Payer Roster and Subrogation Information

The Deficit Reduction Act of 2005 provides States with the ability to identify, and to recover payment from, third parties that are legally required to pay primary to Medicaid. The Michigan Public Act 593 of 2006 (MCL 550.283) requires various entities to provide the Michigan Department of Health and Human Services (MDHHS) with information necessary to determine which of their members are also beneficiaries of the State’s Medical Assistance Program. In order for payers to comply with the Public Act 593, MDHHS will work with payers to implement the National Roster File Process and Subrogation Billing Process explained below.

National Roster File Process

MDHHS recommends beginning this process by the payer submitting their entire National Roster file via direct file transfer. MDHHS will utilize our member match and coverage match logic with the information submitted on the National Roster file from the payer. This will enable MDHHS to have a complete and up-to-date Third Party Liability coverage file.

The steps for this process include (but not limited to) the following:

1. The National Roster file submitted by the payer should be in the format as indicated in the File Technical Record  document. File to be submitted using direct file transfer methods.
2. MDHHS will analyze and review National Roster file information that is received from a payer and will communicate any discrepancies or problems.
3. MDHHS will collaborate with the payer to ensure effective completion of this file.
4. Once the National Roster cumulative file has been approved and moved into MDHHS production, MDHHS will continue to collaborate with the payer and ensure at a minimum monthly direct file transfers.

Subrogation Billing Process

Once the National Roster File Process has been completed between the payer and MDHHS, MDHHS would like to continue with the payer Subrogation Billing Process. MDHHS will extract claims for the payer and create an 837 professional, institutional and/or dental test file to send to the payer for review depending on the type of coverage.  If MDHHS is working with a payer that is a pharmacy benefit manager (PBM), MDHHS will send NCPDP billing files to the PBM.  MDHHS expects the payer to review the 837 (or NCPDP billing file) and send an appropriate response file in return.  

The steps for this process include (but not limited to) the following:

1. MDHHS will collaborate with payer to determine how many records to include for analysis in the 837 professional, institutional, dental and/or NCPDP test file.
2. The payer acknowledges receipt of the 837 professional, institutional, dental and/or NCPDP test file and adjudicates claims.
3. The payer sends MDHHS the response files via 835, 277CA, or 999.
4. MDHHS will review and analyze the response files from the payer and will contact the payer with any discrepancies or problems.
5. MDHHS will collaborate with payer to ensure effective completion of this process.
6. Once this Subrogation Billing Process has been approved, MDHHS will continue to send 837 and/or NCPDP billing files on a monthly basis. It is MDHHS' expectation we will receive the response files from the payer in the same timely fashion.

For additional information, please contact TPL@michigan.gov.