RFP Attachment - 213 MCO Subrogation Sample.xlsx
XLSX spreadsheet 38 KB Posted
- Attached to
- Medicaid Third Party Liability (TPL), Recovery Audit Contracting (RAC), and Medicaid Estate Recovery
- Solicitation number
- 41NHA-S3818
- Issued by
- Nevada
About this file
This is an RFP attachment for the Nevada Health Authority detailing the Third Party Liability (TPL) Subrogation Report template (Report #213) that Managed Care Organizations (MCOs) must submit monthly. The report captures subrogation cases involving Medicaid beneficiaries where third parties bear legal liability for medical costs. MCOs are required to submit the completed report within 30 days following the end of each month, with specific due dates established for each reporting period (ranging from March 2nd for January reports through January 30th for December reports). The report template requires MCOs to document case details including beneficiary information, injury dates, case types, subrogation amounts, recovered amounts, closing dates, and response times in a standardized Excel format named 213_MCO_Subrogation_MMYYYY.xlsx, with submissions directed to the Managed Care SFTP folder.
The subrogation report operates under the authority of Contract S3037 (section 9.2.11), Nevada Revised Statutes sections 422.293 and 422.293003, and federal regulations 42 CFR 433 Subpart D and 42 CFR 447.20. MCOs must classify cases by source type (ranging from beneficiary notification to insurance companies and state agencies), case category (including general liability, medical malpractice, workers compensation, and restitution), and track both claimed and recovered amounts. The reporting framework establishes that the Department must provide written notice of lien amounts to recipients and third parties within 30 days of receiving notification, with response time tracked in calendar days between receipt of subrogation requests and MCO response. The template applies to five MCO carriers identified by codes (ANT, CSO, HPN, MHC, SSH) and establishes a standardized data collection process for monitoring third-party recovery efforts across Nevada's Medicaid program.
View the file
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Text version
Report Header
| Third Party Liability - Subrogation | |
| Report # 213 | |
| Rev Dt. CG 03/2026 | |
| Report Period Ending: | |
| Report Period Timeframe: | |
| Due Date: | Monthly, 30 days after month-end |
| Authority: | Contract S3037 - 9.2.11.; NRS 422.293, NRS 422.293003; 42 CFR 433 Subpart D, 42 CFR 447.20 |
| MCO Name: | |
| Prepared by: | |
| Preparer's Email: | |
| Date submitted: | |
| Calendar Year: |
&F
Subrogation
| Medicaid | |||||||||||||
| Member ID | Case Creation Date | Source Type | Member DOB | Member Last Name | Member First Name | Member Middle Initial | Injury Date | Case Type | Subrogation Amount | Recovered Amount | Closing Date | Case ID | Response Time |
(in days)
Definitions and Instructions
| Definitions and Instructions | |
| Report Header | Please enter the following in the report header section. |
• Report Period Ending
• Report Period Timeframe
• MCO Plan Name
• Report Preparer's name
• Report Preparer's email
• Date Report is submitted
• Calendar Year
| Subrogation | ||
| Medicaid | ||
| Member ID | Nevada State issued 11-digit Medicaid Identification Number for each beneficiary in NUMERIC VALUE | |
| Case Creation Date | Date of notification or date investigation is opened in MMDDYYYY format. | |
| Source Type | Method of receiving initial notice. Please choose most closely fits: |
- Beneficiary: beneficiary provides notice either directly or through trauma edit questionnaires
- County Office or Other State Agency: county case worker, Office of Legal Affairs, etc.
- Data Match : process of identifying leads using various data sources
- Defense Attorney: defense attorney provides notice
- Insurance Company: insurance company provides notice
- Lien Resolution Firm: Specialized third party handling lien resolution between attorneys and Medicaid
- NV DHHS : State of Nevada provides notice
- Plaintiff Attorney: plaintiff attorney provides notice, per NRS 422.293
- Prosecuting Attorney; prosecuting attorney provides notice for restitution cases or other
- Provider: provider gives notice through records request documentation
- Restitution: Order of restitution in a criminal case requiring defendant to repay Medicaid
- Subpoena: attorney issues subpoena to department or MCO for information regarding a beneficiary
- Other: any other source type not identified in the above categories
| Member DOB | Medicaid Member's Date of Birth in MMDDYYYY format. | |
| Member | ||
| Last Name | Medicaid Member Last Name | |
| Member | ||
| First Name | Medicaid Member First Name | |
| Member | ||
| Middle Initial | Medicaid Member Middle Initial | |
| Injury Date | Date of alleged injury in MMDDYYY format | |
| Case Type | Case type. Please choose that most closely fits: |
- General Liability: slip/fall or other that’s related to a general casualty category
- Mass Tort: Multidistrict Litigation (MDL) cases involving numerous plaintiffs with similar claims against one or a few defendants
- Medical Malpractice: medical malpractice (“NH” court case type code)
- No Fault Auto: Personal Injury Protection (“NF” court case type code)
- Pending: unknown or undetermined case type
- Product Liability: case against manufacturers (“NP” court case type code)
- Restitution: payments for medical claims ordered by a judge at the time of a crime conviction
- Third Party Case: pain and suffering (auto) (“NI” court case type code)
- Voluntary Pay: payment voluntarily made by beneficiary or related individual
- Workers Compensation: workers compensation case in the Workers' Compensation Bureau
| Subrogation Amount | The claims amount that may be recovered under NRS 422.293 in $0.00 format. | |
| Recovered Amount | Total amount recovered during the reporting period in 0.00 format | |
| Closing Date | Date you received all you are going to recover, or determined that no recovery is possible in DDMMYYYY format. | |
| Case ID | Optional: ID used by MCO or vendor to identify their case. | |
| Response Time | ||
| (in days) | The number of calendar days between receipt of a request for subrogation and the MCO's response. (NRS 422.293003) | |
| List of Carrier Codes | ||
| For a current list of Carrier Codes, please reach out to a Contract Monitor. | ||
| Please enter all fields required and choose from the appropriate drop down list options, if applicable. |
Do not change the format of this template.
