Claim Edit for Health Choice (NCHC) Recipients With Third Party Coverage

Services are not covered for recipients enrolled in the State Children’s Health Insurance Program (SCHIP), also known as Health Choice (NCHC), who also have comprehensive major medical coverage through a third-party insurance carrier. As of May 3, 2015, claims submitted to NCTracks for Health Choice recipients that have comprehensive major medical insurance through a third-party carrier will be denied with EOB 01813 - CLAIM DENIED. RECIPIENT’S ELIGIBILITY AND/OR CLAIM INDICATE RECIPIENT IS SUBJECT TO OTHER HEALTH CARE COVERAGE.

This is a new requirement for NCTracks, but is not a new State policy. Claims previously paid since July 1, 2013, will be reprocessed. No date has been set for the claim reprocessing. Additional information will be forthcoming.

If there is evidence the recipient does not have comprehensive major medical coverage through a third-party insurance carrier, the provider can report changes to "other insurance" for a recipient by completing a form titled the "Online Submission for Health Insurance Information Referrals." This form is located under the heading Third Party Insurance Forms on the NC Division of Medical Assistance (DMA) Website at the link below. The form is processed by HMS, who will verify the third party liability (TPL) information and the recipient’s record will be updated, if appropriate.