Third Party Liability Frequently Asked Questions
Under federal law, if a Medicaid recipient has other insurance coverage, Medicaid is responsible for paying the medical benefits only in cases where the other coverage has been exhausted or does not cover the service at issue. Thus, a significant amount of the state’s Medicaid recoveries are the result of MFD’s efforts to obtain payments from third-party insurers responsible for services that were inappropriately paid with Medicaid funds. MFD’s Third Party Liability group, working with an outside vendor, seeks to determine whether Medicaid recipients have other insurance and recovers money from private insurers in cases where Medicaid has paid claims for which the private insurer was responsible. In addition, the Third Party Liability group also manages a daily hotline for the public and providers to call and update third-party commercial insurance information for Medicaid recipients.
What is TPL?
TPL stands for Third Party Liability. Federal regulations and applicable state laws require that third party resources, such as private insurance, are used before Medicaid, which reduces the program’s expenditures and saves the State money.
Why is TPL important?
The Federal and state laws, which mandate that third party insurance must pay claims before Medicaid does so, ensure that Medicaid is the payer of last resort and is not making payments when there may be other insurance coverage in place that could be paying such claims.
TPL ensures the per Federal and State Medicaid guidelines, Medicaid is the payer of last resort.
What happens if my private insurance terminates?
When someone signs up for Medicaid, or NJ Family Care, the person signs an application stating that he/she will update any insurance information that changes. If insurance changes or terminates, Medicaid needs a "Certificate of Creditable Coverage" from your insurer, in order to update the insurance information in the Medicaid System. This is required whether it is a change in coverage or a termination of coverage.
Why are my claims not being paid (provider question)?
The most likely scenario, is that you have omitted TPL information or TPL payment from your claim to Medicaid/Unisys.
Is it wrong for my NJM service provider to offer or give me money and/or various items such as gifts, coupons, vouchers, trips, etc?
Yes. An offer of money or any other items or services of value by a Medicaid provider is a violation of the Federal Anti-Kickback Statute Social Security Act 42 U.S.C. § 1320(a) and 7(b).
Am I responsible to pay money to my doctor or pharmacist for the services they provide to me?
No. A New Jersey Medicaid beneficiary is not required to pay any additional fee or co-payment to service providers such as a physician, dentist, or pharmacy. However, drug prescription co-payments are required for State funded only programs such as P.A.A.D. and Senior Gold. P.A.A.D. requires a $6.00 co-pay for generic drugs and a $7.00 co-pay for brand name drugs. Senior Gold requires a co-pay of $15.00 plus half of the remaining cost of the drug.
How can I report Medicaid fraud and abuse to the Medicaid Fraud Division?
You may either call our Fraud Hotline directly at 1.888.937.2835, submit a form online by clicking on the "File a Complaint" link or send us an email to njmedicaidfraud@omig.state.nj.us.
If I report an incident, can I remain anonymous?
Yes.
What happens to my case once I file a report?
Your case will be assigned to an investigator. As long as you provide adequate contact information, the investigator may reach out to you for additional information.
Is everything I say kept confidential?
If you would prefer, we will keep your information confidential. Please note, though, that allegations of patient abuse will be referred to the proper authorities.
Will I be told of the outcome of my case?
If the result is public knowledge and not confidential, you will be notified of the outcome.
What happens if you cannot help me?
We will refer you to the proper agency if we cannot work on your case.
How long does an investigation take?
It depends on the depth of the investigation, but some cases can be resolved within 90 days.
