

<*>

o
X
UJ

o
t

^-

O
O *H
m o ^ o M o o o
1

O
to

O o
UJ CC

c
UJ

f^

_J

3 00
1

o o UJ
a:

>

O a
OJ
ac
t/1

>M

o
ac a.

>

O o o o
a
Ol

r~ ^ ^

o o
UJ

o
(NJ

f\J

oo

u.

UJ

UJ CD

Z UJ X 00 3 -) Q <

J-

^-

z O

o o
1

o o
1

00 UJ z>

i.

<7>
<*

UJ Z) 3. <: 1 00 z: 1 ;

(C >o

o UJ
a
to

<\

(^

o
>0

o
o

<NJ

<^
(VJ

C < o

o 03 o * o
CM
a-

^ z
E

UJ

<NJ

c>

Z z
Qt

oo

> o
o
1

>

>

3 -1
<i

m < r Z o z o ^ a MM o < J o
_)

JJ

o o
1

o o
1

t*l

ro

CO
ITi

ro in
<NJ

(\J f>-

O
o
<.

o o
(*>

^ o
.

-a

^^

rf

M^

o
1

O
1

o
1
1

in r^
1

o
1

o
<\J
1

IT

(NJ

C C C
>o fw r^ oo

;i-

ac

\j
1

*
1

uJ

UJ
1^^

rr\

s: Q. :3

O
OJ
oc

z Q

o O O o o
1
1

ro

O o o
1

in

c r^
\

O O o o
1
1

\i

"

'

1-^

-;

w/

115

Exhibit VI-14

CM Ln "*
I

o
8

g
m Q Q
m

H i
9
en

i
03 01 en CO

1^

rn

^
CO en

CO

U
Di

CO

o u

O u
fa

o U
fa

u H

fa

en

D CO

8 u
Ln
<o

O u
fa

en

en

^ s H H

r-

CN

'^

CM

ro

H >

M
>

fa

C)

M
^
fa

!<

^
en

g 0^ o
^ w sj
Eh

S 2
fa ()
ij

<;

H CO

^ ol W U

116

Esdiibit VI-15

-P

E-i

^
0^

Q
</>

-p

Q
CO

CM

u H
fe

H
[^
Em

in

U e
Q
CO

Di

o ^ o
1

8
,,

Q M
I

Fh

e g

-P

H H

CO
0)

en
-p

h 2
H
fa

CO

u H s CM

2 Q M
1

fe

c
CD

O.
-H

u
Si

117

Exhibit VI -16

uy

>

-t

1
(h

fM

Q H
I

00

o o
I

H
p..

2
H

Q H
I

-H

Eh

118

Exhibit VI-17

4J

60
Pi

1^

ij

119

Exhibit VI-I8

I s

8 H
LO

M
CO

g
Q M

o o
I

w Q
1^

8
M LO O
Q

u w
CO

a.

o 2:

o u
u

u
CO
Oh

cn

en

a. H u

<c en

H
a,

H H u
en

120

Erfilbit VI-19

g
g

o o
I

in "^

8
X
X

2
CO
CO <C

X
Q

< Q

U
cn
fM

2
en cn CO CO

2
05

O u

O u
>i

O u

O u
y

O O

cn

H H

CO

M
CO CO

&
0^

O
<: CQ

^ H

H
<:

en a.

121

Exhibit VI-20

13

D ^ H

O
T)

2D

W
_

t-3

X X X R
k;

OM
en

OH
S

R n

en

o O
I

II

cn Cj

cTi

cn

122

E5diibit VI-21

STATE OF MINNESOTA
DEPARTMENT OF PUBLIC WELFARE
9^L'S.h?^rJ^l COMMISSIONER
612/296-2701

CENTENNIAL OFFICE BUILDING '^


ST. PAUL,

general
INFORMATION
612/296-6117

MINNESOTA

55155

Medical Service Date:

This form must be returned within 14 days.


"

l_

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 happened. (IF YOUR INJURY IS DUE TO NATURAL CAUSES, AN ILLNESS,

how and where

the accident

THAN AN ACCIDENT, PLEASE STATE SO HERE, AND


THE REST OF THIS QUESTIONNAIRE.)

IT

OR ANYTHING OTHER WILL NOT BE NECESSARY TO COMPLETE

2)

On what

date did your accident occur?


drugs,
if

3)

What pharmaceutical

any, have you received?

4)

Do you

feel

the accident was caused by or due to

someone

else?

If so,

who?

5)

If

a)

your accident occurred at work, please answer the following: 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

123

Exhibit VI-21 (continued)

7)

If

a)

your accident involved an automobile, please answer the following: Were you a passenger, driver or pedestrian?

b)

Do you

or

any

relative living in

address, policy and claim

number

your household carry "No-fault" insurance coverage? Please give the name, of the insurance company, indicate in whose name the policy is in and

your relationship to the policyholder.

c)

If

your were
if

also state

a pedestrian or a passenger in the automobile, please give the name of the driver(s). Please 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


if

auto(s). Please also state

in the accident, please give the name of the driver(s) of the other they have "No-fault" insurance, and the name, address, policy and claim

number

of their insurance carrier.

e)

if you have turned in your claim to a "No-fault" insurance have they paid anything on the claim?

