Third Party Liability

An applicant/recipient who receives or will receive health care services as a result of an accident or injury caused by someone else, must assign the right to receive payment for these services to the Department of Health Care Services (DHCS), if those services will be billed to Medi-Cal. If the client is unable to make the assignment, the client's guardian, attorney or the person acting on the client's behalf must make the assignment.

The potential for a third party liability claim exists when:

The third party has liability insurance, or
Client has Workers' Compensation insurance, or
Client has filed or intends to file a claim or lawsuit.

Potential third party liability claims include, but are not limited to:

Insurance claims
Workers' compensation claims
Wrongful death suits
Malpractice suits
Other civil suits for injury

Workers’ Compensation

Workers’ Compensation covers health costs related to injuries on the job. If the client is receiving Workers’ Compensation from a work-related injury, the EW must notify DHCS using the Workers Compensation Notification (New Case) online fillable form. DHCS will recover the cost of any money paid out for services that were paid by MC.

EW Responsibility

When the Eligibility Worker (EW) is made aware of a potential third party liability claim or a client is receiving Workers’ Compensation from a work-related injury, they must notify the Department of Health Care Services (DHCS) within 10 days using the Personal Injury Notification (New Case) or Workers Compensation Notification (New Case) online fillable form as appropriate. For both instances, the EW will need to request the following information from the injured individual:

First and last name
Date of birth
Client Identification Number (CIN)
Date of injury
Type of injury
Third party’s insurance information
Final date of treatment (if known)
Date of settlement (if known)
Client’s attorney information (if applicable)

The EW must also take the following actions:

Advise the applicant/client of the requirement to report potential third party liability information.
Complete the appropriate Third Party Liability page in CalSAWS.
Deny the Medi-Cal application if an applicant refuses to supply the information requested. OR
1. Advise any recipient who fails to provide the requested information that:
  1. DHCS may file a lien against his/her property to recover the costs of health care services, and
  2. His/her Medi-Cal benefits may be discontinued.

When DHCS Receives a Third Party Payment

When DHCS receives payment on an account, notification of the payment is sent to the county in which the client resides to:

Alert the county that a cash settlement from a personal injury case may have been received,
Instruct the EW to:
- Contact the client to inquire about a possible settlement,
- Discontinue aid if the client is over the property limit.

Third Party Liability

Workers’ Compensation

EW Responsibility

When DHCS Receives a Third Party Payment

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