285i Instructions for Form DMA-285: Third Party Liability Health Insurance Information Questionnaire

  1. LEGIBLY PRINT information in every applicable field on the form.

  2. If the DMA-285 is for a legal action, Trust or QIT, write “Legal Action”, “TRUST” or “QIT” in red ink at the top of the form.

  3. If this form is completed to report a change, personal reimbursement, death or cancellation of an insurance policy, write “Change”, “Cancellation”, “Death”, “Reimbursement”, etc. in red ink at the top of the form. You may use a copy of the original 285 sent to DMA if it is legible.

    • If you have a letter confirming cancellation of the policy, attach the letter to the 285.

    • If the A/R has never had the insurance or if it was cancelled several years ago, attach to a 285 a copy of the MHN screen showing the insurance and annotate that the A/R has never had or has not had the insurance in years.

    • If you are reporting the death of an A/R who has a QIT, also write the date of death next to “Death” as MM/DD/YY.

    • If the A/R has personally been reimbursed for a service covered by Medicaid or has received a settlement from a pending legal action, mail/fax a copy of the existing 285 and attach a copy of the Explanation of Benefits (EOB) or letter outlining the settlement that accompanies the check. Attach a copy of the check, if available.

  4. Do not submit this form if the only health insurance the A/R(s) have is Medicare or Medicaid.

  5. Complete the name and address, etc. of the head of household in the AU as entered in SUCCESS.

  6. Check whether the case is for an application or redetermination.

  7. If you plan to send this form to DMA for an active policy, trust, etc., check “Yes” to having a private, group or government health insurance…..

  8. Check yes or no as appropriate if someone else has health insurance on the A/R(s).

  9. Check the appropriate type of policy that exists for the A/R(s). Attach a copy of the front and back of the health insurance card, if possible.

  10. If the form is for a trust or QIT, cross out “Policy Holder” and write in “Trustee”. Enter the name of the policy holder or trustee.

  11. Enter the address of the policy holder or trustee as appropriate.

  12. Enter the policy holder’s SSN.

  13. Enter the phone number of the policy holder or trustee.

  14. Enter the name address, policy number and effective date in the appropriate fields. If insurance is cancelled, write “Cancelled” above “Effective Date” and the date cancelled in the space available.

  15. If the insurance policy is through an employer, enter the information pertaining to the employment in the spaces provided.

  16. List the names of the household members who are Medicaid A/Rs covered under the insurance policy. Enter their relationship to the A/R given as the “Case Name” at the top of the form. If it’s the same write “Self”. Provide the date of birth. Enter the SUCCESS ID #. Enter the SSN of the individual.

  17. If possible, have the A/R or PR sign the document in the two spaces provided.

  18. The worker should LEGIBLY PRINT his/her name, DIRECT phone number and DFCS county.

  19. See Section 2230 for mailing/faxing instructions.

PCG, the entity charged with handling DMA-285, has a 30 day standard of promptness. If it is necessary to have an immediate correction made concerning a TPR, fax the information to PCG rather than mailing. At times MHN may show insurance coverage that the MES is not aware of. Always double check with the A/R before assuming that the insurance shown is not valid. However, a pharmacy should never deny a member their prescriptions because of TPR issues. They have override codes to enter to make the prescription claim be accepted.