For Consolidated Claims Experience (CCE) initial claims, complete the "Health Expenses
& Third Party Liability" page.
For redeterminations when there is a change in TPL coverage, or other posteligibility
changes as described in SI 01730.045C.5., also complete the "Health Expenses & Third Party Liability" page.
The TPL information will be electronically transmitted to the State Medicaid agency.
However, there are situations when a paper SSA-8019 must be completed and mailed to the State TPL agency.
These situations include:
-
•
Non-MSSICS initial claims that are allowed;
-
•
Non-MSSICS redetermination or post-eligibility action with changes in TPL circumstances;
or
-
•
CCE claims when complete TPL information was not available at the time the claim was
adjudicated, SI 01730.045D.2.
Mail the fully-completed paper SSA-8019-U2 on a weekly basis to the appropriate TPL
State agency using the address shown in the table:
Arkansas
|
Department of Human Services TPL Unit - Slot S296
P. O. Box 1437
Little Rock, Arkansas 72203
|
Louisiana
|
Department of Health and Hospitals
BHSF TPL/Medicaid Recovery Unit
P. O. Box 91030
Baton Rouge, Louisiana 70821-9030
|
New Mexico
|
Medical Assistance Division TPL Unit
P. O. Box 2348
Santa Fe, New Mexico 87504-2348
|
Oklahoma
|
Oklahoma is not a Section 1634 State. SSA does not obtain TPL information for Oklahoma
residents.
|
Texas
|
Health and Human Services Commission Office of Investigation and Enforcement
Third Party Resources
P.O. Box 13247
Austin, Texas 78711-3247
|