Coordination of Benefits

Current federal regulations require Medicaid to pay for health care only after the Member’s other health resources have been exhausted. In other words, Medicaid is viewed as the payer of last resort. The requirement that third parties pay first is called Medicaid “third party liability” (TPL).

In guidelines issued by the CMS, TPLs are defined as individuals, entities, insurers, or programs that may be liable to pay all or part of the expenditures for medical assistance provided under a state Medicaid plan.

Third parties include private health insurance (e.g., commercial insurers, self-funded plans, or profit or non-profit pre-paid plans), Medicare, Tricare, Champva, automobile insurance, state worker’s compensation, and other Federal programs.

Pursuant to 42 CFR 136.61 subpart G and the Memorandum of Agreement in OAR 310-146-0000, Indian Health Services or Tribal Health Facilities operating under a section 638 agreement are payers of last resort and are not considered an alternate resource or third party resource (TPR).

Forms

• Coordination of Benefits Intake Form
• Member Accident Form

Contact Us

If you encounter any of the following or have any questions regarding third party liability, please contact the TPR Department by phone at 541.464.4175 or by email at UHTPR@umpquahealth.com.

• Member has other insurance which is not noted by UHA
• Member is pursuing a settlement for an injury or illness
• Member is in police custody at the time treatment is rendered