LIEN INVESTIGATION CHECKLIST

Comprehensive Lien Identification and Resolution Tracking

CLIENT INFORMATION

Client Name: [________________________________]

File Number: [________________________________]

Date of Incident: [________________________________]

Date of Intake: [________________________________]

Assigned Attorney: [________________________________]

Assigned Paralegal: [________________________________]

SECTION 1: INITIAL LIEN IDENTIFICATION

1.1 Client Interview Questions

☐ Are you currently enrolled in Medicare?
- If yes, obtain Medicare number (HICN/MBI)
- Part A effective date: [________________]
- Part B effective date: [________________]
- Medicare Advantage Plan: ☐ Yes ☐ No

☐ Are you currently enrolled in Medicaid?
- State: [________________]
- Medicaid ID: [________________]

☐ Will you be eligible for Medicare within 30 months?
- Reason: ☐ Age ☐ Disability ☐ ESRD

☐ Do you have health insurance through your employer?
- Carrier: [________________]
- Is it self-funded (ERISA)? ☐ Yes ☐ No ☐ Unknown

☐ Did you use workers' compensation for any treatment?
- Claim #: [________________]
- Carrier: [________________]

☐ Did you receive VA medical care?

☐ Do you receive TRICARE benefits?

☐ Have any medical providers placed you on a payment plan or deferred billing?

☐ Did you sign any lien agreements with providers?

☐ Did you receive any letters of protection?

☐ Are there any child support liens or obligations?

SECTION 2: MEDICARE COMPLIANCE

2.1 Medicare Status Verification

2.2 BCRC Registration and Notification

☐ Registered with Benefits Coordination & Recovery Center (BCRC)
- Registration date: [________________]
- Case ID assigned: [________________]

☐ Initial notification sent to BCRC
- Date sent: [________________]
- Method: ☐ Phone ☐ Online Portal ☐ Mail

☐ Rights and Responsibilities letter received
- Date received: [________________]

2.3 Conditional Payment Process

2.4 Medicare Conditional Payment Summary

2.5 Medicare Set-Aside (MSA) Consideration

☐ MSA required: ☐ Yes ☐ No ☐ To Be Determined

MSA Triggers:
☐ Client is Medicare beneficiary AND
☐ Future medical treatment expected AND
☐ Settlement exceeds threshold

MSA Status:
☐ MSA calculation obtained
☐ MSA submitted to CMS for review
☐ CMS approval received
☐ MSA account established
☐ MSA administrator appointed

MSA Amount: $[________________]

SECTION 3: MEDICAID COMPLIANCE

3.1 Medicaid Status

☐ Client enrolled in Medicaid: ☐ Yes ☐ No
☐ State: [________________]
☐ Medicaid ID: [________________]
☐ Managed Care Organization: [________________]

3.2 Medicaid Lien Investigation

3.3 Medicaid Lien Summary

State Medicaid Agency Contact:
Name: [________________________________]
Phone: [________________________________]
Address: [________________________________]
Reference Number: [________________________________]

Lien Status:

SECTION 4: ERISA HEALTH PLAN LIENS

4.1 ERISA Status Determination

☐ Employer-sponsored health plan: ☐ Yes ☐ No
☐ Plan is self-funded/ERISA: ☐ Yes ☐ No ☐ Unknown
☐ Summary Plan Description (SPD) obtained: ☐ Yes ☐ No
☐ Subrogation/reimbursement language reviewed: ☐ Yes ☐ No

4.2 ERISA Plan Information

Plan Name: [________________________________]
Plan Administrator: [________________________________]
Subrogation Contact: [________________________________]
Phone: [________________________________]
Address: [________________________________]
Claim Reference: [________________________________]

4.3 ERISA Lien Analysis

☐ Plan has valid subrogation clause
☐ Plan has valid reimbursement clause
☐ Make-whole doctrine applies: ☐ Yes ☐ No
☐ Common fund doctrine applies: ☐ Yes ☐ No
☐ Plan language is unambiguous
☐ Plan permits equitable reduction

