Submitting claims for Medicaid members with other insurance

When two or more health plans cover the same member, we coordinate between plans following these steps:

  1. Identify if other coverage exists
  2. Review documentation to determine the correct order of benefits
  3. Update our FACETS claim processing system with other benefits
  4. Calculate the allowable expense
  5. Process the payment

Medicaid edit 21007: Why claims get rejected

When a Medicaid member is also covered by another payer, the Michigan Department of Health and Human Services (MDHHS) requires the other payers be:

  • Billed first
  • Identified appropriately on the claim (details below)

In January 2021, MDHHS implemented Medicaid edit 21007, which rejects claims that don’t meet these criteria.

In November 2021, we implemented an edit in our own system that front-end rejects these same claims. Our edit automatically runs through steps 1 and 2 above. If it identifies another payer based on a membership list provided by the State, and that payer isn’t identified on the claim with all the information the State needs (see below), it rejects the claim with the following message:

“Beneficiary Has Other Insurance so providers Must Submit Other Insurance Payer Information on the Encounter”

What the State wants to see on your claims

When you see a Medicaid patient who also has other insurance, make sure to include each of these details on your claim:

At the header level:

  • Primary payer indications
  • Other payer's policy numbers
  • Payor Amount Paid
  • Claim Filing Indicator

At the claim line level:

  • Other Payer Primary Identifier
  • Paid Amount
  • CARC code
  • Claim Filing Indicator

What if the Payer Amount Paid is $0?

Even if the Payer Amount Paid is $0, it still needs to be reported on the claim to show the services aren’t covered with the appropriate CARC codes.

Our system will front-end reject the claim if any of these items are missing or incorrect. If this happens, correct and resubmit your claim.