Prescribed Drugs Provider Manual - Iowa Department of Human ...

IowaDepartmentof HumanServicesProvider and ChapterPrescribed DrugsChapter III. Provider-Specific PoliciesPage95DateAugust 1, 2013♦ For all other Medicaid members with other prescription insurance, thatinsurance is primary and Medicaid is secondary.• Ask the member for the primary prescription insurance card.• If a member has primary pharmacy insurance, submit the claim to theprimary insurance first and then the copay to Medicaid last, using a “8”in the OTHER COVERAGE CODE field (field 308-C8).• If a member has primary pharmacy insurance and the claim is notcovered by the primary insurance, submit the claim to Medicaid usinga “3” in the OTHER COVERAGE CODE field (field 308-C8).• If a member has Iowa Medicaid pharmacy insurance only (or does nothave the primary prescription insurance information), enter a “1” inthe OTHER COVERAGE CODE field (field 308-C8).a. Claims Rejected Due to Other Insurance CoverageWhen a claim is submitted with a blank field or a zero in the OTHERCOVERAGE CODE field but the Iowa Medicaid eligibility file has third-partyliability (TPL) information, the Medicaid claim will be denied and you willreceive a rejection code of 41, “Submit to Primary Payer.”The Point-of-Sale System will give the policy number and the type ofcoverage. Most times the insurance company name is given. However,for the less common companies, a code is given in place of the name.Use the primary prescription insurance billing information to bill theprimary insurance. If necessary, you may contact the IME ProviderServices for the name and address of the health insurance company.After billing the other company, resubmit the claim with one of thefollowing codes the OTHER COVERAGE CODE field:♦ Use code 1 if the member states that there is no other insurancecoverage. If the claim has already been rejected with a reject codeof 41 “Submit to Primary Payer,” Iowa Medicaid’s eligibility fileconflicts with the primary third-party insurance company’sinformation. See Correction of Insurance Information.♦ Use code 3 if other coverage does exist but the drug is not coveredunder the primary insurance plan.♦ Use code 8 when payment is not collected. Example: The primarythird-party insurance is 100% major medical.