Medi-Cal Rx Medicare coordination of benefits (COB) claims process changes
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Defines upcoming changes to how Medi-Cal Rx processes Medicare COB pharmacy claims for dual-eligible beneficiaries and instructions for pharmacy providers to update billing; affects pharmacy providers submitting Medicare COB claims to Medi-Cal Rx.
Medi-Cal Rx will no longer allow Other Coverage Code (OCC) = 3 when Medicare Part D has denied the claim with Reject Code A5 or 65; such submissions will deny with Reject Code 13 and a supplemental message directing submission to the member's Medicare plan.
Medi-Cal Rx will require a Benefit Stage Qualifier (BSQ) in NCPDP Field 393-MV on all Medicare COB claims at a future announced date and will deny claims missing the BSQ once implemented.
Medicare COB Processing Rules
Relevant Codes and Upcoming Field Requirement
| OCC = 3 | Other Coverage Exists Claim Not Covered — will no longer be allowed when Medicare Part D denied with specific reject codes |
| Reject Code A5 | Not Covered Under Part D Law — triggers disallowance of OCC=3 |
| Reject Code 65 | Patient Is Not Covered — triggers disallowance of OCC=3 |
| Reject Code 13 | M/I Other Coverage Code — denial code returned with supplemental message directing submission to Medicare plan |
| NCPDP Field 393-MV | Benefit Stage Qualifier (BSQ) — will be required on Medicare COB claims at a future date |
Billing and Submission Changes for Pharmacy Providers
Do not bill OCC=3 for Part D denials; submit to member's Medicare plan
Do not submit claims with Other Coverage Code (OCC) = 3 when Medicare Part D has denied the claim with Reject Code A5 or Reject Code 65; such submissions will deny and must be submitted to the member's Medicare plan as directed.
- Claims submitted with OCC = 3 will deny with Reject Code 13 and the supplemental message: "Member is Medicare Part D eligible. Submit claim to member's Medicare Plan. Part D copays and deductibles are not covered."
- Refer beneficiaries with questions about Medicare eligibility or drug/product coverage to their Medicare plan.
Key Term Definitions
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