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Utah Administrative Code (Current through November 1, 2019) |
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R527. Human Services, Recovery Services |
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R527-936. Third Party Liability, Medicaid |
| R527-936-1. Definition and Purpose |
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Latest version.
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A third party is an individual, institution, corporation, public or private agency, trust, estate, insurance carrier, employee welfare benefit plan, health maintenance organization, health service organization, preferred provider organization, governmental program such as Medicare, CHAMPUS, and workers' compensation, which may be obligated to pay all or part of the medical costs of injury, disease, or disability of a recipient, and a spouse or a parent who: (i) may be obligated to pay all or part of the medical costs of a recipient under law or by court or administrative order; or (ii) has been ordered to maintain health, dental, or disability insurance to cover medical expenses of a spouse or dependent child by court or administrative order. The Utah Third Party Liability Program has been established to assure that all private medical resources have been exhausted before a claim is paid by Medicaid; or that when the agency discovers a liable third party after payment of a claim, reimbursement is sought. The Utah Third Party Liability Program has been established to assure that all private medical resources have been exhausted before a claim is paid by Medicaid; or that when the agency discovers a liable third party after payment of a claim, reimbursement is sought. |
| R527-936-2. Authority |
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Latest version.
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Federal Regulations 42 CFR 433.135 through 433.154(1995) require the state agency to establish and administer a Third Party Liability Program, and specify the requirements for a state plan concerning Third Party Liability. The office adopts these sections and incorporates them by reference. Sections 26-19-1 through 26-19-19 authorize a Third Party Liability Medicaid Recovery Program and establish the legal liabilities of third parties and recipients. |
| R527-936-3. Assignment of Benefits |
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Latest version.
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Federal regulations 42 CFR 433.145 and 433.146 specify the applicant/recipient responsibility to assign their rights to third party payments as a condition of eligibility. |
| R527-936-4. Cooperation as a Condition of Eligibility |
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Latest version.
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The applicant/recipient must cooperate in establishing paternity and obtaining medical support and other third party payments as specified in 42 CFR 433.147. Office of Recovery Services will initiate sanctions for non-cooperation in accordance with the Federal regulations and state procedures. |
| R527-936-5. Payor of Last Resort |
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Latest version.
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Medicaid shall be the payor of last resort as specified in 42 CFR 433.138, 42 CFR 433.139, and Subsection 26-18-10(4). |