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.