Home    HIPP      Estate Recovery    Trauma Recovery     Void Request     Insurance Adjustment    Provider Recoupment Reports    Recoupment Guidelines    Feedback

Tort / Trauma Recovery - Accident and Injury Questionnaire

One aspect of the Third Party Liability (TPL) program is that of the Trauma/Tort Recovery Unit which recovers Medicaid resources for the State of West Virginia.  This unit provides case management services for automobile accident, malpractice/negligence, personal injuries, workers’ compensation, general liabilities, and any other trauma/tort recoveries.  

Tort / Trauma Recovery Legalities

Dealing with the Trauma Recovery Unit

 

Important Notice: This page is provided to collect information concerning Medicaid recipients injured in a trauma related accident / incident. Medicaid may have paid for medical bills as a result of that accident / incident. Please complete the below information so that we can determine the liable third party or company responsible to pay for medical treatment.

 

Failure to cooperate could result in the loss of Medicaid eligibility. State law requires recipients or their representative to provide insurance information. 

 

Instructions:

  • Fill out the Accident and Injury Questionnaire as thoroughly as possible.

  • Click "Submit" at bottom of page.  (Information will be forwarded to our Tort/Trauma Recovery Supervisor)

  • Receive response within three business days of submittal.

                     

    Name of Injured Medicaid Recipient(s)

    Date of Birth

    Recipient Medicaid ID Number (11 Digits)

    Social Security Number

    Date of Accident / Injury Month           Day            Year
    Type of Accident
    Place Where Accident / Injury Occurred (If other please specify)
    Was there another party at fault? Yes     No     Unknown
    Are you making a claim against the other party? Yes     No     Undetermined
    Liable Party's Insurance Company:
    Liable Party's Insurance Claim Number:
    Liable Party's Name:
    Liable Party's Insurance   Address:
    City:    State:  Zip:
    Name of Adjuster:
    Telephone number of Insurance
    Explain circumstances of accident or incident and describe injuries:

    If you are represented by an attorney, please give their name, address and phone number below:
    Your Attorney's Name:
    Your Attorney's Address:
    City:   State:    Zip:
    Attorney's Phone Number
    Please give the name and address of Your Insurance Company
    Insurance Claim or Group ID Number:
    Company Name:
    Address:
    City:    State:   Zip:
    Phone Number:
    Have you made a claim or received settlement or other benefits? Yes No
    If yes, explain:
    If injury occurred at work, was it related to employer?     Yes     No
    If claim was for workers compensation benefits, give claim number:  
    Name, Address and Phone number of Injured Person(s) Employer(s):
    Name:    
    Address:
    City:       State:  Zip:
    Phone:

    I acknowledge that I have read this questionnaire, or that it was read to me, and that I understand it's purpose and effect, and that it is a true and correct statement to the best of my knowledge and belief.         

    Check Here

    Your Name:
    Your Address:
    Your City:   State:   Zip:
    Your County:
    Your Phone Number:
    Your e-mail Address:

    Email questions or comments about this web site to wvrecovery@hms.com                             
    Copyright © 2010 HMS
    Last modified: January 29, 2010