What steps should I take to send a letter of representation to a health plan partner?: North Carolina personal injury cases
What steps should I take to send a letter of representation to a health plan partner? - North Carolina
Short Answer
In North Carolina personal injury cases, send a clear, written letter of representation to the health plan’s recovery vendor or plan administrator as soon as you’re retained. Identify your client and the accident, assert representation, request that all contact go through you, and ask the plan to open a file and provide a paid-claims report. Include a HIPAA-compliant authorization or plan-specific release if requested, and ask for written confirmation of the file opening.
Understanding the Problem
In North Carolina, how do I, as my client’s personal injury attorney, get a health plan’s recovery vendor to open a subrogation/reimbursement file and communicate with me? Here, the vendor asked that a letter of representation be faxed after confirming no file was open.
Apply the Law
North Carolina law recognizes liens and reimbursement rights that can affect injury settlements. Medical providers can assert statutory liens on personal injury recoveries. Public programs (like Medicaid) and certain health plans (such as the State Health Plan) have statutory reimbursement rights. Your representation letter is the first step to channel communications through counsel, trigger a recovery file, and obtain itemized information needed to resolve any lien or reimbursement claim before disbursing settlement funds.
Key Requirements
Identify the claim: Client’s full name, date of birth, date of loss, and any member/claim numbers to help the plan locate benefits paid.
Assert representation and direct contact: State you represent the client for the accident and request all communications go to your office only.
Authorization for information: Enclose a HIPAA-compliant release or the plan’s preferred authorization so the vendor can share paid-claims data.
Request file opening and documentation: Ask the vendor to open a recovery/subrogation file, provide a paid-claims ledger related to the injury, and identify the legal basis for reimbursement (plan type and terms).
Confirm plan type: Ask whether the plan is Medicaid, the North Carolina State Health Plan, Medicare Advantage, insured ERISA, or self-funded ERISA, because rights and limits differ.
Written confirmation: Request written confirmation of file opening, assigned contact, and preferred method for updates (fax, secure email, portal).
Apply the Rule to the Facts: Because the vendor said no subrogation file was open and asked for a faxed representation letter, you should immediately send a letter on firm letterhead identifying your client, the accident date, and your contact details, and direct all communications to you. Include a signed HIPAA authorization so they can release the paid-claims ledger. Ask them to open a recovery file, confirm the plan type and legal basis for reimbursement, and provide written confirmation and a point of contact.
Process & Timing
Who files: Plaintiff’s attorney. Where: To the plan administrator or the plan’s recovery/subrogation vendor (by the fax or secure email they provided). What: Letter of representation with client identifiers, accident date, and a HIPAA-compliant authorization; request a paid-claims ledger and plan terms. When: Send immediately after engagement and before any settlement discussions; ask for written confirmation within 10 business days.
After the letter, the vendor typically opens a file and issues a questionnaire and preliminary paid-claims report within a few weeks; provide updates on treatment, providers, and the liability claim number as they arise.
Before disbursement, request a final lien/repayment figure and any required release; after payment, obtain written acknowledgment that the lien or reimbursement claim is satisfied for your file.
Exceptions & Pitfalls
Plan type matters: Medicaid and the North Carolina State Health Plan have statutory rights; ERISA self-funded plans rely on plan terms; insured plans and provider liens are subject to state lien limits. Ask the vendor to identify the plan type and basis for recovery.
Missing authorization: Without a HIPAA-compliant release, vendors often will not share paid-claims data. Use the plan’s preferred form if provided.
Scope of claims: Verify the ledger only includes injury-related payments; dispute unrelated charges promptly with brief medical context.
Settlement timing: Do not disburse settlement funds until you have addressed valid liens and reimbursement claims in writing.
Data security: Transmit PHI by the vendor’s secure method; avoid sending unnecessary identifiers (e.g., full SSN) unless required.
Conclusion
To place a health plan partner on notice in a North Carolina personal injury case, send a prompt representation letter that identifies your client and accident, directs all contact to you, encloses a HIPAA-compliant release, and requests a paid-claims ledger and the plan’s legal basis for reimbursement. Confirm the plan type and open file details in writing. Next step: fax or securely email the signed representation letter and authorization to the vendor now and request written confirmation within 10 business days.
Talk to a Personal Injury Attorney
If you're dealing with a health plan or subrogation vendor after an injury, our firm has experienced attorneys who can help you understand your options and timelines. Call us today at 919-341-7055.
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.
