Section 16.03.09.215 - THIRD PARTY LIABILITY01.Determining Liability of Third Parties. The Department will take reasonable measures to determine any legal liability of third parties for medical care and services rendered to a participant.02.Third Party Liability as a Current Resource. The Department is to treat any third party liability as a current resource when such liability is found to exist and payment by the third party has been made or will be made within a reasonable time.03.Withholding Payment. The Department must not withhold payment on behalf of a participant because of the liability of a third party when such liability, or the amount thereof, cannot be currently established or is not currently available to pay the participant's medical expense.04.Seeking Third Party Reimbursement. The Department will seek reimbursement from a third party when the party's liability is established after reimbursement to the provider is made, and in any other case in which the liability of a third party existed, but was not treated as a current resource, with the exceptions provided in Subsection 215.05 of this rule.a. The Department will seek reimbursement from a participant when a participant's liability is established after reimbursement to the provider is made; andb. In any other situation in which the participant has received direct payment from any third party resource and has not forwarded the money to the Department for services or items received.05.Billing Third Parties First. Medicaid providers must bill all other sources of direct third party payment, with the following exceptions: a. When the resource is a court-ordered absent parent and there are no other viable resources available, the claims will be paid and the resources billed by the Department;b. Preventive pediatric care including early and periodic screening and diagnosis. Screening and diagnosis program services include:i. Regularly scheduled examinations and evaluations of the general physical, dental, and mental health, growth, development, and nutritional status of children under age twenty-one (21), provided according to guidance for child wellness exams published in the Medicaid General Provider and Participant Handbook;ii. Immunizations recommended by the American Academy of Pediatrics immunization schedule;iii. Diagnosis services to identify the nature of an illness or other problem by examination of the symptoms.c. When prior authorization has been approved according to Section 883 of these rules, treatment services to control, correct, or ameliorate health problems found through diagnosis and screenings;d. If the claim is for preventative pediatric care as described in Subsection 215.05.b of this rule, the Department will make payment for the service provided in its fee schedule and will seek reimbursement from the third party according to 42 U.S.C. 1396a(a)(25)(E).06.Accident Determination. When the participant's Medicaid card indicates private insurance or when the diagnosis indicates an accident for which private insurance is often carried, or both, the claim will be suspended or denied until it can be determined that there is no other source of payment.07.Third Party Payments. The Department will pay the provider the lowest amount of the following: a. The provider's actual charge for the service; orb. The maximum allowable charge for the service as established by the Department in its pricing file. If the service or item does not have a specific price on file, the provider must submit supporting documentation to the Department. Reimbursement will be based on the documentation; orc. The third party-allowed amount minus the third party payment, or the patient liability as indicated by the third party.08.Subrogation of Third Party Liability. In all cases where the Department will be required to pay medical expenses for a participant and that participant is entitled to recover any or all such medical expenses from any third party, the Department will be subrogated to the rights of the participant to the extent of the amount of medical assistance benefits paid by the Department as the result of the occurrence giving rise to the claim against the third party.a. If litigation or a settlement in such a claim is pursued by the medical assistance participant, the participant must notify the Department.b. If the participant recovers funds, either by settlement or judgment, from such a third party, the participant must repay the amount of benefits paid by the Department on their behalf.09.Subrogation of Legal Fees.a. If a medical assistance participant incurs the obligation to pay attorney fees and court costs for the purpose of enforcing a monetary claim to which the Department is subrogated, the amount which the Department is entitled to recover, or any lesser amount which the Department may agree to accept in compromise of its claim, will be reduced by an amount which bears the same relation to the total amount of attorney fees and court costs actually paid by the participant as the amount actually recovered by the Department, exclusive of the reduction for attorney fees and court costs, bears to the total amount paid by the third party to the participant.b. If a settlement or judgment is received by the participant that does not specify which portion of the settlement or judgment is for payment of medical expenses, it will be presumed that the settlement or judgment applies first to the medical expenses incurred by the participant in an amount equal to the expenditure for benefits paid by the Department as a result of the payment or payments to the participant.Idaho Admin. Code r. 16.03.09.215