Understanding third party liability

What is third party liability?

Third Party Liability (TPL) is the legal obligation of another insurer (like your car insurer, for example) to pay part or all of the services furnished under a Priority Health plan. In some instances, these services are related to an accident or injury that is covered under a different insurer’s plan.

The Third Party Liability department at Priority Health is a specialized team that examines and investigates claims identified as having a high probability of a TPL. We investigate these claims to see what other insurance plans may have an obligation to pay. Many times, the provider identifies the claims when they submit them for payment of services rendered.

When does a third party have a legal obligation to pay a claim?

Some examples of third party payers that may be liable to pay for services are:

  • Auto insurance
  • Home owner’s insurance
  • Worker’s compensation insurance

What is the purpose of TPL at Priority Health?

The purpose of Third Party Liability is to ensure all other available third party payers meet their legal obligations. In other words, we want to make sure the right insurance companies are paying the right amounts for any services you may have received that would fall under TPL.

What happens to my claims when they are under TPL review?

Often times, more information is needed about the circumstances related to your treatment before we can process your claims. We may deny claims while we seek this information to ensure PH doesn’t inadvertently pay for something another payer is responsible to pay

What is my role as a Priority Health Member in the TPL process?

While your claim is under review, we need your help in gathering important information. We send you a letter requesting information related to your treatment or injury/condition. This information helps us determine if another party is responsible for payment of your care. The best thing you can do to make sure your claims are paid in a timely manner is to respond to our letter with the requested information as quickly as possible.

Requested information may include:

  • When the injury, condition or treatment occurred
  • How the injury/condition happened (slip and fall, burn, animal bite, attack by another person, etc.)
  • If the injury/condition is related to an automobile accident, or contact with an automobile, motorcycle, or moped
  • Whether or not the injury/condition is work-related
  • Where the injury/condition occurred (i.e. store or other business, someone else’s home, sporting event, community park, etc.)

Depending on the circumstances of the injury/condition, we may need additional information about other applicable insurance coverages, such as your auto insurance, worker’s compensation insurance, business insurance, etc.

Once we receive the information we need, we typically take over from there. Our team of specialists handles coordinating with the other payers on your behalf and getting your claims processed according to your health plan benefits.

What if I don’t respond to your requests for information about my claims?

Your claim or claims could be denied if you don’t respond. That means we will not pay your provider for the services you received. Providers will eventually seek payment from you, which can lead to collections calls and possibly even litigation.  The best way to avoid this is to respond to our requests for information as soon as possible.

What if my claim is not related to an accident/injury?

The only way we will know if your claims are or are not related to an accident/injury is if you respond to our requests for information. Once we receive your response and determine no other party was responsible for your injury/condition, we will process your claims according to your health plan benefits.

How does TPL benefit me?

The TPL process is an integral part of containing the cost of healthcare. Without it, you or your employer could face higher premium costs. By providing timely information, TPL processes can be handled efficiently, which will help ensure the cost of your care is billed to the correct payer.