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DHS home | APD Staff Tools | APD Worker Guide | D.11 Third-Party Insurance, Health Insurance Premium Payments (HIPP) and Private Health Insurance (PHI) Reimbursements
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APD Worker Guide

D.11 Third-Party Insurance, Health Insurance Premium Payments (HIPP) and Private Health Insurance (PHI) Reimbursements

Updated 8/16/16

Third-Party Liability (TPL) – Private or Employer-Sponsored Insurance

When a client is identified as having private or employer sponsored health insurance, the insurance is added to MMIS so claims payments or denials are done accurately. In most cases, when there is TPL, Medicaid is the payer of last resort. Other insurance is known as third-party liability (TPL), third-party resources (TPR) and health care coverage (HCC).

The Health Insurance Group (HIG) verifies third-party insurance policies and updates MMIS. In addition:

Notification of Other Health Insurance - Internet-Based Web Form

Use for non-emergent requests only

Clients are required to report to the Department when they or any member of the household receiving or applying for Medicaid have other health insurance. This is done by completing and submitting an online from to HIG. The web form can be completed by the worker, client, provider, CCO, assistor, or other individual. Submitters receive a confirmation e-mail and tracking number for their records. After HIG receives the web form, they will verify the policy details with the insurance carrier and update the TPL file in MMIS. The online web form should be submitted to HIG to report new insurance, terminated insurance, or other insurance policy changes. It can also be used to apply for the Health Insurance Premium Payment (HIPP) program.

The online web form can be accessed here or at the following URL: https://apps.oregon.gov/dhs/opar. You can also get more information here. You must have a current browser to use the form (Mozilla Firefox, Google Chrome, Internet Explorer versions 8 or higher). Once you receive your confirmation e-mail, it means that HIG has successfully received the information, so you should not send the form more than once. The online form can be used on any device with internet access, including cell phones, tablets, and personal computers.

Remember: The internet-based web form should only be used for non-urgent requests. If you have an urgent need, see the instructions below.

Click here for information on the referral process and detailed instructions on how to complete the online form (also see OPAR-IM-15-001).

DHS 156 – Request for Rush Verification of Third Party Insurance form

If a client is having an emergency and is unable to get prescriptions or urgent/emergent medical services due to inaccurate TPL information in MMIS, a worker can request “Rush” processing by e-mailing the DHS0156 to HIG at REFERRALS, TPR. In most cases rush requests are completed the same day they are received. Note: Due to the volume of work received, it's very important to write "Rush-meds" or Rush-urgent care" on the top of the form as well as in the e-mail subject line so it can be identified as urgent.

Health Insurance Premium Payment (HIPP)

The HIPP program provides premium reimbursement to eligible policyholders who are paying for individuals also covered by Medicaid. Eligibility for the HIPP program is determined by a HIG Premium Reimbursement Coordinator (PRC) instead of by branch offices. Individuals wanting to apply for HIPP can apply in Step 4 of the online web form at www.reporttpl.org. Eligible policyholders can be reimbursed even if they don't live in the same household as the covered individual. HIPP can be applied for at any time as long as the Medicaid benefits and insurance are still active. If determined eligible, payments begin the month after they are approved. HIPP payments are not approved for periods prior to the request date.


To qualify for HIPP, the private or employer-sponsored health insurance must be:

  1. A comprehensive major medical plan that includes inpatient and outpatient hospital, physician, lab, x-ray and full pharmacy benefits. The insurance is not considered major medical if it only covers a specific condition or disease such as a cancer-only policy or if the prescription benefit is a discount card; and
  2. Determined cost-effective based the Medical Standard Chart (MSC); and
  3. Compliant with the HIPP requirements in OAR 410-120-1960.

For detailed information about the HIPP program including the eligibility criteria, referral process, and the Medical Savings Chart (MSC) please see the Medical Assistance Programs worker guide.

Click here for information on the referral process and detailed instructions on how to complete the online form (also see OPAR-IM-15-001 and OPAR-IM-15-003).

 

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Oregon Department of Human Services
500 Summer St. NE E02, Salem, OR 97301-1073
Phone: (503) 945-5811
Toll-free: (800) 282-8096 (V/TTY)