Current through Register Vol. 54, No. 45, November 9, 2024
Section 259.5 - Cooperation in obtaining payment from third parties-statement of policy(a) A beneficiary has a duty to cooperate with the Department in obtaining payment from third parties and insurers as a condition of eligibility for MA.(b) If a beneficiary does not cooperate with the Department's efforts to obtain payment of medical care from any third party or insurer, then the Department will determine the beneficiary to be ineligible for MA and pursue an overpayment of MA received after the date of noncooperation. The Department is not limited to recovering from the medical portion of a tort recovery when an overpayment is established.(c) Cooperation with the Department's efforts to obtain payment of medical care from any third party or insurer includes the following:(1) Disclosing to the Department that a claim was filed against an insurer or third party.(2) Identifying and providing information to assist the Department in pursuing a third party who may be liable to pay for medical care and services.(3) Consenting to the Department's intervention into the beneficiary's pending lawsuit.(4) Consenting to a reasonable extension of time requested by Department counsel in the case.(5) Providing Department counsel copies of discovery documents and legal papers filed in the lawsuit upon request.(6) Disclosing to the liable third party or insurer that the beneficiary has elected not to pursue recovery of expenses paid by MA and the third party or insurer will remain liable to the Department on the claim.(7) Not agreeing to indemnify or release the liable third party or insurer from the Department's claims.(8) Providing testimony and evidence in support of the Department's claim.(9) Providing notices required under section 1409(b)(5) of the Public Welfare Code (62 P. S. § 1409(b)(5) in compliance with this section.(10) Including medical expenses paid by MA in a claim or lawsuit if requested to do so by the Department.(11) Taking any other action requested by the Department that is necessary to pursue a claim against a third party.The provisions of this §259.5 adopted October 31, 2008, effective 11/1/2008, 38 Pa. Code 5970.