Coordination of Benefits

The system receives daily pharmacy insurance eligibility and insurer information verified by the Medicaid third-party recovery vendor. The system then checks each pharmacy claim at point of sale for other insurance.

Field Name	Field Number	Usage
337-4C	Coordination of Benefits/Other Payments Count	Required
338-5C	Other Payer Coverage Type	Required
339-6C	Other Payer ID Qualifier	Required if the Other Payer ID is submitted
340-7C	Other Payer ID	Required if the Other Payer ID Qualifier is submitted
443-E8	Other Payer Date	Required
341-HB	Other Payer Amount Paid Count	Required when submitting payment from Other Payer
342-HC	Other Payer Amount Paid Qualifier	Required when submitting Other Payer Amount Paid Count
431-DV	Other Payer Amount Paid	Required when submitting Other Payer Amount Paid Qualifier
471-5E	Other Payer Reject Count	Required when not submitting Other Payer payment
472-6E	Other Payer Reject Code	Required when submitting Other Payer Reject Count
392-MU	Benefit Stage Count	Required when submitting Benefit Stage Qualifier
393-MV	Benefit Stage Amount	Required when submitting Benefit Stage Qualifier

If Medicaid is billed as primary insurer, and other third-party insurance (other than Medicare) exists in the system, then the claim will reject with NCPDP error code 41 ("Submit Bill To Other Processor or Primary Payer"). The pharmacy will be provided with the third-party billing information needed for claim submission to the other payer. The message will be returned in the “Additional Message Information” field (526-FQ) as follows: “Bill Other Payer (Payer ID:x, Policy No: x, Bin:x, PCN:x, Group:x, Cardholder ID:x)”.

Pharmacy providers should contact their software provider if the “Additional Message Information” field is not displayed.

Refer to the Coordination of Benefits chapter for more information on Medicaid, Medicare, and third-party insurances.