In the event treatment is provided to a HealthChoice member for injuries sustained in an accident, and there is a third party at fault, the Plan has subrogation rights. It is important that Network Providers are aware that their provider contract requires them to file claims with HealthChoice. In addition, the provider contract prohibits Network Providers from collecting from the member any amounts in excess of the Allowable Fee and/or that exceed the member’s deductible and coinsurance liability. The only exception is for services not covered by the Plan or if annual or lifetime benefit has been reached.
Beginning Feb. 1, 2016, the new subrogation administrator for EGID is McAfee & Taft and Healthcare Recovery Solutions (HRS). McAfee & Taft and HRS will provide subrogation services including compiling liens, pursuing and monitoring of third party cases, recovery of liens and performing all detailed investigation regarding possible subrogation claims including but not limited to the following:
- Medical claims,
- Dental claims,
- Defective medical devices,
- Dangerous prescription drugs, and/or
- Toxic exposure.
More information regarding subrogation can be found in Oklahoma Statutes, (74 O.S. 2012, §§ 1301, et seq.). Subrogation information is also available in the unofficial copy of the Administrative Rules 260:50-5-49 on this website.