Third Party Liability

Third party liability is when the patient has been injured or becomes ill, and:

• The injury or illness is caused, or alleged to have been caused, by someone else, and
• The patient has or may have the right to recover damages or receive payment in connection with the injury or illness, or
• The patient has or may have the right to recover damages or receive payment without regard to fault.

Examples of situations for which a third party may be financially responsible for a member's injury or illness:

• The patient was bitten by a neighbor’s dog.
• The patient fell on the front steps of a friend’s house.
• The patient fell in a department store.
• The patient was assaulted by a third party.

For HMSA to determine its liability for coverage and protect its rights to recover payments in the event of a settlement, the member’s cooperation is essential. HMSA will provide benefits in connection with the injury or illness, in accordance with the member’s plan benefits, if the member assists HMSA by providing the information indicated below. The member must:

• Give HMSA timely notice in writing no later than 30 days after the occurrence of each of the events listed below:
  • His or her knowledge of any potential claim against any third party or other source of recovery in connection with the injury or illness
  • His or her knowledge of any written claim or demand (including legal proceedings) against any third party or other source of recovery in connection with the injury or illness
  • Any recovery of damages (e.g., settlements, judgments, awards or insurance proceeds) against any third party or other source of recovery in connection with the injury or illness
• Sign requested documents. The member must sign and deliver to HMSA the documents (e.g., liens, assignments) HMSA deems necessary to secure its rights to recover payments. The member also must direct any person receiving payment on his or her behalf to reimburse HMSA for claims paid to the member’s healthcare providers for services related to the injury or illness.
• Provide information. The member must provide HMSA with any and all information required to investigate its liability for coverage and to determine its rights to recover payments. The primary source of this information is HMSA’s Injury/Illness Report Form.

Although the Injury/Illness Report Form is sent by HMSA to the member when an investigation is opened, members sometimes forget to return the completed form in a timely manner. A provider may assist HMSA with its information gathering by copying the form and asking the member to complete the form in his or her office. The provider may then return the unaltered, signed and completed form to HMSA to facilitate the investigation. The form should be sent to:

HMSA

Third Party Liability, 8th floor

P.O. Box 860

Honolulu, HI  96808-0860

Once the required documents are received and the HMSA member record has been updated, HMSA will process claims in accordance with the benefits of the member’s plan.

Notes: All claims paid by HMSA are subject to member eligibility at the time of service, HMSA’s guidelines for payment determination, and the provisions and limitations of the member’s plan.

If member does not provide the information requested by HMSA in connection with the injury or illness, claims for related services may be delayed or denied.

To insure the proper coordination of benefits, participating providers need to adhere to filing requirements of third-party carriers.

The following are scenarios for which HMSA would review for consideration to apply member’s HMSA plan benefits. The provider would need to submit to HMSA as a claim attachment.

• Third-party carrier denial—Submit documentation of reason for non-payment (i.e., Carrier Denial letter).
• Provider is disputing HMSA’s denial that care is part of the member’s third-party case—Submit clinical notes for review.

Member Questions

Members having questions regarding HMSA’s third party rules should refer to their Guide to Benefits (GTB). Members may request a copy of their GTB or other assistance from HMSA’s Customer Service Department at:

Member Correspondence, 7th floor

HMSA Customer Service Department

P.O. Box 860

Honolulu, HI  96808-0860

Resources

• Workers’ Compensation
• Motor Vehicle Insurance
• Injury/Illness Report Form

Revision History