Effective Dates: 08/01/2016 - Present Previous | Next

SI CHI01730.040 (IN, MI, OH, WI) Assignment of Rights and Third Party Liability (RTN 402 -- 03/2007)

 

See SI 01730.040 – Assignment of Rights (AOR)

See SI 01730.045 – Third Party Liability (TPL)

See SI 01730.050 – Exhibits, Assignment of Rights and Third Party Liability

Address of State Agency to mail the Third Party Liability Information Statement (Form SSA-8019), where required. Refer to TPL reference above.

A. Indiana

  

Indiana Family & Social Services Administration
Office of Medicaid Policy & Planning
402 W. Washington Street, Room W374 MS07
Indianapolis, IN 46204

Attn: Joe Moser, Director of Medicaid

B. Michigan

 

Michigan Department of Community Health
Third Party Liability Division
P.O. Box 30479
Lansing, MI 48909-7979

Attn: Keelie Honsowitz, Manager
Health Insurance Liability Section

 

C. Ohio

 

Ohio Department of Medicaid
Claims Operations
50 West Town Street, 4th Floor, B419
Columbus, OH 43215–4173

Attn: Patrick A. Tighe, Bureau Chief

D. Wisconsin

  

HP, Coordination of Benefits (COB) Unit
P. O. Box 6220
Madison, WI 53716
To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0501730040CHI
SI CHI01730.040 - (IN, MI, OH, WI) Assignment of Rights and Third Party Liability (RTN 402 -- 03/2007) - 08/01/2016
Batch run: 10/02/2017
Rev:08/01/2016