Third Party Liability & Recoveries

Health First Colorado (Colorado's Medicaid Program) is the payer of last resort when a member has other insurance or Medicare. Federal regulations require that all available resources be used before Health First Colorado considers payment. This means that if a member is able to provide for their care, the member must pay for medical benefits first. If there is a responsible third-party who should be paying for the member's health benefits -- for example, a health insurance provider -- that responsible third-party should be paying first. Coordinating benefits makes sure that the correct party pays first by, 1) cost-avoiding claims where a known other party should be paying, or 2) cost-recovering from a claim Health First Colorado paid that should have been paid by someone else.

  • A member's commercial insurance, as opposed to an insurance policy belonging to an at-fault party, must be billed first. The Colorado Medical Assistance Program is always the payer of last resort.
  • Lower of Pricing is used to calculate reimbursement.
  • If a member is not insured by a commercial insurance company, bill the Colorado Medical Assistance Program.
  • A provider may not bill the member for the difference, nor place a lien for medical assistance against the member's right to recover against at-fault parties, or bill the at-fault party's insurance