What information does a health plan subrogation company typically need from an injury settlement to start and process a case?
What information does a health plan subrogation company typically need from an injury settlement to start and process a case? - North Carolina
Short Answer
In North Carolina, a health plan subrogation company usually needs enough information to (1) confirm the injured person’s coverage and the plan’s reimbursement rights, (2) identify the injury event and the third-party claim, and (3) match the plan’s paid medical claims to that injury so it can issue a lien/reimbursement demand and resolve it before funds are fully disbursed. Practically, that means proof of representation, a signed authorization, claim identifiers (date of loss and insurance claim info), and settlement details (amount, parties, and expected disbursement timing).
Understanding the Problem
If your North Carolina injury case has already settled, can a health plan subrogation vendor open the file and confirm what it needs to calculate and resolve any reimbursement claim, especially when you have already sent referral materials more than once?
Apply the Law
“Subrogation” and “reimbursement” are ways a health plan (or a government program) may seek to be paid back from a personal injury recovery for medical expenses it paid that were caused by someone else. In North Carolina, the rules depend heavily on what type of coverage paid the bills (for example, Medicaid versus a private employer plan versus the State Health Plan). The subrogation company’s job is to gather the minimum information needed to confirm the plan’s rights, identify the correct claim, and calculate what portion of the plan’s payments are related to the injury and therefore potentially recoverable.
Key Requirements
Coverage identification: The injured person’s full identifying information and the health plan identifiers (member ID, group number, and plan name) so the vendor can locate the correct plan file.
Authority to communicate: A letter of representation and a signed HIPAA-compliant authorization (or the plan’s preferred authorization) so the vendor can discuss protected health information and billing details with the attorney’s office.
Injury event details: Date of loss, type of incident (auto crash, slip and fall, etc.), and a short description so the vendor can match medical payments to the injury.
Third-party claim identifiers: Liability carrier name, claim number, adjuster contact info, and (if filed) lawsuit caption and file number so the vendor can track the recovery source.
Settlement status and numbers: Whether the case is settled, the gross settlement amount, and whether there are multiple claimants or multiple settlements that affect allocation and timing.
Medical payment detail: A list of treating providers and date ranges (and sometimes the attorney’s medical billing spreadsheet) so the vendor can confirm which charges are injury-related and avoid unrelated claims.
Disbursement timing and holdback: When funds are expected to be disbursed and whether any portion is being held in trust pending lien resolution, so the vendor can prioritize issuing a demand and closing the file.
N.C. Gen. Stat. § 44-49 (Medical provider liens) - Creates liens for certain medical providers on personal injury recoveries and includes requirements tied to itemized statements and notice to the attorney.
Analysis
Apply the Rule to the Facts: Here, the key issue is not whether the plan has a valid reimbursement right in the abstract, but whether the vendor has enough information to (1) find the correct plan/member file, (2) confirm you are authorized to receive claim details, and (3) connect the plan’s payments to the settled injury claim so it can issue a demand and provide payoff instructions. Because the claim is already settled and you have not received confirmation of setup, providing (or re-sending) a complete “opening packet” plus the settlement status and expected disbursement timing often triggers assignment and escalation inside the vendor’s workflow.
Process & Timing
Who files: The injured person’s attorney (or the injured person) typically initiates the subrogation/lien process with the plan or its vendor. Where: With the plan’s subrogation vendor (and, for Medicaid issues, with the North Carolina Department of Health and Human Services, Division of Health Benefits). What: A referral/opening packet that includes a letter of representation, signed authorization, coverage identifiers, date of loss, third-party claim information, and settlement status. When: As early as possible; if Medicaid paid, North Carolina law requires notice to the Department within 30 days of receiving settlement/judgment proceeds.
Vendor setup and investigation: After setup, the vendor typically requests (or generates) a payment ledger and then filters payments to those related to the injury date and diagnosis codes. If something is missing (member ID, authorization, date of loss, or carrier claim number), setup can stall without a clear “we opened the file” response.
Demand, negotiation, and payoff: The vendor issues a demand/payoff figure (sometimes labeled as a lien, reimbursement claim, or subrogation interest) and provides payment instructions and required release language. Once paid and documented, the vendor closes the file and should provide written confirmation (often a “paid in full” or “no further interest” letter).
Exceptions & Pitfalls
Different payer, different rules: Medicaid, the State Health Plan, and private employer plans can follow different reimbursement frameworks. A vendor may need to confirm the plan type before it can even tell you what documents it requires.
No authorization = no meaningful response: Even with a letter of representation, many vendors will not discuss payment details without a signed authorization that matches their compliance requirements.
Missing identifiers cause “lost referrals”: The most common setup failures are missing member ID/group number, missing date of loss, or missing liability claim number/adjuster contact—so the vendor cannot match the injury to the correct payment history.
Settlement already disbursed: If funds are distributed before resolving reimbursement, the plan may still pursue recovery depending on the plan terms and applicable law. Holding back a reasonable amount in trust until you receive a written payoff or waiver helps avoid later disputes.
Multiple claims/allocations: If there are multiple injured people, multiple settlements, or multiple incidents, the vendor may require the settlement agreement (or at least a settlement summary) to avoid applying payments to the wrong recovery.
Medicaid timing traps: When Medicaid paid, North Carolina’s statutory notice and timing rules can matter quickly after settlement, so delays in confirming setup should be addressed promptly.
Conclusion
In North Carolina, a health plan subrogation company typically needs proof of representation and authorization, the health plan/member identifiers, the injury date and third-party claim details, and the settlement status and amount so it can match injury-related payments and issue a payoff or demand. If Medicaid paid, notice obligations can run within 30 days of receiving settlement proceeds. A practical next step is to send (or re-send) a complete opening packet and request written confirmation of file setup and a target date for the initial payment ledger/demand.
Talk to a Personal Injury Attorney
If you're dealing with a settled injury case and a health plan or subrogation vendor is not confirming setup or providing next steps, our firm has experienced attorneys who can help you identify the right payer rules, organize the required documentation, and push the process toward a written payoff or resolution. Reach out today. Call [CONTACT NUMBER].
Disclaimer: This article provides general information about North Carolina law based on the single question stated above. It is not legal advice for your specific situation and does not create an attorney-client relationship. Laws, procedures, and local practice can change and may vary by county. If you have a deadline, act promptly and speak with a licensed North Carolina attorney.
