A claim could be held for possible other party liability review (OPL) for multiple reasons. Reasons may include:

  • Services related to a work or auto accident
  • Services related to a known injury or accident
  • Combination of dollar amount and diagnosis code billed
  • Services related by body area to an open or ongoing investigation
  • Accident indicator on claim of auto, work, or work related auto accident

Note: This list is a general informational and not all inclusive.

If a claim is held for accident information from the member, the member needs to follow directions indicated on the letter he or she received from us or from our contracted vendor. This will consist of either an incident report, or a letter to call our vendor to provide information about the claim that is considered a potentially a third party situation.

When an accident investigation is created, claims related to those services will pend in our claims system for up to 25 days. If the information is not received within 25 days, the investigation will close with the claim remark indicating information is required from the member. The closed claim will become member responsibility.

It is possible that an accident investigation has already been initiated and the submitted claim is related to information we already have a pended investigation on file. In this situation the claim will be attached to the pended accident investigation and held until requested information has been received or the 25 day time period is met with no information being received.

Note: The 25 days limit commences from the day the investigation is created in our system.

Based on the claim denial reason the member may need to either:

  • Contact our trusted vendor to provide the requested incident report information (reason codes O3X, O4J, O4K, O3W, O4G, O4H, O39, O4P, O4N)
    • If the member contacts Customer Service, the member will be asked to contact the vendor directly, if he or she has not already done so.
    • If the member has contacted the vendor first and then contacts our Customer Service, he or she will be transferred to the OPL department.
  • Complete and return the incident report to the Health Plan (if reason code is O1V, O3D or O1D)
    • If you have questions, contact the Provider Contact Center at the phone number indicated on the back of the member ID card

The claim closure codes, including those above, will help determine how the member needs to return the required information. The member can contact Customer Service with questions or he or she can complete an Incident Report on our member website.