Report Third Party Liability (TPL)

Health Plans (HPs) are required by AHCCCS contract to submit new additions and updates to existing Commercial Third Party insurance coverage information associated with their enrolled Medicaid Members. This TPL information is processed, verified and stored in the AHCCCS PMMIS database. It is used to cost avoid medical, dental and pharmacy expense where AHCCCS members have other insurance coverage that must be exhausted prior to using Medicaid funds.

TPL coverage addition, change and termination information is provided through either of two coverage notification processes. Both have the same data requirements for an acceptable transaction.

The website provided by the AHCCCS TPL Contractor

An online Third Party Commercial Insurance Referral may be completed and submitted to AHCCCS through the Health Management Systems (HMS) Referral Database (REFDB) web-based tool whenever an AHCCCS recipient is discovered to have other medical, pharmacy, dental, and/or Medicare Supplement insurance, or whenever other commercial insurance has terminated or changed. The Contractor then verifies the TPL coverage information provided and submits only verified records back to AHCCCS to be used for benefit coordination.

To gain access to the HMS portal, please contact Andrea Beaty at andrea.beaty@gainwelltechnologies.com to create a user account. https://ecenter.hmsy.com/

The Third Party Leads file submission file process

The Third Party Leads File submission process is accomplished by Health Plans depositing a prescribed TLP Lead File on the AHCCCS communications server- SFTP. (See file layout below) The file records will be edited and records with invalid syntax or missing required fields will be rejected.

Coordination of Benefits

AHCCCS is the payor of last resort unless specifically prohibited by applicable Federal or State Law. Health Plans are required by AHCCCS Contract to take reasonable measures to identify potentially legally liable third party sources, and coordinate benefits as outlined in ACOM Policy 434, Coordination of Benefits and Third Party Liability.

For more information, please view the COB FAQs

Filename protocol - yymmdd.tpl

File Location - placed in the Health Plan's folder under AZ/*** /PROD/IN

(Where *** = HP mnemonic)

The files may be placed on the server at any time and are picked up in a nightly sweep for incoming “.tpl” files with that days processing date. It is recommended that Plans place their files for that day on the server no later than 6 p.m. to insure that they proceed that days sweep run. Plans may deposit multiple files with the same date. Advance dated files will be picked up on that processing date. However, prior dated files will never be picked up. If the sweep fails to pick up the file, it must be renamed for the next full days processing.