MEDICAL LIEN RESOLUTION AND TRACKING WORKSHEET

CASE INFORMATION

Case Caption: [________________________________]

Plaintiff/Claimant Name: [________________________________]

Date of Birth: [__/__/____]

SSN (Last 4): XXX-XX-[____]

Date of Injury: [__/__/____]

Settlement/Judgment Date: [__/__/____]

Settlement/Judgment Amount: $[________________________________]

Case Number: [________________________________]

Prepared By: [________________________________]

Date Prepared: [__/__/____]

PART I: LIEN IDENTIFICATION CHECKLIST

A. Federal Liens

☐ Medicare (CMS)
- Medicare Beneficiary: ☐ Yes ☐ No
- Medicare Number (HICN/MBI): [________________________________]
- Benefits Coordination & Recovery Center (BCRC) contacted: ☐ Yes ☐ No
- Date of initial query: [__/__/____]
- Conditional Payment Letter received: ☐ Yes ☐ No

☐ Medicare Advantage (Part C)
- Plan Name: [________________________________]
- Contacted: ☐ Yes ☐ No
- Date: [__/__/____]

☐ Medicare Part D (Prescription Drug)
- Plan Name: [________________________________]
- Contacted: ☐ Yes ☐ No
- Date: [__/__/____]

☐ Medicaid
- State: [________________________________]
- Medicaid ID: [________________________________]
- State Agency contacted: ☐ Yes ☐ No
- Date: [__/__/____]

☐ TRICARE/VA
- Sponsor Name: [________________________________]
- TRICARE Region: [________________________________]
- Contacted: ☐ Yes ☐ No
- Date: [__/__/____]

☐ Indian Health Service (IHS)
- Facility: [________________________________]
- Contacted: ☐ Yes ☐ No
- Date: [__/__/____]

B. Private Insurance/ERISA Liens

☐ ERISA Health Plan
- Plan Name: [________________________________]
- Administrator: [________________________________]
- Plan Type: ☐ Self-Funded ☐ Fully Insured
- State law applies: ☐ Yes (fully insured) ☐ No (self-funded/ERISA)

☐ Non-ERISA Private Insurance
- Carrier: [________________________________]
- Policy Number: [________________________________]
- Subrogation Clause: ☐ Yes ☐ No

☐ Workers' Compensation (if applicable)
- Carrier: [________________________________]
- Claim Number: [________________________________]

C. Provider/Hospital Liens

☐ Hospital Lien(s)
- Hospital: [________________________________]
- Lien Filed: ☐ Yes ☐ No
- Recording Information: [________________________________]

☐ Provider Liens
- Provider: [________________________________]
- Letter of Protection: ☐ Yes ☐ No

D. Government Assistance Programs

☐ Child Support Enforcement
☐ SNAP/Food Stamps
☐ SSI/SSDI (check for interim assistance)
☐ State Disability Benefits
☐ Other: [________________________________]

PART II: MEDICARE LIEN RESOLUTION

A. Medicare Conditional Payment Information

Medicare Status: ☐ Part A ☐ Part B ☐ Part C ☐ Part D ☐ Not a Beneficiary

BCRC Contact Information:
Medicare Secondary Payer Recovery Contractor (MSPRC)
P.O. Box 138832
Oklahoma City, OK 73113
Phone: 1-855-798-2627
Website: www.cob.cms.hhs.gov/MSPRP

Case ID Number: [________________________________]

Date Rights and Responsibilities Letter Sent: [__/__/____]

Date Conditional Payment Notice Received: [__/__/____]

B. Conditional Payments Summary

TOTAL CONDITIONAL PAYMENTS (Initial): $[________________________________]

C. Disputed Items

TOTAL DISPUTED: $[____]

Date Dispute Submitted: [__/__/____]

Dispute Resolution: ☐ Pending ☐ Approved ☐ Denied

D. Procurement Cost Reduction

Formula: Medicare lien can be reduced by attorney fees and costs allocated to Medicare's recovery.

