Other Coverage Code Quicksheet | Department of Health Care Policy and Financing

Colorado Medicaid – Pharmacy Billing Other Coverage Code (OCC) Quicksheet

Colorado Medicaid OCC codes (field 308-C8):

0 = Not Specified
1 = No other coverage identified
2 = Other coverage exists – payment collected
3 = Other coverage exists – this claim not covered
4 = Other coverage exists – payment not collected

Note:

If any other codes are used for Colorado Medicaid, the claim will be denied
Use the code that best fits the situation
Codes 2 and 4 look similar, however the functionality of the codes are very different
An incorrect OCC code selection may affect pharmacy reimbursement

How The OCC Field Affects Other Fields

353-NR – Other Payer – Patient Responsibility Amount Count

Required field if OCC field has a value of 4 (Other coverage exists – payment not collected)
This field has maximum count of 25 areas where information can be entered to show amounts paid by the patient

351-NP – Other Payer-Patient Responsibility Amount Qualifier

Required field if OCC field has a value of 4 (Other coverage exists – payment not collected)
Enter one of the following qualifiers* for Colorado Medicaid as reported by the previous payer

CODE	Description
01	Amount applied to periodic deductible (517-FH)
02	Amount Attributed to Product Selection/Brand Drug (134-UK)
03	Amount Attributed to Sales Tax (523-FN)
04	Amount Exceeding Periodic Benefit Maximum (520-FK)
05	Amount of Co-pay (518-FI)
06	Patient Pay Amount (505-F5)
07	Amount of Co-insurance (572-4U)
08	Amount Attributed to Product Selection/Non-preferred Formulary Selection (135-UM)
10	Amount Attributed to Provider Network Selection (133-UJ)
11	Amount Attributed to Product Selection/Brand Non-Preferred Formulary Selection (136-UN)
12	Amount Attributed to Coverage Gap (137-UP)
13	Amount Attributed to Processor Fee (571-NZ)

*Note: Code 09 is a negative amount and is not a valid option for field 351-NP.

352-NQ – Other Payer – Patient Responsibility Amount

Required field if OCC field has a value of 4 (Other coverage exists – payment not collected)
The amount must be a monetary amount over zero
This field is the amount reported by the previous payer. Do not put the Medicaid co-payment in this field

472-6 E – Other Payer Reject Code

Required field if OCC field has a value of 3 and the other payer has denied the payment for billing
If this field is not completed, a reject message 6E will be generated
All codes are acceptable

471-5 E – Other Payer Reject Count

Required field if Other Payer Reject Code (472-6E) is used
Required field if OCC field has a value of 3
If this field is not completed, a reject message 5E will be generated

338-5 C – Other Payer Coverage Type

Required field if there is another payer
Use the following codes:
- Blank = Not specified
- 01 = Primary
- 02 = Secondary – Second
- 03 = Tertiary – Third
- 04 = Quaternary – Fourth
- 05 = Quinary – Fifth

443-E8 – Other Payer Date

Required field if OCC field has a value of 2, 3 or 4
Use the date on the check from the other carrier
Format must be CCYYMMDD (ex. 20230130)

341- HB – Other Payer Amount Paid Count

Required field if Other Payer Amount Paid Qualifier (342-HC) is used
Information in this field can be entered to show amounts paid by up to nine different payers' maximum

342- HC – Other Payer Amount Paid Qualifier

Required field if there is a payment from another source
Use the following codes*:

CODE	Description
01	Delivery
02	Shipping
03	Postage
04	Administrative Cost
05	Incentive
06	Cognitive Service
07	Drug Benefit
09	Compound Preparation
10	Sales Tax

*Note: Code 08 is non-compliant and is not a valid option for field 342-HC.

The following examples are intended to show the importance of completing the necessary fields for each transaction. The examples listed do not cover all possibilities but provide information as to why a claim will be paid or denied based on the information provided.