Authority
| Link: | eCFR :: 42 CFR Part 433 Subpart D -- Third Party Liability |
| Link: | eCFR :: 42 CFR 447.20 -- Provider restrictions: State plan requirements. |
&F
Authority
Contract S3037
9.2.11.A. The Contractor must submit reporting on TPL subrogation to the State in accordance with the Reporting Requirements exhibit.
NRS 422.293
Subrogation: Department subrogated to rights of recipient of Medicaid or of insurance provided pursuant to Children’s Health Insurance Program; lien on proceeds of recovery.
1. When a recipient of Medicaid or a recipient of insurance provided pursuant to the Children’s Health Insurance Program incurs an illness or injury for which medical services are payable by the Department and which is incurred under circumstances creating a legal liability in some person other than the recipient or a division of the Department to pay all or part of the costs of such medical services, the Department is subrogated to the right of the recipient to the extent of all such medical costs and may join or intervene in any action by the recipient or any successors in interest to enforce such legal liability.
2. If a recipient or any successors in interest fail or refuse to commence an action to enforce the legal liability, the Department may commence an independent action, after notice to the recipient or successors in interest, to recover all medical costs to which it is entitled. In any such action by the Department, the recipient or successors in interest may be joined as third-party defendants.
3. In any case where the Department is subrogated to the rights of the recipient or any successors in interest as provided in subsection 1, the Department has a lien upon the proceeds of any recovery from the persons liable, whether the proceeds of the recovery are by way of judgment, settlement or otherwise. Such a lien must be satisfied in full, unless reduced pursuant to subsection 4, at such time as:
(a) The proceeds of any recovery or settlement are distributed to or on behalf of the recipient, the successors in interest or the attorney of the recipient; and
(b) A dismissal by any court of any action brought to enforce the legal liability established by subsection 1.
4. If the Department receives notice pursuant to NRS 422.293001, the Director or a representative designated by the Director may, in consideration of the legal services provided by an attorney to procure a recovery for the recipient, reduce the lien on the proceeds of any recovery.
5. The attorney of a recipient shall not condition the amount of attorney’s fees or impose additional attorney’s fees based on whether a reduction of the lien is authorized by the Director or a designated representative pursuant to subsection 4.
(Added to NRS by 1981, 1909; A 1989, 757; 1993, 923; 1997, 1239, 2624; 1999, 2228, 2242; 2007, 2390)
NRS 422.293003
Subrogation: Department required to provide notice of amount of lien; enforceability of lien. Upon receiving the notice required pursuant to NRS 422.293001, the Department shall, within 30 days, provide written notice to the recipient or the attorney of the recipient and to the third party. The written notice must include, without limitation, the name of the recipient and the amount of the Department’s lien. No lien created pursuant to NRS 422.293 is enforceable unless written notice is first given to the person against whom the lien is asserted or the attorney of the person against whom the lien is asserted.
(Added to NRS by 2007, 2390)
Federal Authority
42 CFR Part 433 Subpart D -Third Party Liability ~ see link below
42 CFR 447.20 -Provider Restrictions: State Plan Requirements ~ see link below https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-433/subpart-Dhttps://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-447/subpart-A/section-447.20 Due Dates_Naming Format
Do not change the format of this template.
This report is due monthly, 30 days after month-end.
If the due date falls on a weekend or holiday, the report is due the next business day.
Please submit the 213 Subrogation Report in the Managed Care SFTP Folder.
| NAME FORMAT |
| Please use the following Naming Format: |
213_MCO_Subrogation_MMYYYY.xlsx
MCO : ANT, CSO, HPN, MHC, SSH
MMYYYY = The month/year the report is being submitted for.
| Due Dates | |
| January | March 2nd |
| February | March 30th |
| March | April 30th |
| April | May 30th |
| May | June 30th |
| June | July 30th |
| July | August 30th |
| August | September 30th |
| September | October 30th |
| October | November 30th |
| November | December 30th |
| December | January 30th |
File details come from the government source that posted it. Updated .