Problem Resolutions with Medicaid Billing and TPL

Pharmacies should never deny filling an A/R’s prescription because of an insurance issue. However, follow the instructions below if the insurance continues to be a barrier to getting prescriptions filled or Medicaid claims paid:

Worker is notified by A/R, pharmacy, or provider that a claim cannot be processed because of a TPL.

Worker checks with A/R to validate if TPL exists. Also check case record/Gateway for information regarding either the existence of TPL or cancellation of TPL.

If the TPL is valid, inform A/R that the TPL is the primary payer of prescription. No further action needed.

If the TPL is valid, but the benefits have been exhausted for that particular service, that TPL may not be deleted from GAMMIS. The pharmacy provider may process the claim Point of Sale (POS) using an Other Coverage Code = 4 Other coverage exists - payment not collected. If the pharmacy system does not allow for POS processing the pharmacy provider may submit the claim manually on a Universal Claim Form (UCF). The pharmacy provider should also include an explanation of benefits (EOB) from the primary carrier or a pharmacy screen print/profile with primary carrier detail that should include: the primary (copay/deductible), and remaining amount due that is being billed to DCH. The provider must maintain documentation in their records concerning the denial in case of an audit. Mail pharmacy paper claims (Universal Claim Form (UCF)) to: OptumRx PO Box 968021 Schaumburg IL 60196-8021

If evidence is that the TPL is no longer valid, complete a Form DMA 285 and put a note on the top of the form that the insurance is not valid and attach a copy of the GAMMIS screen showing the invalid TPL. Fax to HMS at 770-937-0180. HMS has 30 days to act on the cancellation.

If the TPL was cancelled many months ago or has never been a valid TPL for the A/R, complete a Form DMA 285 and put a note on the top of the form that the insurance is not valid and attach a copy of the GAMMIS screen showing the invalid TPL. Fax to HMS at 770-937-0180.

However, if this is an emergency and the prescription needs to be processed immediately, you may need to contact HMS by phone at 678-564-1162 option 3 or by fax at 770-937-0180.

The pharmacy should immediately fill the prescription, but in the event that the pharmacist, at the “Point of Sale”, is unsure of what COB override code to use, the table below provides the appropriate designation for their use. If necessary, direct them to the OptumRx Pharmacy Services Helpdesk at 1-866-525-5826. FIELD NAME OF FIELD VALUES/DEFINITIONS OF FIELDS 308-C8 Other Coverage Code 2 = Other coverage exists – payment collected 3 = Other coverage exists – claim not covered 4 = Other coverage exists – payment not collected 8 = Claim is billing for patient financial responsibility only(co-pay/coinsurance)

Paper processing is allowed if the pharmacy system does not allow for online processing of Medicaid secondary or tertiary claims. If the carrier returns payment for the claim, the pharmacy provider must include EOB from primary carrier or a pharmacy screen print/profile with primary carrier detail that paid, recipient amount paid (co-pay/deductible), and remaining amount due that is being billed to DCH. If the other carrier denied the claim, attach the denial statement from the other insurance carrier to your claim form for processing. If no response is received from the insurance carrier, attach the coordination of benefits confirmation statement to the back of your claim for payment. Please mail pharmacy paper claims (Universal Claim Form (UCF)) to: OptumRx PO Box 968021 Schaumburg IL 60196-8021