Medicaid With Other Insurance
Pharmacy providers must bill all other third party payers when a person has coverage through another payer for prescription drugs, including non-prescription (over the counter) medications, some products used in symptomatic relief of cough and colds, and some prescription vitamins and mineral products. Refer to Section 1.2.2 below for more information regarding Medicaid coverage of wrap-around drugs for people who are dual eligible.
If other insurance exists in the VDP Pharmacy Claims System and Medicaid is billed as the primary insurer, 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 claims submission to the other payer. Refer to the System Requirements section for more information about COB program requirements.
If the pharmacy submits the claim to the primary payer and it is not paid, the pharmacy should contact the primary payer and/or prescriber to address the rejection reason. If the claim is not payable by the other payer, Medicaid may pay the claim depending on the rejection reason (including expired coverage). The pharmacy should submit the claim to Medicaid and include the other payer’s rejection code in the “Other Payer Reject Code” field (472-6E).
Medicaid will continue to reject the claim until billing to all other known payers has been attempted. If the person is assessed a deductible or co-payment, the pharmacy should submit the claim to Medicaid (as secondary payer) and include the amount paid by the primary payer. The VDP Pharmacy Claims System will pay deductibles and co-payments, up to the amount Medicaid would have reimbursed, for eligible people and covered drugs.
The person should always walk out of the pharmacy with their prescribed medications and no out-of-pocket expense.
Texas Pharmacy Third Party Insurance Call Center
The Texas Pharmacy Third Party Insurance Call Center ensures the accuracy of third-party information used in the claims adjudication processes.
Pharmacy providers may contact the call center to confirm non-Medicare third party insurances for people eligible for fee-for-service Medicaid or report discrepancies found with other payers.
Pharmacy providers should attempt to bill the third-party payer in question before contacting the call center. The call center cannot process a request until the pharmacy has received a rejection from the third-party payer. Once the pharmacy receives the rejection, the call center will verify insurance within 72 hours and provide updates to the HHSC claim system.
Contact the Texas Pharmacy Third Party Insurance Call Center to verify other insurance.
Third-party Contact Guidance
| What Happens | Who to Contact |
|---|---|
| Pharmacy provider receives a rejection from the primary insurance. | The primary insurance. Medicaid does not have the ability to assist with the correction of a non-Medicaid rejection. |
|
Pharmacy provider is told the person does not have any other insurance although Medicaid has other insurance on file. |
The Texas Pharmacy Third Party Insurance Call Center. The call center will re-verify the other insurance within 72 hours and update the claim processing system as necessary. |
| Pharmacy provider does not know how to enter a coordination of benefits claim. | Your software help desk or corporate office. |