Settlement Amount: $[____]
Attorney Fees: $[____] ([____]%)
Litigation Costs: $[____]
Total Procurement Costs: $[____]
Procurement Cost Percentage: [____]%

Conditional Payment Amount: $[____]
Less Procurement Cost Reduction: $[____]
Reduced Medicare Claim: $[________________________________]

E. Final Demand

Final Demand Requested: ☐ Yes ☐ No

Date Requested: [__/__/____]

Date Received: [__/__/____]

Final Demand Amount: $[________________________________]

Payment Deadline: [__/__/____]

Note: Beneficiaries must notify and pay Medicare within 60 days of settlement

F. Medicare Resolution

Negotiated Amount: $[____]

Date Paid: [__/__/____]

Confirmation Number: [________________________________]

Method of Payment: ☐ Check ☐ EFT ☐ Other

PART III: MEDICAID LIEN RESOLUTION

A. Medicaid Information

State: [________________________________]

Agency Name: [________________________________]

Contact: [________________________________]

Phone: [________________________________]

Medicaid ID: [________________________________]

B. Medicaid Payments

TOTAL MEDICAID PAYMENTS: $[________________________________]

C. State Anti-Lien Provisions

State Limits on Medicaid Recovery:
☐ Ahlborn reduction applies (limited to portion of settlement for medical expenses)
☐ State has made whole statute
☐ State has procurement cost reduction
☐ Other protections: [________________________________]

Calculated Medical Portion of Settlement: [____]% = $[____]

D. Medicaid Resolution

Initial Lien Amount: $[____]

Disputed Items: $[____]

Ahlborn/Made Whole Reduction: $[____]

Negotiated Amount: $[________________________________]

Date Paid: [__/__/____]

PART IV: ERISA/PRIVATE INSURANCE LIENS

A. Plan Information

Plan Name: [________________________________]

Plan Administrator: [________________________________]

Third-Party Administrator (TPA): [________________________________]

Contact Name: [________________________________]

Phone: [________________________________]

Address: [________________________________]

B. Plan Type Determination

Funding Type:
☐ Self-Funded (ERISA applies - federal preemption)
☐ Fully Insured (State law may limit subrogation)

How Determined:
☐ Plan documents reviewed
☐ 5500 filing reviewed
☐ Confirmation from administrator

C. Subrogation/Reimbursement Language

Does Plan Have Subrogation Clause: ☐ Yes ☐ No

Does Plan Have Reimbursement Clause: ☐ Yes ☐ No

First Dollar Recovery Language: ☐ Yes ☐ No

Make Whole Doctrine Applies: ☐ Yes ☐ No ☐ Unknown

Common Fund/Procurement Cost Reduction: ☐ Yes ☐ No

Relevant Plan Language:
[________________________________]
[________________________________]
[________________________________]

D. Payments by Plan

TOTAL PLAN PAYMENTS: $[________________________________]

E. ERISA Resolution

Initial Claim Amount: $[____]

Less: Disputed/Unrelated Items: $[____]

Less: Common Fund Reduction: $[____]

Negotiated Amount: $[________________________________]

Date Paid: [__/__/____]

PART V: HOSPITAL AND PROVIDER LIENS

A. Hospital Lien (Statutory)

State Hospital Lien Statute: [________________________________]

Hospital Name: [________________________________]

Lien Amount: $[________________________________]

Date Lien Filed: [__/__/____]

Recording Information:
County: [________________________________]
Book/Page or Instrument Number: [________________________________]

Lien Properly Perfected: ☐ Yes ☐ No

Defenses to Lien:
☐ Lien not timely filed
☐ Improper notice
☐ Amount exceeds statutory limit
☐ Other: [________________________________]

B. Letter of Protection Obligations

TOTAL LOP OBLIGATIONS: $[________________________________]

C. Provider Lien Negotiation

TOTAL HOSPITAL/PROVIDER LIENS: $[________________________________]

PART VI: LIEN PRIORITY AND DISTRIBUTION

A. Lien Priority (Typical Order)

Note: Priority varies by jurisdiction

B. Distribution After Liens

PART VII: LIEN RESOLUTION SUMMARY

A. All Liens Tracking

TOTAL ORIGINAL CLAIMS: $[____]

TOTAL NEGOTIATED/FINAL: $[________________________________]

TOTAL SAVINGS: $[________________________________]

B. Outstanding Issues

☐ Medicare final demand pending
☐ Medicaid response pending
☐ ERISA plan appeal pending
☐ Hospital lien dispute
☐ Other: [________________________________]

PART VIII: LIEN SATISFACTION DOCUMENTATION

A. Release/Satisfaction Received

B. Payment Confirmation

IMPORTANT DEADLINES

VERIFICATION

Prepared By: [________________________________]

Date: [__/__/____]

Reviewed By: [________________________________]

Date: [__/__/____]

SOURCES AND REFERENCES

• Medicare Secondary Payer Manual (CMS Pub. 100-05)
• 42 C.F.R. Part 411 (Medicare Secondary Payer regulations)
• State Medicaid agency recovery procedures
• ERISA § 502(a)(3) and applicable case law
• State hospital lien statutes

This worksheet is for lien tracking and resolution purposes. Lien resolution is complex and involves federal and state law. Failure to properly satisfy liens may result in personal liability for attorneys and clients. Consult with qualified legal counsel.