Neighborhood Health Plan of Massachusetts Coordination of Benefits


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Neighborhood Health Plan of Massachusetts Coordination of Benefits (COB) for Recipients with Third Party Liability (TPL)

***PLEASE POST FOR YOUR STAFF*** March 1, 2012 Dear Neighborhood Health Plan Provider: Managed Medicaid programs including Neighborhood Health Plan are required by Title 42 of the Code of Federal Regulations (42 CFR) to be the payer of last resort when other insurance coverage exists. By enrolling in Neighborhood Health Plan, recipients automatically assign the right to collect third party liabilities (TPL) to the State. Historically, Neighborhood Health Plan has applied retrospective processes to identify and collect TPL through a mechanism referred to as “Pay and Chase” recovery. Identification of TPL at the point-of-sale will prove more efficient and result in greater cost avoidance. Effective April 1, 2012 Neighborhood Health Plan will begin interrogating pharmacy claims for TPL and require coordination of benefit (COB) billing on all point of sale transactions. Claims in which the recipient has TPL will reject with the NCPDP code “41” with the member’s TPL information being messaged to the pharmacy allowing for proper resubmission. Pharmacies may resubmit the claims with the appropriate NCPDP “other coverage code" and required COB segment fields to override the TPL edit and gain payment from Neighborhood Health Plan. Please refer to the attached payer sheet for claim’s system set up requirements. If you require additional assistance please contact the SXC Pharmacy help-desk at 800-9187545.

Thank you for your participation in the Neighborhood Health Plan pharmacy program