Problem Statement

By federal law, Medicaid is the payer of last resort. If another insurer or program is liable for the claim, it must pay first before Medicaid covers anything Medicaid. If the other payer on the claim shows as "inactive" when RTE is run, it may not be actively processing claims, but it could still be legally liable. States must still identify and document this liability to avoid paying Medicaid funds for services the other payer should have covered. Third Party Liability (TPL) letters should be sent to Medicaid when: RTE shows another payer as primary; That payer's RTE is inactive (or not actively processing claims); You believe the payer is still legally liable for the claim; You want to ensure Medicaid does not pay for services the other payer should cover. Doing this manually is slow and error-prone; gaps that slip through surface later will cause avoidable rework.

Automation Solution

This automation submits a TPL letter to Medicaid when Real Time Eligibility (RTE) shows another payer as primary but that payer's RTE is inactive.