Virginia Law

A. The Medicaid agency meets all requirements of:

1. 42 CFR 433.138 and 433.139;

2. 42 CFR 433.145 through 433.148;

3. 42 CFR 433.151 through 433.154; and

4. Section 1902(a)(25)(H) and (a)(25)(I) of the Social Security Act.

B. 12VAC30-20-190, governing the identification of liable resources with respect to third-party liability:

1. Specifies the frequency with which the data exchanges required in 42 CFR 433.138(d)(1), (d)(3), and (d)(4) and the diagnosis and trauma code edits required in 42 CFR 433.138(e) are conducted;

2. Describes the methods the agency uses for meeting the follow-up requirements contained in 42 CFR 433.138(g)(1)(i) and (g)(2)(i);

3. Describes the methods the agency uses for following up on information obtained through the state motor vehicle accident report file data exchange required under 42 CFR 433.138(d)(4)(ii) and specifies the timeframes for incorporation into the eligibility case file and into its third-party database and third-party recovery unit of all information obtained through the follow-up that identifies legally liable third-party resources; and

4. Describes the methods the agency uses for following up on paid claims identified under 42 CFR 433.138(a) (methods include a procedure for periodically identifying those trauma codes that yield the highest third-party collections and giving priority to following up on those codes) and specifies the timeframes for incorporation into the eligibility case file and into its third-party database and third-party recovery unit of all information obtained through the follow-up that identifies legally liable third-party resources.

C. Providers are not required to bill liable third parties when services covered under the plan are furnished to an individual on whose behalf child support enforcement is being carried out by the state Title IV-D agency.

D. 12VAC30-20-200, governing the payment of claims with respect to third-party liability, specifies:

1. The method used in determining a provider's compliance with the third-party billing requirements at 42 CFR 433.139(b)(3)(ii)(C).

2. The threshold amount or other guideline used in determining whether to seek recovery or reimbursement from a liable third party, or the process by which the agency determines that seeking recovery of reimbursement would not be cost-effective.

3. The dollar amount or time period the state uses to accumulate billings from a particular liable third party in making the decision to seek recovery of reimbursement.

E. The Medicaid agency ensures that the state has in effect the laws that require third parties to comply with the provisions, including those that require third parties to provide the state with coverage, eligibility, and claims data under § 1902(a)(25) of the Social Security Act, and specifies the compliance with § 1902(a)(25)(E) and (a)(25)(F) of the Social Security Act.

F. The Medicaid agency ensures that laws are in effect that bar liable third-party payers from refusing payment for an item or service solely on the basis that such item or service did not receive prior authorization under the third-party payer's rules. These laws comply with the provisions of § 202 of the Consolidated Appropriations Act of 2022.

G. The Medicaid agency ensures that the provider furnishing a service for which a third party is liable follows the restrictions specified in 42 CFR 447.20.

H. The Medicaid agency has written cooperative agreements for the enforcement of rights to and collection of third-party benefits assigned to the state as a condition of eligibility for remedial assistance with the state Title IV-D agency. The requirements of 42 CFR 433.152(b) are met.

I. The Medicaid agency ensures that the state has in effect the laws relating to medical child support under § 1908 of the Social Security Act.

J. The Medicaid agency specifies the guidelines used in determining the cost-effectiveness of an employer-based group health plan; the state provides methods for determining cost-effectiveness in 12VAC30-20-210.