Edit 150

Issue: Claim needs to be filed to another insurance payer before Medicaid. Resolution steps

Identify your specific issue:

Did you enter the correct 3-character carrier code?

• The carrier code may be different, because it's for a subsidiary or partner company to the insurance company carrier code you are familiar with, but it has its own carrier code.
  • Look up the correct carrier code on the Web Tool. (Web Tool User Name and Password required.)
    
    • See an example of a carrier code on the Web Tool.
    • Watch a tutorial on how to check eligibility on the Web Tool.
    • Need Web Tool access? Complete and send the Trading Partner Agreement Enrollment Form to get a user name and password.
  • See Appendix 2: Carrier Code Listing which includes company name, address, and contact information. (SCDHHS.gov, Provider Manuals, Appendix 2 "Carrier Codes")

Did you enter the correct policy number?

• The policy holder's number may differ from their dependent's. For instance, a dependent's policy number may include a suffix.

Does the patient no longer carry that primary insurance?

• Complete and fax the Health Insurance Information Referral Form (HIIRF) to remove the primary insurance on record with SC Medicaid.
• To print the HIIRF form: Visit SCDHHS.gov, select Provider Manuals, choose your specialty, select "Forms", select and print the HIIRF form. See the HIIRF form and instructions.

Did you only attach the other insurance's EOB with the Medicaid claim?

• Attaching the EOB will not resolve this denial. You must also enter the correct Medicaid claim data on the claim. CMS-1500 example, UB claim example. 

Did you mix and match the data between fields 9 and 11 on the CMS-1500? 

• Make sure that the policy number, payment amount and carrier code for primary insurance(s) are entered in either field 9 (9a, 9c, 9d) or field 11 (11, 11b, 11c). For example, do not put the policy number in field 11 and then separate the payment amount and carrier code in field(s) 9c and 9d. CMS-1500 example.

Did you line up the policy number, carrier code, and payment amount correctly on the UB claim?

• For UB claims: Ensure that corresponding data is on the same line: A, B, or C. If the carrier code is on line A of field 50, the policy number should also be on line A (not B or C) of field 60. UB claim example.

Did you indicate a third party payer on the claim?

• Ensure that the primary insurer's payment is entered correctly.
• If the primary insurer denied payment, you must enter 0.00 and indicate TPL denial.
  • CMS-1500: field 9c or 11b; TPL denial indicator "1" in field 10d CMS-1500 example
  • UB claim: field 54 UB claim example

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