Coordination of Benefits

Coordination of benefits ensures that providers file with the primary payer first and enables the Alabama Medicaid Agency to save millions in claims costs by deferring those costs to the appropriate primary payers.

EPSDT / Prenatal Providers:
  • Claims for EPSDT and Prenatal Services must be filed with a recipient’s health insurance before filing Medicaid if the recipient is enrolled in an HMO or employer-based managed care plan.
Pregnancy-Related Claims:
  • In some cases, recipients have health insurance coverage but do not have maternity coverage. If a provider’s pregnancy-related claim is denied by Medicaid because of other health insurance on file when in fact no maternity coverage exists, providers should contact the Third Party Division to update the file so claims may be processed electronically.

  • Medicaid’s records cannot be changed if the patient is not covered for pregnancy-related services because a waiting period has not been met. In this case, providers must obtain and submit a third party denial with their claim.

Medicaid Eligibles in HMO or Managed Care Plans:
  • Medicaid is a secondary payer, which means that recipients must use all available resources prior to using Medicaid.

  • Medicaid recipients who are enrolled in a Medicare HMO or an employer-based managed care plan are generally required to use a plan-approved provider. If a recipient uses a non-approved provider, Medicaid may not pay for that care.

Subrogation Claims / Benefit Recovery
  • As a general rule, pharmacy providers are required to file a patient’s primary insurance prior to filing Medicaid. Once the primary payer has responded, the patient’s claim can be submitted to Medicaid. Medicaid will pay the Medicaid rate less any third party payment and applicable contractual adjustment. Medicaid should not pay more than the sum of the health plan’s patient co-pay, coinsurance and/or deductible.

  • An exception to the rule is when the patient has a Point-of-Sale (POS) Drug Plan, which requires the cost of the prescription to be paid up front by the patient. A claim can then be submitted to the insurance plan for reimbursement directly to the patient. These POS Drug Plans require special handling when the patient is also a Medicaid recipient.

  • Special Instructions for Point-of-Sale Drug Plans

  • When filing Medicaid, providers should submit the entire charge to Medicaid and indicate the amount paid or covered by the third party. The provider should also indicate the appropriate NCPDP “other coverage” code.

  • NCPDP Code List

  • Resources for Pharmacy Providers