About TPL Billing

During the claims adjudication cycle, claims processing attempts to match third party liability (TPL) polices to claims using the TPL Matrix. Where matches are found, ND MMIS determines whether the claim should be cost avoided (denied) or billed (pay-and-chase). If the claim is paid and a pay-and-chase exception code set, a billing record is automatically created and TPL can begin the process of billing the third-party.

Note: In some situations, third-party insurance coverage for a member may be newly identified that affects already paid or denied claims. When this happens, the account is updated and all current and future claims will be adjudicating based on TPL rules.

For each covered claim that is to be billed, a separate TPL billing record is produced. All billing records are generated by ND MMIS; you cannot add one manually.

Billing Recovery Methods

The TPL Billing component of the TPL function of Financial allows you to view these records and edit limited information about them - most importantly the recovery reasons and recovery methods. Some possible recovery methods are:

• First In - First Out - Posts the recovery amounts to all outstanding claims/claim lines billed for a specific invoice (or to outstanding claims for a specific member in the invoice) in a first in, first out sequence based on the Claim Service Date.
• Last In - First Out - Posts the recovery amounts to all outstanding claims/claim lines billed for a specific invoice (or to outstanding claims for a specific member in the invoice) in a last in, first out sequence based on the Claim Service Date.
• Fixed Amount - Posts a fixed dollar amount you indicate to all outstanding claims/claim lines billed on a specific invoice (or to outstanding claims for a specific member in the invoice). If the Claim Carrier Billed Amount is less than the specified Fixed Amount, the Carrier Billed Amount is posted to the claim as the Recovery Amount.
• Manual - Posts the manually entered recovery amount to the billed line items on a specific claim in the invoice.
• Percentage Based - Posts a percentage-based amount to each outstanding claim billed. The percentage is calculated by dividing the Total Amount Recovered from the Total Carrier Billed Amount for all outstanding claims in an invoice. The Recovery Amount applied to each claim is determined by multiplying the Carrier Billed Amount on each claim and the calculated percentage.

You can work with a billing record at one of these levels:

• The invoice level where changes apply to all members and their outstanding claims
• At the member level where changes apply only to the claims in the invoice that apply to this member
• At the claim level where changes apply only to a specific claim or selected lines on a claim

Billing Letters

Periodically as specified by a system parameter, TPL billing letters are produced to initiate the recovery process. You can also manually request that a bill be re-issued during the next billing cycle. ND MMIS reviews all billing records to determine whether bills should be produced. Bills are produced for services paid by State-administered programs where the member has third-party coverage. In addition, bills are re-issued for claims which have not had a response entered against it or for invoices you have identified by selecting the Re-issue Bill field. ND MMIS automatically generates a cover letter to the carrier or other responsible party, the Invoice Summary report detailing what claims and lines have been invoiced for each member, and a facsimile of the associated claims.

Provider Recoupment Letter

If a carrier denies paying an invoice because the provider was paid directly and you enter this as the recovery reason for the claim, ND MMIS automatically sends the provider a letter requesting that the appropriate amount be reimbursed to the State within a set time period or the amount due will be recouped from claims billed in the future.

Closing Billing Records

TPL billing records are automatically closed when:

• All claims associated with the invoice have been satisfied (closed) in some way.
• A replacement claim's reimbursement amount is zero.
• A billing response is entered that the coverage has been terminated.
• A mass change process terminates a carrier, based on the user request. Any claims/claim lines in bills associated with the terminated carrier that have a claim service date after the carrier termination date is closed. If all claims/claim lines in a bill are closed, then that bill is also closed.

Bills that are closed automatically cannot be reopened. However, you can post payments manually at the claim or claim line level to the closed bills.

You can also close TPL billing records manually at the invoice, member, or claim level.

A closed billing record is not billed again nor is it automatically incorporated in the billing process.

Instructions

How to Search for a TPL Billing

How to Edit a TPL Billing

Field Descriptions

Search TPL Billing Page

• Search TPL Billing (TCN Tab) Page
• Search TPL Billing (Member Tab) Page
• Search TPL Billing (Carrier Tab) Page
• Search TPL Billing (National Payer ID Tab) Page
• Search TPL Billing (Policyholder Tab) Page
• Search TPL Billing (Policy Number Tab) Page
• Search TPL Billing (Invoice Tab) Page
• Search TPL Billing (Search Results) Page

TPL Billing Page

See Also

What Is Third Party Liability?

About TPL Matrix

About Mass Change Request

What Is a Map Definition?

About Financial

Version as of 5/16/14.