21-271 Report Third-Party Liability
Date: 04/12/21
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.
For Medi-Cal, this information applies to Kern, Los Angeles, Riverside, Sacramento, San Bernardino, San Diego, San Joaquin, Stanislaus, and Tulare counties.
Be ready for changes to the reporting requirements for third-party tort liability cases
The Department of Health Care Services (DHCS) issued a draft All Plan Letter (APL) with new guidance on the reporting requirements. This is to improve the process for submitting service information and/or copies of paid invoices/claims related to third-party liability (TPL) torts from managed care health plans (MCP).
Responsibilities
Health Net is responsible for notifying and providing the DHCS with information related to potential and confirmed TPL cases that involve Health Net members. Upon request from DHCS, providers are also required to help Health Net with the needed information.
Why we’re advising you now
We are informing you about the new reporting requirements to help you prepare for the final APL. This notice will give providers, who use a proprietary method to extract the requested TPL data, a chance to adjust to the new requirements.
Health Net will issue a separate update to our providers with the final details when the DHCS releases the final APL. Health Net will require all TPL submissions to be delivered in the new format described in the draft APL. The submission format in the draft APL is expected to be the same in the final APL.
The focal points of the requirements are the new data elements and the format in which they are transferred. Listed below are the data headers and a description of an acceptable format.
New reporting requirements for TPL
The new submission process will replace any existing process once the final APL is released. Providers may continue to follow the current reporting requirements for TPL requests until the release of the final APL. However, we urge our providers to start using the new format to adjust to the change and be able to address any potential system issues.
New report format
This new format will require providers to combine all information in a DHCS-approved Excel template for each member. All claims data must include the following data elements within the Excel template:
- Name of the MCP/Independent Physician Association (IPA)
- Member name
- Date of birth (provided by DHCS)
- Client index number (CIN)
- Date of injury
- Claim control number
- Claim line number
- Claim type
- Service from date
- Service to date
- Provider legal name
- National provider identifier
- Diagnosis code 1 (primary diagnosis)
- Diagnosis code 2 (secondary diagnosis)
- Drug label name
- Amount billed
- Amount paid (the actual amount the MCP paid to the provider for services.
If service is capitated, indicate amount as “0”) - Reasonable value (absent the “amount paid,” due to capitated or other service type, the “reasonable value” of the service must be provided, pursuant to Title 28, California Code of Regulations (CCR), section 1300.71(a)(3))
- Current procedural terminology (CPT) code
- CPT type
- Primary/secondary claim deny reason code and description(s)
Additional information
Providers are encouraged to access the provider portal online at the Health Net Provider Website for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.
If you have questions regarding the information contained in this update, contact the Health Net Medi-Cal Provider Services Center within 60 days at 800-675-6110.