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South Carolina Medicaid Coordination of Benefits

Place Client Logo here. South Carolina Medicaid Coordination of Benefits. General Info. Providers must bill all other insurance carriers before billing SC Medicaid If payment is received from multiple payer sources, Medicaid requires Total Amount Paid in “Other Payer Amount Paid” field .

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South Carolina Medicaid Coordination of Benefits

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  1. Place Client Logo here South Carolina Medicaid Coordination of Benefits

  2. General Info Providers must bill all other insurance carriers before billing SC Medicaid If payment is received from multiple payer sources, Medicaid requires Total Amount Paid in “Other Payer Amount Paid” field

  3. SC Medicaid is Always Payer of Last Resort

  4. Compliance is Key If a primary carrier requires a PA, the primary carrier’s prior authorization procedures must be followed

  5. Fields Required in Processing Medicaid Secondary Claims Other Coverage Code (OCC) (NCPDP field # 3Ø8-C8) Other Payer Date (NCPDP field # 443-E8) ID Qualifier =“99” (NCPDP field # 339-6C) Other Payer ID (NCPDP field # 34Ø-7C)

  6. Other Coverage Codes (NCPDP field # 3Ø8-C8)

  7. Other Coverage Codes (NCPDP field # 3Ø8-C8) • Enter OCC of 2 if payment was received from primary insurer • Enter primary insurer payment amount in the “Other Payer Amount Paid” field (NCPDP 431-DV) • Effective September 15th, 2010 providers must populate patient’s copayment in the “Patient Paid Amount Submitted” field (NCPDP 433-DX) • Enter OCC of 3 if a particular drug is not covered by an individual’s active primary/secondary coverage • Effective September 15th, 2010 the reject code after billing the primary insurer should be populated in the “Other Payer Reject Code” field (NCPDP 472-E)

  8. Other Coverage Codes (NCPDP field # 3Ø8-C8) • Enter OCC of 4 if instructed to collect money from patient for not meeting deductible or co-pay with active primary insurance (No changes for the OCC of 4) • Enter OCC of 7 if verified by insurance carrier that beneficiary has no other coverage on date of service • Effective September 15th, 2010 the reject code after billing the primary insurer should be populated in the “Other Payer Reject Code” field (NCPDP 472-E)

  9. Other Payer ID (NCPDP field # 34Ø-7C)

  10. Insurance Carrier Codes Click one of the links to access Insurance Carrier Codes to enter in the “Other Payer ID” field http://southcarolina.fhsc.com/providers/rxdocuments.asp

  11. Don’t Forget! Do not use a 1, 5, 6, or 8 in the OCC Field-(claim will reject) Medicaid does not coordinate benefits with Medicare Part D or with a beneficiary’s creditable coverage

  12. Contacts • Magellan Medicaid Administration • SCProvidersupport@magellanhealth.com • SCDHHS • Janet Giles • Gilesje@scdhhs.gov • Brandie Crider • Criderb@scdhhs.gov • Phone: 803-898-2876

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