Medi‑Cal Rx Coordination of Benefits (COB) Reminder
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Guidance for pharmacy providers on billing Other Health Coverage (OHC), Medicare, and Medi‑Cal Rx when a beneficiary has multiple payers; explains billing order, required OHC documentation on claims, and tools to verify or update OHC.
No material clinical or coverage changes in this revision.
Coverage Criteria
OHC submission and update criteria
Submission and processing requirements when other payers exist:
Verification and updates
- Verify eligibility and OHC via the Medi‑Cal Rx Provider Portal eligibility lookup, POS, or the Customer Service Center (1-800-977-2273).
- If the beneficiary reports no OHC for pharmacy services, update or remove OHC using the OHC Online Form, the OHC Online Step-by-Step Reference Guide, or the referenced instructions for adding or removing OHC for Medi‑Cal beneficiaries.
Coding and Reimbursement
| OCC (Allowed Other Coverage Codes) | Use allowed other coverage codes for standard OHC and Medicare Part D as listed in the Medi‑Cal Rx Provider Manual. |
Provider Actions and Billing Order
Submit OHC details and primary payer response
Obtain and include Other Health Coverage (OHC) details and the primary payer's response (payment or denial) on the Medi‑Cal Rx pharmacy claim before submitting to Medi‑Cal Rx. Submit the claim to Medi‑Cal Rx only after the primary payer has been billed and the primary payer response (including a denial when applicable) is available to include on the Medi‑Cal Rx claim.
- Include primary payer ID and the primary payer's payment or denial on the Medi‑Cal Rx claim.
- Do not submit to Medi‑Cal Rx until the primary payer has been billed and a response obtained.
Billing order
When a beneficiary has Medi‑Cal Rx, Medicare, and OHC, bill payers in this order: (1) OHC insurance, (2) Medicare-covered services, (3) Medi‑Cal Rx.
- Obtain a denial from the primary payer before submitting a claim to Medi‑Cal Rx when applicable.
- After billing the primary payer, submit the Medi‑Cal Rx claim containing OHC details and the other payer's response so Medi‑Cal Rx can process the claim accordingly.
Definitions
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