If you are displaced or affected by wildfire, all Washington Apple Health and PEBB/SEBB medical plans are allowing prescription refills before the refill date.
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Personal injury, casualty recoveries, and special needs trusts

The Health Care Authority (HCA) seeks reimbursement for claims paid by Medicaid when Apple Health (Medicaid) clients receive medical care due to an injury caused by the action, inaction, or negligence of third parties and another insurance should have paid.

If you are a lawyer and become aware of an Apple Health client who may have had a personal injury, you are required by statute to report the information to Medicaid. 

Contact HCA when the case begins and again 30 days before settlement. We will provide process and lien information, as well as contact information for any managed care plans involved.

It is critical to contact HCA both at the beginning of the case and then again when you are negotiating settlement. Providers have up to one year from their date of service to bill HCA. Even if HCA does not have a subrogated interest at the beginning of a case, claims may have received by the time the case is ready to settle, which must be paid from the settlement.

Third-party subrogation inquiry / request

To submit a request, complete your letter of representation and HIPAA compliant medical release, and return it to HCA.

Don't get delayed: We highly recommend that you include only one client per correspondence. HCA is required to follow HIPAA and privacy guidelines. For compliance, we must redact all correspondence referencing more than one client. Multiple clients on the same communication may result in a delay.

To expedite your request, include the following information on your letter of representation. This information helps us determine if we have a subrogated interest.

  • Client’s full name (correctly spelled)
  • Client’s ProviderOne identification number from their blue ID card
    (It will begin with a 1 or 2 and end with WA.)
  • Social security number
  • Date of birth
  • Date of injury
  • City and county where injury occurred
  • Details of the injuries sustained by our recipient
  • Source of accident (i.e. MVA, slip and fall)
  • Name of attorney assigned to the case
  • Name of defendant / at-fault party
  • Name and address of insurance company
    • Claim number
    • Policy number

In addition, answer the following:

  • Confirm whether PIP / MedPay is available.
  • Has the client completed treatment? If yes, state the last service / treatment date.

You have three options for sending your letter of representation and current HIPAA compliant authorization. To expedite a response, select only one.

  • Email (preferred): directly to the case manager or HCACasualtyUnit@hca.wa.gov
    (PDF documents preferred)
  • Fax: 360-753-3077
  • Mail to:
    The Health Care Authority
    PO Box 45561
    Olympia, WA 98504-5561

We process requests in the order of date received. Allow at least 10 business days for a response. If you have waited 20 days and have not received a response, resubmit your request.

Note: Providers have up to one year from their treatment date of service to bill the agency for any charges. With recent accidents, there may not been enough time for insurance companies, MCOs, and HCA to receive and process claims from providers. If the client received any treatment or required any emergency transportation such as ambulance or airlift, there will likely be subrogation at some point.

  1. After we receive the settlement documentation, we calculate the final amount due by completing a Medicaid Payment Worksheet (MPW).
    1. Settlement documentation: Per RCW 41.05A.070(4)(c) HCA requires the following documents and information be sent in all cases so we can determine the amount due the agency:
      1. Copies of ALL settlement agreements. This may be a copy of the settlement, conformed copy of the arbitrator’s award, amended arbitrator’s award, or a verdict form in the case of a jury trial.
      2. Copy of your fee agreement and the actual fee charged.
      3. Itemized statement of costs:
        1. If more than one claimant settled, identify which costs are related solely to our Medicaid client, and which are joint costs.
        2. Identify costs related to the settling defendant(s).
        3. Identify costs related to any defendant who has not yet settled or was dismissed without recovery in your client’s favor.
    2. Send these documents to the assigned case manager directly via email or fax to 360-753-3077.
  2. We will send a copy of the complete MPW to your office as soon as possible. This MPW is your invoice and includes all of the payment instructions needed.

Any requests for reductions beyond our proportionate share should include the documents listed above and be sent directly to our Torts Recovery Advisors.

Note: If you prefer to forgo the aforementioned documentation and choose to remit the full amount due, then a written statement waiving the reduction is required. Any checks received without following the above process, will be placed on hold until the required documentation is received.

If your client is under 65, we will need to know:

  • If a special needs trust has been or will be established , or 
  • If the funds were or will be dispersed to the client directly.

If your client has been incarcerated and received injury related medical treatment there may be subrogation with Department of Corrections (DOC) as well.

Firm or insurance company changes

It is important that you notify us of any change of address for your firm or insurance company as soon as possible. This also includes any changes to the firm's name, attorney's name, e-mail, and phone or fax numbers.

Mass tort / class action litigation

For information, send an email to the attention of "Casualty Unit Supervisor" at HCACasualtyUnit@hca.wa.gov.

Managed care organizations (MCO)

When a person signs up for Washington State Apple Health (Medicaid) they are placed in either fee­ for-service (FFS or Classic Medicaid) or are placed in a managed care plan. If a person is placed in a managed care plan, Apple Health pays for the client's managed care premiums, and most of their health care services are paid through the plan.

However, some services are still paid by Medicaid even when the client has a managed care plan.  That’s why the HCA may have a subrogated interest in addition to the managed care plan’s subrogated interest.  You will work with HCA every time a client has Medicaid. If there is a managed care plan, you will also have to work with the plan.

HCA's Casualty Unit handles HCA's subrogated interest only

When you contact us regarding subrogation claims, and the client is in a managed care plan, we send you a letter to inform you which plan(s) the client is in. You will contact plan(s) directly regarding their subrogated interest.

As the attorney representing these clients you will need to contact both our office and the managed care organization (MCO) to satisfy everyone's interest.

