What Usually Must Happen Before Payment
- Settlement terms confirmed: The parties confirm the settlement in writing and identify what claims are being resolved (injury claim, and sometimes related reimbursement issues).
- Documents signed: The injured person typically signs settlement paperwork, including a release. Separate paperwork may be needed to allow the health plan’s recovery vendor to share lien/reimbursement details with the attorney.
- Liens/reimbursements addressed: If a health plan paid accident-related medical bills, it may assert a right to be repaid from the settlement. The recovery vendor’s job is often to identify those payments and provide an itemization so the parties can address them.
- Disbursement: After the settlement funds arrive, the attorney typically resolves approved reimbursements and then disburses the remaining funds according to the settlement paperwork and applicable rules.
What Information Health Plan Recovery Vendors Commonly Ask For
Different plans and vendors use different intake forms, but the information below is commonly requested to open a file or locate an existing one.
- Member identifiers: Full name as it appears on the health plan, current address/phone (sometimes), date of birth, and often the member ID. Some vendors also use the last four digits (or full) Social Security number to avoid mismatches when names are common.
- Date of loss (accident date): This is one of the most important matching fields. A wrong date can cause the vendor to pull the wrong claim history or miss the file entirely.
- Type of incident: For example, motor-vehicle collision versus slip-and-fall. A short description (like “merge/T-bone collision”) is usually enough.
- Injury description (high-level): A general description such as “neck and back pain” helps the vendor filter which medical claims may be related. Your attorney should keep this general and consistent with the medical records.
- Attorney and representation details: Law firm name, contact person, phone/fax/email, and a representation letter so the vendor knows who it can speak with.
- Signed authorization: A HIPAA-style medical authorization (or the plan’s own authorization form) allowing the vendor/plan to release information to the attorney. Without this, many vendors will only provide limited information.
- Claim identifiers (if known): If the vendor already opened a file, it may have an internal reference number or “file ID.” If you don’t have it, the identifiers above are what they use to locate it.
- Settlement status (when applicable): If the case is already settled, the vendor may ask for the settlement date and gross settlement amount so it can issue a “final” reimbursement figure or closing statement (the exact request varies by plan).
What Can Cause Delays
- Missing or inconsistent identifiers: A nickname versus legal name, a wrong date of birth, or an incorrect accident date can prevent a match.
- No signed authorization on file: Vendors often cannot discuss details or release an itemization without it.
- Late-arriving medical claims: Providers sometimes bill the health plan weeks or months after treatment ends, which can change the final paid-claims list.
- Disputes about relatedness: Vendors may initially include charges that the attorney believes are unrelated. Resolving that often requires supporting documentation and back-and-forth review.
- Multiple coverages: If more than one health plan or payer was involved, it can take longer to confirm who paid what and who is asserting reimbursement rights.
Liens and Reimbursement Claims (Plain English)
When a health plan pays medical bills that are later tied to an accident caused by someone else, the plan may claim a right to be repaid from the injury settlement. In North Carolina, these rights can come from different places depending on the plan (for example, certain government-related plans have specific statutory recovery rights, and medical providers can also have lien rights in some situations). The recovery vendor’s file is essentially the plan’s way of tracking: (1) whether the plan paid accident-related bills, (2) how much was paid, and (3) what amount the plan says should be reimbursed before the settlement is fully disbursed.
How This Applies
Apply to the facts: Because treatment has ended and the claim has been settled, the recovery vendor will usually focus on confirming the correct member identifiers and the correct accident date so it can generate an accurate, itemized list of accident-related payments. If no reference number existed, opening a new file typically requires the client’s plan/member information, date of birth (and sometimes Social Security number), the accident date, a short description of the crash and injuries (neck/back), and a signed authorization so the vendor can communicate with the attorney and release the payment itemization.
Conclusion
To open or locate a health plan recovery file, your attorney usually needs enough information to confirm coverage and match the accident date to the plan’s paid medical claims—plus a signed authorization to receive details. The most common issues are missing identifiers, an incorrect date of loss, or delays caused by late billing and “relatedness” disputes. One practical next step is to confirm the client’s exact plan name, member ID, date of birth, and accident date before submitting the request.
