ELG Third Party Recovery Services (“TPRS”) is a contracted Business Associate of the Mail Handlers Benefit Plan, the Rural Carriers Benefit Plan, the Foreign Service Benefit Plan, and the SAMBA Health Benefit Plans. TPRS assists these Federal Employees Health Benefit plans by looking into claim payments that may be the responsibility of another insurance company or workers’ compensation carrier. These efforts help to contain the cost of healthcare that are reflected in the premium paid by you and/or your federal or postal employer.
Your Plan brochure contains a section called “When others are responsible for injuries” which you can find in Section 9. To find a copy of the brochure, click here. This section explains when the Plan pays medical bills for an injury or illness that has been caused by or are the responsibility of a third party, the Plan has a right to seek reimbursement of those medical bills from the third party, their insurance company, the U.S. Office of Workers Compensation Programs (“OWCP”), another workers’ compensation carrier, and/or your insurance company. The Plan also has the right to seek reimbursement of the medical bills from you if you receive a payment from the third party or an insurance company/OWCP for this injury or illness. We exercise these rights for the Plan.
A third party is a person (other than you), a business, a non-profit organization, or the government.
When you see a doctor or other health care provider, the health care provider includes on the claim for diagnosis codes that help explain the reasons for your visit. When claims are processed through the Plan’s system, we flag diagnosis codes for injuries or illnesses that in our experience may result from a third party or work related incident. A questionnaire is generated if the patient has received treatment for an injury or illness that has an accidental injury or illness diagnosis code(s). We mail out letters with questionnaires asking for more information about the incident. If we learn that no third party was involved, e.g., you slipped and fell at home, we close our case. If a third party was involved or if an auto accident occurred, we will continue our work with lawyers and insurance adjusters.
Your state may have no-fault automobile insurance, which sometimes is called personal injury protection (PIP). Also it’s a good idea to carry uninsured/underinsured motorists coverage under your own auto insurance policy. That coverage pays if the party at fault carries a level of insurance which is insufficient to cover the damages that he or she caused you. Under the “When others are responsible for injuries” provision of the Plan brochure, the Plan’s reimbursement right applies to these types of coverage.
We notify any attorneys or insurance companies involved in the case about our lien. We then remain in contact with them until we collect our lien from any recovery.
A lien is the formal legal name for the Plan’s right to recover its benefit payments from the recovery that you receive from the third party, the third party’s insurer or your own automobile insurance.
These subrogation/reimbursement procedures help to contain the cost of healthcare that is reflected in the premiums paid by you and/or your federal employer.
If you recently responded to a questionnaire and have received another, it is likely that we did not receive or process your response before the next questionnaire in the cycle was automatically mailed out. TPRS sends out three questionnaires on a 30 day cycle.
If you responded to a questionnaire several months ago and have continued treatment, it is possible that a new questionnaire was produced due to those additional claims. TPRS tries its best to avoid sending duplicate questionnaires for the same treatment. If you believe you have received a duplicate questionnaire, please contact us to verify that we received your previous response.
Once TPRS receives and processes a response to a questionnaire, the status of the case is changed to prevent another questionnaire from being processed for the same medical treatment. However, if treatment is continued for six months or more or if a new injury is sustained, another questionnaire is mailed out to determine if the new or additional treatment is related to a workers’ compensation case or is the responsibility of a third party.
If you have an injury or illness which is not related to a workers’ compensation claim and is not the responsibility of a third party and you will require extended treatment for your condition, please contact us so that we may note your file and prevent additional questionnaires from being sent for this injury or illness.