There are certain times during the handling of a case when you are required to contact the HCA. See RCW 41.05A.080(1) for a list of those times.

Current carriers

The following are the five MCOs currently contracted with Washington State Apple Health (Medicaid). All plans have hired a vendor for their subrogration work.

  • Amerigroup
    C/O Optum
    PO Box 13216
    Green Bay, WI 54307-3216

    Toll Free: 1-888-246-6290
    Fax: 1-844-709-3392

  • Community Health Plan of Washington
    C/O Discovery Health Partners
    2 Pierce Place Ste 1900
    Itasca, IL 60143

    Toll Free: 1-866-223-9974
    Direct: 1-224-265-0015
    Fax: 1-224-220-5017

  • Coordinated Care of Washington
    C/O Equian
    26555 Evergreen Rd Ste 200
    Southfield, MI 48076

    Direct: 1-248-443-4800
    Fax: 1-248-443-4804

    Email: frgreferrals@equian.com

  • Molina Healthcare of Washington, Inc.
    C/O Equian
    PO Box 32100
    Louisville, KY 40232-2100

    Toll Free: 1-888-449-4805
    Fax: 1-248-443-4804

  • UnitedHealthcare Community Plan
    C/O Optum​
    PO Box 26649​​
    Wauwatosa, WI 53226

    Toll free:1-866-876-2790
    Fax: 1-800-842-8810​
    Email: subrogationreferrals@optum.com
    Website: Optum subrogation referral portal (attorney portal to check online or set up a case)

Previous carriers

  • Group Health
  • Regence Blue Shield
  • Asuris Northwest Health
  • Columbia United Providers, Inc. (CUP) (CUP closed it's business and transferred it's assets to Molina Healthcare of Washington, Inc., effective 01/01/2016. Please contact Molina or its subrogation agent for further information.)

Frequently asked questions (FAQ)

No. MCOs are separate from HCA.

When a Washington resident needs state Medicaid—known in Washington as Washington State Apple Health (Medicaid), or Apple Health—they apply for coverage through the Health Care Authority (HCA). In an effort to make health coverage more affordable and accessible to all eligible clients that live in Washington, the HCA contracts with MCOs.

HCA pays the client’s monthly premium and any carve-outs not covered by their managed care plan. In those cases, the managed care plan becomes the primary payer and we become secondary for any non-covered services. ALL Medicaid clients will have a blue ProviderOne ID card in addition to the card provided by their managed care plan. It has a nine-digit number that starts with a 1 or a 2 and all of our ID numbers end with WA.

Sample ProviderOne Services Card

If a client has a managed care plan, they will have an additional insurance card with an ID number for that MCO. They may change MCOs several times during their time on Medicaid.

Apple Health managed care member id cards

HCA should be your first point of contact. We will let you know whether HCA has subrogation and we will respond with a letter that:

  • Reflects our subrogation amount, and
  • Has all of the managed care plan(s) contacts and coverage dates.

We will always follow how the client name is listed in the ProviderOne system. If they have legally changed their name and not updated it with us, we will go by their old name.

Please have the client contact our customer service center:

  • Medical Assistance Customer Service Center (MACSC)
    Phone: 1-800-562-3022 (choose "client services")

If the client was covered, even retroactively for the date of service, then a contracted provider may not seek payment from the client.

Please have the client call our customer service center right away to stop any collection action: 

  • Medical Assistance Customer Service Center (MACSC)
    Phone: 
    1-800-562-3022 (choose "client services")

Denials and take-backs can happen for a variety of reasons, including:

  • Billing submission errors.
  • Issues with eligibility.
  • Incorrect plan billing.

If a provider has an unpaid balance for any reason, or a claim was not paid correctly, they have a responsibility to follow-up on the unpaid claim.

Providers have a limited amount of time to complete this process—usually one year from the date of service. 

Their billing department should contact the MCO directly or HCA provider services immediately upon receiving their remittance advice (RA) if they have any questions or are having difficulties getting a claim paid.

More information is available for providers on our claims and billing webpages

Providers can also contact our customer service center for assistance:

  • Medical Assistance Customer Service Center (MACSC)
    Claims line:
    1-800-562-3022 (choose "provider services")

Additional contact information for providers is available on our Contact HCA webpage.

Yes.

The HCA Casualty Unit recovers money from the at-fault parties when a Medicaid member has been involved in an accident or incident. When the agency has paid claims on behalf of a Medicaid member, we are required by law to identify and seek reimbursement from the responsible parties. HCA uses the TQ to gather information for this purpose.

If the completed medical treatment did not relate to an accident or incident, please explain in section A on the front of the form and section D on the back of the form.

If there was an accident, but no one else caused it, complete the form with the circumstances explained in detail in section D.

If a client has further questions regarding a TQ, have them contact: 

  • Medical Assistance Customer Service Center (MACSC)
    Phone:
     1-800-562-3022 (choose "client services")

No. MCOs are separate from HCA. Separate checks or payments are required.

In addition to HCA, you must contact MCOs directly for payment of their lien amounts. HCA can only accept checks for our subrogation balance. We are unable to forward checks received by HCA for an MCOs payment. Those checks will be returned to your office for reprocessing.

We are Washington State’s Medicaid agency and ERISA does not apply to Medicaid.

Medicaid is not an insurance company or employee benefits plan, so will not respond to requests for ERISA plan documents. The agency is not required to or able to provide "plan" documents under 29 U.S.C. § 1024(b)(4).

Contact

Casualty Unit

Email: HCACasualtyUnit@hca.wa.gov
Fax: 360-753-3077
Phone: 360-725-9580
Mail:
The Health Care Authority
PO Box 45561
Olympia, WA 98504-5561