Please state

carrier. If so,

which

carrier,

and

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)

give the

Does the school, store, neighbor, etc. carry any homeowner's liability, or school insurance? If so, please name, address, policy and claim number of the insurance company, and in whose name the
is

policy

in.

b)

Have you turned

in a

claim to the insurance

company?

9)

Do you

plan to bring legal action against

person(s)

you

will

anyone for your accident? Please state the name and address of the 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 without your prior written approval.

ciated.

you do not have the information that is requested, please obtain it. Your immediate cooperation 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
If

will

be appre-

(612) 296-7660

(612) 296-7855
DPW-2237
(3-79)

PZ -02237-02

124

'

'

'

'

Exhibit VI-22

I OJ OJ N) NJ NJ u> 00

o ^
1 1 1 1 1 1

__i

U1

NJ

o
o
X O

o o o
o X O
I

D
D
CD
!t3

<y\

Ol

^ ooOo oo
l*J
;^

00

un
-c/>

O
X

^X

h3

g^

M O

O H K

I
I
I

H D
I

X X

XXX
?3

o
n Q

XXX
>< ><

O M

s
?3

cn

B 8 o
I

M D
I

X X

D
3=:

125

Exhibit VI-22a

o o o o
I

>

OJ cj oj (vj ro Nj <T\ CO -J *

O
I

o
i
I

en

oj (jj u> ro ivj * o^ oj un

^ oo ooo

U1

o o o o
I

^ ^

> X

tx

g
CO

X^

E
hd

en

o o
M D
I

S3

w
X H Q
?3 1^

S3

X X X

Tl

X X X X

M M H
?d

El

X W X X

126

Ejdiibit VI-23

S
CO

S
t^

9
H^

S
X

X X
<A0

en

D X

:^

s
X

a
X
o

127

Exhibit VI-23a

s 8

X X

D > > Q k; m m

D > ^ Q W K en

en

^9

a >

128

Ejdiibit VI-24

X i X

X I
X

p
w

>

X
en

K en ^ S X
en

o
X

en
n
X
en

o o
X

en

K en

s
o D

O >u
I

p X
D3
3=1

tl

o
w
X

XXX
129

Ejdiibit VI-2Aa

'XI

cn

X
dP

8Q

CO
(Ji

en

00

I ^ 8
I

dp

dP

g
?3

130

Esdiibit VI-25

53

H n X

X X
3 S

><

K
CO

o
??

i
VD

g O

^ 2 M n

pO

own
H

Q W

8 o
I

131

X
CO

Exhibit VI-26

O
I

O >*
T
I

ID

O
I

OJ
CO

8 g
I

w Q S M

>H PQ

Ln

O
Q 2 X X U CQ CQ PQ g Q Q Q M 3 3 ^ Oi [2 p^
Ci( ICC

in
I

>H >H >l

O o o o
CO
to-

fo fe fe fe O OOO

u>

o o
I

CTi

-K

* *

o o o
I

05

CO

o
o m o o o o
I

?S ^S ?N

X X X X
co-

k^ S,^ S>| kS rN f^

S
U3

U M
hi cu

CO

X
X
co-

X X X
{/>

X X
CO
to-

en

I en
Q M
CQ

g M U U
Q
Cli

B g
E-i C/3
fit

CO Fh

I
S Q
Eh

04
<;

to

M
CQ

s
u

Q
CU

&

fe

^8
O
u

ct;

s
<1

8l
132

o u

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 There is no doubt that without this in the developmental stage. 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 The county workers have been cooperative as well as of the forms. 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 The assistance of great significance to the Benefit Recovery Unit. provided by the HIAA and Blue Cross/Blue Shield of Minnesota has been instrumental to the viability of the operation.

Minnesota has an inherent that It IS not a "1634" State, specific eligibility standards require the cooperation of the resources to the county and in

advantage over some other States in i.e., SSI individuals must meet the Thus, the State can for Title XIX. SSI population in identifying available assigning available benefits.

There are numerous reasons why Minnesota took this approach Among these is the fact that providers frequently cannot secure the complete insurance infonnation from the recipient Additionally, the provider has little, if due to various factors. any, incentive to pursue all available resources in that oftentimes it results in double billing and may delay his/her cash flow.
to TPL utilization.

133

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 Additionally, it provides for a of all available resources. 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 Minnesota chose to include all well as the aforementioned factors, third party resources in its post payment recovery activity.

134

CMS LIBRARY

6015 DDDDSLLfl

^stRv.Cf

U.S. Department of Health and Human Services Health Care Financing Administration

HC FA -20045

Anda mungkin juga menyukai