Subrogation — Third Party Recovery
The State Health Plan ("Plan") has the right of subrogation upon its injured members' right to recover from liable third parties. The Plan's objective is to recover medical expenditures incurred by the Plan where a third party is liable for the care. The recovering of such expenditures will ensure the financial viability of the Plan and allow it to continue to provide cost-efficient health care coverage to all its members.
Please note that in accordance with North Carolina General Statute (N.C.G.S.) § 135-48.37, the Plan is required to inquire about the terms of any third party recovery and disbursement to all lien holders if payment to the Plan is less than 100% of its lien. The Plan collects fifty (50%) percent of the total damages recovered by members after reasonable costs of collection have been subtracted from the total recovery.
Members should contact Health Management Systems, Inc. (HMS), which has been contracted by the Plan to perform subrogation services, at 800-294-2757 to determine whether the Plan is claiming a right to recovery. Alternatively, members may complete and fax the Lien Request form to 919-714-8575. Within five (5) business days HMS will provide a lien amount to members or their duly authorized representatives.
A Third Party Recovery Overpayment form is to be completed by providers for any overpayments due back to the Plan when a third party liability carrier has also paid the same claims. Please complete the information on the Third Party Recovery Overpayment Form to the extent known, attach the refund check and forward to State Health Plan for Teachers and State Employees, Overpayments, PO Box 20733 Raleigh, NC 27619. This information allows the Plan to properly credit members' accounts and pursue other claims paid by the Plan where a third party is liable.
For a complete copy of N.C.G.S. § 135-48.37, which governs the Plan's right of subrogation and right of recovery, please click here.