THIRD PARTY LIABILITY UPDATE

Instructions

Use this form to notify the MO HealthNet Division (MHD) of a participants verified private health insurance information (also known as Third Party Liability (TPL)) or to update existing insurance records. MHD is the payer of last resort when there is the possibility of a third party resource (TPR) for the payment of a participant’s claims. Examples include private or employer-sponsored health insurance, Medicare, and Medicare Replacement plans (Part C).

Allow up to three weeks for the information to be verified and updated to the participant's eligibility file. Eligibility can be verified through eMOMED or by calling Provider Communications at (833) 222-7916.

Do not send claims with this form. Your claims will not be processed for payment if attached to this form.

Provider Information

Choose One

New TPR

Update TPR

Provider Name

Date

Contact Person

Phone Number

Participant Information

Participant Name (required)

MO HealthNet ID Number/DCN

Date of Birth (required)

Policyholder Information

Policyholder Name

Policyholder’s Social Security Number (Required)

Additional Household Members on the Insurance Policy (Attach an additional sheet if necessary)

Names

DCN

Third Party Resource Information

Insurance Company Name

Insurance Phone Number

Insurance Address

City

State

Zip Code

Policy Number (Required)

Group Name or Number

Verification

Source of Verified Information

Employer

Insurance Company

Name of Source

Describe what policy information was verified and how:

Please attach copies of insurance cards or screenshots of insurance verification websites.

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Thank You for Submitting Your TPL Insurance Resource Form.

Your submission has been received successfully.

Our team will review and process your form as promptly as possible in the order it was received. If additional information is needed, we will contact you.

If you have any questions, please contact us at tpl.database@dss.mo.gov or call 573-751-2005.

Thank you for helping us keep your insurance information up to date.

The Form ID for this submission is {formuniqueid}.

Form ID