Third-Party Liability (TPL)

Third-party liability (TPL) is when the financial responsibility for all or part of a member's health care expenses rests with an individual entity or program (e.g., Medicare, commercial insurance) other than Keystone First.

Coordination of benefits (COB) is a process that establishes the order of payment when an individual is covered by more than one insurance carrier.  Keystone First is always the payer of last resort. This means that all other insurance carriers (the “primary insurers”) must consider the health care provider’s charges before a claim is submitted to Keystone First.

Please refer to the Claims Filing instructions (PDF) for more specific information, including submitting TPL claims and COB/secondary claims.

Medicare as a third-party resource

For Medicare services that are covered by Keystone First, we will pay, up to the plan contracted rate, the lesser of:

  • The difference between the Keystone First contracted rate and the amount paid by Medicare, or
  • The amount of the applicable coinsurance, deductible, and/or copayment.

In any event, the total combined payment made by Medicare and Keystone First will not exceed the Keystone First contracted rate.

Commercial third-party resources

For services that have been rendered by a network provider, Keystone First will pay, up to the plan contracted rate, the lesser of:

  • The difference between the Keystone First contracted rate and the amount paid by the primary insurer, or
  • The amount of the applicable coinsurance, deductible, and/or copayment.

In any event, the total combined payment made by the primary insurer and Keystone First will not exceed the plan contracted rate.

Prenatal TPL

Keystone First complies with the requirements outlined in the Bipartisan Budget Act of 2018 (Pub. L. 115-123), amended section 1902(a) (25) (E) of the Social Security Act and the Department of Human Services (DHS) MA bulletin (01-19-12) (PDF), regarding payment for prenatal care as follows:

If there is a third-party resource; providers are to submit claims to that resource prior to submitting a claim for prenatal services to Keystone First.

Providers must verify whether a member has insurance coverage in addition to Medical Assistance (MA).  Providers can verify member eligibility and benefits through any of the following methods:

  • NaviNet
  • Keystone First eligibility line – 1-800-521-6007
  • Pennsylvania Eligibility Verification System (EVS) – 1-800-766-5387

All requirements are outlined in MA bulletin 01-19-12 (PDF).

Providers