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South Carolina Medicaid
Coordination of Benefits
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
Click one of the
links to access
Insurance Carrier
Codes to enter in
the “Other Payer
ID” field
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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
Other Payer Reject Code
NCPDP field #
472-6E
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Contacts
Magellan Medicaid Administration
[email protected]
SCDHHS
Janet Giles
Brandie Crider
[email protected]
[email protected]
Phone: 803-898-2876
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