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State of Wisconsin |
Release 25-02 |
Casualty claims are those claims for Medicaid benefits resulting from an accident or injury for which a third party may be liable.
| Example 1: | Mike receives treatment for injuries suffered when he was hit by a car. The vehicle owner is the third party and may be responsible for reimbursing Medicaid for those benefits. If Mike is working with an attorney or insurance agency to settle the claim, he is legally obligated to give notification to the local agency. |
Medicaid members should report any casualty claims before the case is settled. The Medicaid ID number of the Medicaid member, date of the accident, and the insurance company or name of the attorney to bill should be included with the referral.
If members are in an accident or are injured and receive a cash award or settlement due to the accident or injury and Medicaid (including SSI enrollees) pays for part or all of the care, it must be reported. When Medicaid pays for a claim that is related to an accident, a letter is sent to the member informing him or her of the requirement to report the information.
If a member has hired an attorney or is working with an insurance agency to settle the claim, that must also be reported. If a member reports a claim, he or she must report the accident or injury case to the Casualty Recovery Unit using one of the following methods:
If the member is enrolled in an HMO or MCO they must also report the accident or injury to that organization.
All other Medicaid members should report in person or phone their local agency and any HMO or MCO that may have provided services before the case is settled. Members should include the date of the accident and any insurance and attorney information.
This page last updated in Release Number: 17-03
Release Date: 11/03/2017
Effective Date: 11/03/2017
The information concerning the Medicaid program provided in this handbook release is published in accordance with: Titles XI and XIX of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapters 46 and 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2, 10 and 101 through 109 of the Wisconsin Administrative Code.
Notice: The content within this manual is the sole responsibility of the State of Wisconsin's Department of Health Services (DHS). This site will link to sites outside of DHS where appropriate. DHS is in no way responsible for the content of sites outside of DHS.
Publication Number: P-10030