JurisdictionCaliforniaCode WICWelfare and Institutions Code - WIC
Div. 9.DIVISION 9. PUBLIC SOCIAL SERVICES
Part 3.PART 3. AID AND MEDICAL ASSISTANCE
Ch. 7.CHAPTER 7. Basic Health Care
Art. 3.5.ARTICLE 3.5. Third Party Liability
(a)
(1)It is the intent of the Legislature to comply with federal law requiring that when a beneficiary has third-party health coverage or insurance, the State Department of Health Care Services shall be the payer of last resort.
(2)In order to assess overlapping or duplicate health coverage and adjudicate claims, all of the following entities shall maintain a centralized file of the eligibility and coverage information for each subscriber, policyholder, enrollee, or insured:
(A)Health insurer or any health care entity licensed through the Department of Insurance.
(C)Group health plan, as defined in Section 607(1) of the Employee Retirement Income Security Act of 1974.
(E)Managed care organization, including a health care service plan a
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(a)
(1)
It is the intent of the Legislature to comply with federal law requiring that when a beneficiary has third-party health coverage or insurance, the State Department of Health Care Services shall be the payer of last resort.
(2)
In order to assess overlapping or duplicate health coverage and adjudicate claims, all of the following entities shall maintain a centralized file of the eligibility and coverage information for each subscriber, policyholder, enrollee, or insured:
(A)
Health insurer or any health care entity licensed through the Department of Insurance.
(B)
Self-insured plan.
(C)
Group health plan, as defined in Section 607(1) of the Employee Retirement Income Security Act of 1974.
(D)
Service benefit plan.
(E)
Managed care organization, including a health care service plan as defined in subdivision (f) of Section 1345 of the Health and Safety Code, licensed pursuant to the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code).
(F)
Pharmacy benefit manager.
(G)
Third-party administrator.
(H)
Union trust.
(I)
Other party that is, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service.
(b)
(1)
The eligibility and coverage information shall include, at a minimum, all of the following information about a subscriber, policyholder, enrollee, or insured:
(A)
Full name.
(B)
Address.
(C)
Date of birth.
(D)
Social security number.
(E)
Policy number.
(F)
Group identification number.
(G)
Policy or plan type.
(H)
Types of covered services under the policy or plan.
(I)
Effective dates of coverage.
(J)
Policy or plan termination date.
(2)
For any other persons covered under the policy or plan, if any, the eligibility and coverage information shall include, at a minimum, all of the following information:
(A)
Full name.
(B)
Social security
number.
(C)
Date of birth.
(D)
Place of birth.
(E)
Parents’ names, if applicable.
(c)
The information described in subdivision (b) shall be provided to the State Department of Health Care Services at least once a month, in a format provided by the department. The information shall also be provided to the department’s agents and contracted Medi-Cal managed care plans, upon reasonable request, to perform cost avoidance on behalf of the department.
(d)
An entity listed in subdivision (a) shall provide to the department access to real-time, electronic eligibility verification, at no cost, and in a
form and manner specified by the department, as is necessary to conduct its coordination of benefits responsibilities pursuant to this section.
(e)
Notwithstanding Section 20134 of the Government Code, the Board of Administration of the California Public Employees’ Retirement System and affiliated systems or contract agencies shall permit data matches with the state department to identify Medi-Cal beneficiaries with third-party health coverage or insurance. A recipient’s Medi-Cal identification card shall, where information is available, contain information advising providers of health care services of any third-party health coverage for the recipient. Providers shall seek reimbursement from available third-party health coverage before billing the Medi-Cal program.
(f)
Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section, in whole or in part, by means of policy letter, information notice, or other similar instruction, without taking any further regulatory action.