Submitting Denied Claims to Medicaid

Providers may submit denied third party claims to Medicaid. The following third party-related information is required on the claim, in addition to the other required claim data:

Claim Form - CMS-1500

Include the Following Third Party Information                             In These Claim Fields

• Other Insured’s name, policy number,                                             BLOCKS 9 -9D

insurance co.                                                                                 

• Was condition related to (accident)                                                  BLOCK 10

• TPL denied dates                                                                           BLOCK 19

• Amount paid                                                                                   BLOCK 29