Third-Party Recovery Rules Effective Jan. 1, 2024

Recent State Plan Amendment outlines duties of a responsible third party

The Centers for Medicare & Medicaid Services (CMS) recently approved a State Plan Amendment for NC Medicaid regarding duties of a responsible third party (other than original Medicare fee-for-service program under parts A and B of Title XVIII). This rule change applies to:

  • Medicare Part C (Medicare Advantage)
  • Medicare Cost Plan
  • A health care prepayment plan (employer or union sponsored manage care plans that provides Medicare Part B), or 
  • A prescription drug plan offered by a PDP (Medicare Advantage offering Medicare Advantage Prescription Drug)   

Third parties that requires prior authorization for an item or service furnished to an individual eligible to receive medical assistance under title 42 of the United States Code, must accept authorization provided by the State or its Prepaid Health Plan that the item or service an individual received (and for which third-party reimbursement is being sought) is a covered service or item under the Medicaid state plan (or waiver of such plan) for that individual, as if such authorization were the prior authorization made by the third party for such item or service.  

A third party is barred 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.

Third parties must respond no later than 60 calendar days after receiving any inquiry by the Division or its Prepaid Health Plan regarding a claim for payment for any health care item or service that is submitted not later than three years after the date of the provision of the health care item or service.


Third-Party Recovery, 919-527-7690

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