TO: All Pharmacy Providers
FROM: Kathleen Allyn, Deputy Administrator
Effective August 1, 2003 the Idaho Medicaid program will reinstate the electronic edit process that ensures that all other known insurances have been billed for clients with other pharmacy insurance coverage. Drug claims must be billed to the client’s other insurance prior to submission to Medicaid for payment.
Please refer to Information Release #2003-25 dated April 29, 2003 for provider billing instructions, coverage, and carrier codes. For a copy of the Information Release please see the Medicaid internet site at:
In response to Information Release #2003-25 we received questions from providers and Medicaid clients regarding the collection of payment and co-pays from clients with other insurance. This change in Idaho Medicaid policy does not require the Medicaid client to pay towards their prescriptions.
When an insurance company requires the client to pay the full prescription price first, Medicaid will provide payment to the pharmacy and will then coordinate benefits with the other insurance. Pharmacies are requested to bill as follows:
Electronic (POS) or Batch claims - bill Medicaid but do not enter a payment for other insurance. Use the 04 coverage code (Other coverage exists – payment not collected) and AD reject reason code (Billing provider not eligible to bill this claim type).
Paper claims – bill Medicaid as the primary provider by entering $0.00 as the other insurance amount and note an explanation that the client’s insurance requires payment be made to patient/insured/responsible party.
When an insurance company requires a co-payment or partial payment from the Medicaid client, do not collect the partial payment or co-payment from the client. Follow billing instructions for billing Medicaid as the secondary insurance.
If you are having problems using the software or issues with billing please call – EDS Claims Billing Issues/Training and Other Insurance Verification 1-800-685-3757 or 383-4310.
If you have questions regarding Medicaid’s third party billing policy please call: Medicaid Third Party Recovery Unit at 1-208-334-5724.