Example 1

Scenario	Claim Paid or Denied	Corrections
Claim is submitted with: OCC = 4 (Other coverage exists – payment not collected) Other Payer Amount Paid = $0 Other Payer-Patient Responsibility Amount =$1.00 Other Payer- Patient Responsibility Amount Qualifier = 05	Paid	None – All necessary fields for OCC were completed with an acceptable value

Example 2

Scenario	Claim Paid or Denied	Corrections
Claim is submitted with: OCC = 4 (Other coverage exists – payment not collected) Other Payer – Patient Responsibility Amount = 0 Other Payer- Patient Responsibility Amount Qualifier = 05	Denied	The Other Payer – Patient Responsibility amount must be a monetary amount over $0.00. Note: Enter the information that is on the explanation of benefits from the other carrier.

Example 3

Scenario	Claim Paid or Denied	Corrections
Claim is submitted with: OCC = 4 (Other coverage exists – payment not collected) Other Payer – Patient Responsibility Amount = $0 Other Payer – Patient Responsibility Amount Qualifier = 09	Denied	The Other Payer – Patient Responsibility amount must be a monetary amount over $0.00. Other Payer-Patient Responsibility Amount Qualifier – 09 is not an acceptable Qualifier

Example 4

Scenario	Claim Paid or Denied	Corrections
Claim is submitted with: OCC = 3 (Other coverage exists – this claim not covered) Other Payer – Patient Responsibility Amount = $0 Other Payer Reject Code = 70	Paid	None – All necessary fields for OCC were completed with an acceptable value

Example 5

Scenario	Claim Paid or Denied	Corrections
Claim is submitted with: OCC = 3 (Other coverage exists – this claim not covered) Other Payer Amount Paid = $0 Other Payer Reject Code = Blank	Denied	Other Payer Reject Code was not entered and is required with OCC = 3 Note – any code is acceptable in the Other Payer Reject Code field

Example 6

Scenario	Claim Paid or Denied	Corrections
Claim is submitted with: OCC = 3 (Other coverage exists – this claim not covered) Other Payer Amount Paid = $0 Other Payer – Patient Responsibility Amount = $20.00 Other Payer Reject Code = Blank	Denied	Other Payer Reject Code was not entered and is required with OCC = 3 Note – any code is acceptable in the Other Payer Reject Code field If there is an amount in the Other Payer-Patient Responsibility field, most likely the claim was processed by another carrier and the correct OCC code should be used.

Example 7

Scenario	Claim Paid or Denied	Corrections
Claim is submitted with: OCC = 2 (Other coverage exists – payment collected) Other Payer Amount Paid = Blank Other Payer Amount Paid Qualifier = Blank	Denied	Other Payer Amount Paid Qualifier was not completed, which defaults to zero. Other Payer –Amount field must be a monetary amount over $0.00.

Example 8

Scenario	Claim Paid or Denied	Corrections
Claim is submitted with: OCC = 2 (Other coverage exists –payment collected) Other Payer Amount Paid = $20 Other Payer- Amount Paid Qualifier = 05 Pricing on the claim: Allowed Ingredient Cost: $3.33 Dispensing Fee: $4.00 Allowed Charge: $7.33	Paid	None – All necessary fields for OCC were completed with an acceptable value Note – The claim will show as Paid, but with a value of $0. The Other Payer Paid $20, which is more than the amount ($7.33) Colorado Medicaid would pay for this drug.

Example 9

Scenario	Claim Paid or Denied	Corrections
Claim is submitted with: OCC = 1 (No other coverage identified) Member does not have other insurance	Paid	None – No other information needs to be added in the Other Coverage Code fields

Example 10

Scenario	Claim Paid or Denied	Corrections
Claim is submitted with: OCC = 1 (No other coverage identified) Member has other insurance listed in the Colorado Medicaid pharmacy benefits management system	Denied	If the client has other insurance, the information must be provided when the claim is submitted.