4.4 ERISA Payment Summary

SECTION 5: NON-ERISA HEALTH INSURANCE

5.1 Insurance Information

Carrier: [________________________________]
Policy Number: [________________________________]
Group Number: [________________________________]
Subrogation Contact: [________________________________]
Phone: [________________________________]
Reference Number: [________________________________]

5.2 State Law Considerations

☐ State anti-subrogation statute applies
☐ Made-whole doctrine applies
☐ Common fund doctrine applies
☐ Collateral source rule applies
☐ Reduction for comparative fault
☐ Other state protections: [________________]

5.3 Non-ERISA Lien Summary

SECTION 6: WORKERS' COMPENSATION LIENS

6.1 Workers' Comp Status

☐ Third-party claim with WC benefits: ☐ Yes ☐ No
☐ WC claim number: [________________]
☐ WC carrier: [________________]
☐ WC adjuster: [________________]
☐ Phone: [________________]

6.2 Workers' Comp Lien Summary

6.3 WC Lien Negotiation

☐ State permits WC lien reduction
☐ Reduction percentage allowed: [___]%
☐ Procurement cost reduction: ☐ Yes ☐ No
☐ Comparative fault reduction: ☐ Yes ☐ No

Negotiated WC Lien: $[________________]

SECTION 7: MEDICAL PROVIDER LIENS

7.1 Hospital Liens

Hospital Lien Requirements Checklist:
☐ Statutory hospital lien law in jurisdiction
☐ Lien properly filed within time limits
☐ Lien properly served on all parties
☐ Lien amount does not exceed statutory limits
☐ Lien applies to liability recovery (not UM/UIM)

7.2 Physician/Provider Liens

7.3 Letters of Protection (LOP) Tracking

SECTION 8: GOVERNMENT LIENS

8.1 Veterans Administration (VA)

☐ VA provided treatment: ☐ Yes ☐ No
☐ VA lien asserted: ☐ Yes ☐ No

VA Contact:
Address: [________________________________]
Reference: [________________________________]
Amount: $[________________]

8.2 TRICARE/Military Health

☐ TRICARE provided coverage: ☐ Yes ☐ No
☐ TRICARE lien asserted: ☐ Yes ☐ No

TRICARE Contact:
Address: [________________________________]
Reference: [________________________________]
Amount: $[________________]

8.3 Indian Health Services

☐ IHS provided treatment: ☐ Yes ☐ No
☐ IHS lien asserted: ☐ Yes ☐ No

Amount: $[________________]

8.4 Child Support Liens

☐ Child support arrearage: ☐ Yes ☐ No
☐ State CSE agency notified: ☐ Yes ☐ No

Amount: $[________________]

SECTION 9: OTHER LIENS

9.1 Prior Attorney Liens

☐ Prior attorney on case: ☐ Yes ☐ No
☐ Prior attorney asserting lien: ☐ Yes ☐ No

Prior Attorney:
Name: [________________________________]
Amount Claimed: $[________________]
Basis: [________________________________]
Resolved: ☐ Yes ☐ No

9.2 Litigation Funding Liens

☐ Client obtained litigation funding: ☐ Yes ☐ No

9.3 Medical Financing

☐ Client used medical financing: ☐ Yes ☐ No

SECTION 10: LIEN SUMMARY AND NEGOTIATION

10.1 Master Lien Summary

10.2 Settlement Impact Analysis

10.3 Lien Negotiation Savings

SECTION 11: PRE-SETTLEMENT CHECKLIST

☐ All liens identified
☐ All lien amounts verified
☐ Medicare final demand obtained
☐ Medicaid final amount confirmed
☐ ERISA liens resolved
☐ Hospital liens verified/negotiated
☐ Provider liens verified/negotiated
☐ All government liens resolved
☐ Child support status verified
☐ MSA established (if required)
☐ Client approved lien resolution
☐ Settlement funds received
☐ Ready for disbursement

SECTION 12: NOTES AND CORRESPONDENCE LOG