Presentation on theme: "South Carolina Medicaid Coordination of Benefits"— Presentation transcript:
1South Carolina Medicaid Coordination of Benefits Place ClientLogo hereSouth Carolina Medicaid Coordination of BenefitsWelcome to the accelerated training method offered to you by Magellan Medicaid Administration. Within this presentation, we are going to discuss the required Coordination of Benefits fields which include the appropriate other coverage code values on claims submitted to SC Medicaid. We appreciate you taking the time out of your busy work schedules to view this presentation and hope it is very informative in regards to the Coordination of benefits guidelines. One note that I would like to point out before you start the presentation is that we have applied an audio feature. To listen turn your speakers on and adjust the volume before advancing from this current slide. Remember, simply left click with your mouse to advance throughout this tutorial. Thank you. Enjoy the presentation.
2General InfoProviders must bill all other insurance carriers before billing SC MedicaidIf payment is received from multiple payer sources, Medicaid requires Total Amount Paid in “Other Payer Amount Paid” fieldProviders should bill all other insurance carriers before billing SC Medicaid. Remember, if a payment is received from multiple payer sources or insurance carriers, Medicaid will require the total amount paid from all sources or carriers in the Other Payer Amount Paid Field. To avoid recoupment of Medicaid monies, care should be taken prior to billing to ensure that appropriate claims filing procedures have been followed.
3SC Medicaid is Always Payer of Last Resort It is federally mandated that SC Medicaid is always the payer of last resort in situations where a SC Medicaid beneficiary has other insurance coverage. Providers are reminded that ALL other payers should be billed before a claim is submitted to SC Medicaid.
4Compliance is KeyIf a primary carrier requires a PA, the primary carrier’s prior authorization procedures must be followedTake note that providers are required to comply with plan rules of the primary insurance carrier. For example, if the primary insurance carrier requires a PA then the primary carrier’s prior authorization procedures must be followed prior to submitting the claims to SC Medicaid. If a primary insurer makes payment on the claim, a second PA from Medicaid is not required.
5Fields 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)The following fields are required when a primary insurer is involved regarding claims processing with SC Medicaid. In addition to these requirements of the Other Coverage Code field being populated when processing a Medicaid secondary claim, there are other fields that must be populated in order for the claim to adjudicate successfully which are included on this slide.
6Other Coverage Codes (NCPDP field # 3Ø8-C8) COB requirements vary based on the appropriate Other Coverage Code which is submitted on the claim. The appropriate other coverage code should be listed in the NCPDP field 3Ø8-C8.
7Other Coverage Codes (NCPDP field # 3Ø8-C8) Enter OCC of 2 if payment was received from primary insurerEnter 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 coverageEffective September 15th, 2010 the reject code after billing the primary insurer should be populated in the “Other Payer Reject Code” field (NCPDP 472-E)The Other Coverage Code of “2” should be utilized when payment is received from a primary insurer. The payment amount must be reported in the “Other Payer Amount Paid” field (NCPDP field # 431-DV). Effective September 15th, 2010, a new requirement will include indicating the amount of the patient’s co-payment that is generated after billing the primary insurer in the “Patient Paid Amount Submitted” field (NCPDP field # 433-DX).The Other Coverage Code of “3” should be populated when a SC Medicaid beneficiary has other primary insurance, but the particular drug is not covered by the specific plan(s).Effective September 15th, 2010, a new requirement will be incorporated for pharmacy providers to submit the reject code generated after billing the other insurer(s) in the “Other Payer Reject Code” field (NCPDP field # 472-6E).
8Other 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 serviceEffective September 15th, 2010 the reject code after billing the primary insurer should be populated in the “Other Payer Reject Code” field (NCPDP 472-E)At this time there are no changes involved with the Other Coverage Code of 4. The Other Coverage Code of “4” should only be submitted if other coverage exists, but payment was not collected because individual did not meet the co-payment or deductible obligation with the other insurance carrier.The Other Coverage Code of “7” is appropriate when a SC Medicaid beneficiary does not have active coverage and it has been verified by billing the primary insurer carrier prior to the pharmaceutical product is being dispensed. Effective September 15th, 2010, a new requirement will be incorporated around the Other Coverage Code of “7” for pharmacy providers to submit the reject code generated after billing the other insurer(s) in the “Other Payer Reject Code” field (NCPDP field # 472-6E).
9Other Payer ID (NCPDP field # 34Ø-7C) One of the required fields on a claim Submitted to SC Medicaid for those Medicaid beneficiaries having other insurance is the “Other Payer ID” field. Magellan Medicaid Administration will respond to a pharmacy in the transaction message text field indicating other insurance coverage that may be on file with SC Medicaid.
10Insurance Carrier Codes Click one of the links to access Insurance Carrier Codes to enter in the “Other Payer ID” fieldIn locating the insurance carrier information and/ or a 5 digit insurance carrier code to populate in the “other payer id” field for those Medicaid beneficiaries having other insurance, click on the link provided at the top of the current slide. There are two different links to view the insurance carrier codes, one sorted by name and one sorted by code.
11Don’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 coverageThere are a few key notes to remember regarding the COB process. First, if you submit an other coverage code of 1, 5, 6 or 8 in the other coverage code field, the claim will reject. Lastly, remember Medicaid does not coordinate benefits with Medicare Part D.
12Required on ALL COB claims Field Name NCPCP field # Other Coverage Code (OCC)3Ø8-C8Other Payer Date443-E8ID Qualifier339-6COther Payer ID34Ø-7CRequired on ALL OCC= 2 claimsNCPDP field #Other Payer Amount Paid431-DVPatient Paid Amount Submitted433-DXRequired on ALL OCC= 3 claimsOther Payer Reject Code472-6ERequired on ALL OCC= 4 claimsNo additional fields requiredN/ARequired on ALL OCC= 7 claimsThis chart serves as a quick reference guide to illustrate fields required when processing a claim to SC Medicaid when other insurance is involved.
13Contacts Magellan Medicaid Administration SCDHHS SCDHHSJanet GilesBrandie CriderPhone:Should you have questions which pertain to this Coordination of Benefits presentation, feel free to contact us. Thanks for your time.