Third Party Liability Account Balance Form
Facilities must submit the Personal Funds Account Balance Report (TPL Form) to MO HealthNet for any expired resident that was a MO HealthNet participant; or was a recipient of aid, assistance, care, services; or if the resident had money expended on his/her behalf by the Department of Social Services. This does not apply to discharged residents.
If a resident had no personal funds remaining at the facility, in any account, with whatever title the account may be known when they expired, then a TPL form does not need to be sent.
Certified facilities must submit the TPL Form within 30 days of expiration, while state licensed facilities must submit within 60 days of expiration.
The TPL form can be found at manuals.momed.com/forms/Personal_Funds_Account_Balance_Report.pdf.