When an allowed SSI applicant or recipient has a third party source to cover medical expenses, SSA district offices (DOs) should obtain complete third party liability (TPL) information for residents of Colorado, Montana, South Dakota and Wyoming.

TPL information is an important tool used by State agencies to reduce Federal and State Medicaid expenditures. States pay SSA to collect TPL information. To effectively use this tool, States must receive complete TPL information from SSA (e.g., Hutterite colony, policy number, name and address of insurance company, effective date of coverage, etc.).

For MSSICS initial claims, complete the Health Expenses & Third Party Liability page . Also complete the Health Expenses & Third Party Liability page for redeterminations when there is a change in TPL coverage, or other post eligibility changes as described in SI 01730.045C.5. 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;

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  Non-MSSICS redetermination or post-eligibility action with changes in TPL circumstances;

  or

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  MSSICS 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 below:

Colorado

Department of Health Care Policy & Financing

Attn: Third Party Resources

1575 Sherman Street

Denver, Colorado 80203-1714

Montana

Department of Public Health & Human Services

TPL Unit

P. O. Box 202953

Helena, Montana 59620-2953

North Dakota is not a Section 1634 State. SSA does not obtain TPL information for North Dakota residents.

South Dakota

Department of Social Services

Medicaid Eligibility Administrator

700 Governors Drive

Pierre, South Dakota 57501

Wyoming

Department of Health

Office of Medicaid, Attn: Debbie Paiz

Hathaway Building

Cheyenne, Wyoming 82002

Utah is not a Section 1634 State. SSA does not obtain TPL information for Utah residents.