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South Carolina Medicaid Coordination of Benefits
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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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SC Medicaid is Always Payer of Last Resort
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Compliance is Key
If a primary carrier requires a PA, the primary carrier’s prior authorization procedures must be followed
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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)
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Other Coverage Codes(NCPDP field # 3Ø8-C8)
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)
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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)
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Other Payer ID(NCPDP field # 34Ø-7C)
Insurance Carrier Codes
http://southcarolina.fhsc.com/providers/rxdocuments.asp
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Click one of the links
to access Insurance
Carrier Codes to
enter in the “Other
Payer ID” field
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
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Required on ALL COB claims
Field Name NCPCP field #
Other Coverage Code (OCC) 3Ø8-C8
Other Payer Date 443-E8
ID Qualifier 339-6C
Other Payer ID 34Ø-7C
Required on ALL OCC= 2 claims
Field Name NCPDP field #
Other Payer Amount Paid 431-DV
Patient Paid Amount Submitted 433-DX
Required on ALL OCC= 3 claims
Field Name NCPDP field #
Other Payer Reject Code 472-6E
Required on ALL OCC= 4 claims
Field Name NCPDP field #
No additional fields required N/A
Required on ALL OCC= 7 claims
Field Name NCPDP field #
Other Payer Reject Code 472-6E
Contacts
Magellan Medicaid Administration [email protected]
SCDHHS Janet Giles
Brandie Crider
Phone: 803-898-2876
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