Sep 15, 2014 - Please contact your software vendor before 10/8/2014 to verify your system ... The call center will not e
** Important Information ** TennCare Coordianation of Benefits Update Effective 10/8/2014 Other Coverage Code 1 within NCPDP Field #308-C8 will no longer be accepted when there is active other coverage on file with Magellan. Other Coverage Code 3 will be required in instances where there is other coverage on file but the patient or drug is not covered. Please contact your software vendor before 10/8/2014 to verify your system will submit information properly. The call center will not enter overrides due to system limitations. See examples below for allowable Other Coverage codes and submission requirements. Please provide these requirements to your software vendor for correct claims submission. Incorrect or incomplete requirements will lead to claim rejections. Magellan’s System always returns Other Payer details in the “COB Response Segment”on claims that reject for bill other payer. Please use these other payer details (i.e. BIN, PCN, ID, Group and Help desk phone number) to properly bill the primary payer first then to Tenncare as the payer of last resort. Please contact your software vendor for where this is located within your system. NCPDP Field #308-C8 0–Not Specified
When to Use OCC 0 is allowed; submit when member does not have TPL.
Submission Requirements/Responses Claim will reject with a 41 error if member record has TPL. Additional fields in the NCPDP COB segment should not be submitted with this OCC. Claim should be submitted to TPL and then resubmitted with proper OCC and COB required fields.
1– No Other Coverage
OCC 1 is allowed when When the enrollee has TPL on file with Magellan and the enrollee does not the OCC 1 is submitted, the claim will continue to reject for NCPDP 41. have TPL on file with Magellan.
2 – Exists Payment Collected
OCC 2 is used when any positive amount of money is collected from another payer. Submit the amount collected from the primary payer (TPL), along with the date the claim was adjudicated to the primary payer (TPL) in order override the TPL denial.
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Paid claim and completed COB segment inclusive of the following fields:
Other Payer Amount Paid (431-DV) that is > $0 Other Payer Amount Paid Qualifier (342-HC) must be a valid value Other Payer-Patient Responsibility Amount Submitted (352-NQ) if >/= $0 Other Payer Date (443-E8) that is compliant with timely filing. Other Payer ID (340-7C) that is valid Other Payer ID Qualifier (339-6C) that is valid
Claims submitted without required COB fields will reject with NCPDP code 13 or other specific reject codes
NCPDP Field #308-C8 3 – Exists Claim Not Covered
When to Use OCC 3 is used when the TennCare beneficiary has TPL, but the particular drug or patient is not covered by the specific plan(s).
Submission Requirements/Responses Requires submission of:
Other Payer Date (443-E8) Other Payer ID (340-7C) Other Payer ID Qualifier (339-6C)
And the reject code generated after billing the other insurer(s) in the “Other Payer Reject Code (472-6E). Claim will pay only if the following Other Payer Reject codes are submitted: 52-Non-Match Cardholder ID 60-Product/Service not covered for Patient age 61- Product/Service not covered for Patient gender 63-Institutionalized patient Product/Service ID not covered 65-Patient is not covered 66-Patient age exceeds maximum age 67-Filled before coverage effective 68-Filled after coverage expired 69-Filed after coverage terminated 70-Priduct/Service not covered 3Y-Prior Authorization Denied. Claims submitted without required COB fields will reject with NCPDP code 13 or other specific reject codes
4 – Exists Payment Not Collected
8 – Claim Billing for a Co-pay
OCC 4 is used when a patient’s TPL is active, but there is no payment collected from the primary insurer (i.e., the beneficiary has not met their primary payer’s deductible obligation, plan capitation, etc.). OCC 4 should also be used if the total cost of the claim is less than the patient’s TPL co-pay requirement and the primary insurance plan made no payment.
Paid claim; also requires submission of:
Other Payer Amount Paid (431-DV) that = $0 Other Payer Amount Paid Qualifier (342-HC) Other Payer-Patient Responsibility Amount Submitted (352-NQ) this is > or = $0 Other Payer Date (443-E8) that is valid Other Payer ID (340-7C) that is valid Other Payer ID Qualifier (339-6C)
Claims submitted without required COB fields will reject with NCPDP code 13 or other specific reject codes
OCC 8 is not accepted
Providers, if you have additional questions please contact the following: TennCareProvider Education: Email:
[email protected] Pharmacy Help desk: Phone: (866)434-5520 Magellan Health Services, Inc. / Magellan Pharmacy Solutions
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