Blue Review
A newsletter for Medicaid providers

August 2019

How to Keep the Cash Flowing: Billing BCBSTX Medicaid as a Secondary Payer

To keep the cash flowing, it’s important to understand secondary billing. When applicable, Blue Cross and Blue Shield of Texas (BCBSTX) coordinates benefits with other carriers and programs that a member may have for coverage, including Medicare. You will need to indicate ”other coverage” information on the appropriate claim form if BCBSTX is the secondary payer.

Make sure you’re aware of potential denial reasons that can occur when you bill BCBSTX as a secondary payer:

1. If the primary insurance denies due to a "Unclean Claim" and the provider could submit a corrected claim to primary and get paid, the provider would need to submit a corrected claim to primary insurance.

2. If the primary insurance denies the claim for "Timely Filing," then BCBSTX will uphold the primary decision to deny and the provider will not get a payment from Medicaid.

3. If the primary insurance denies for "No Authorization," then BCBSTX will uphold the primary decision to deny and the provider will not get a payment from Medicaid.

4. If the provider is out of network with the primary payer and is also out of network under Medicaid, then BCBSTX is not required to pay the claim per the Texas Health and Human Services Commission (HHSC).

  • Medicaid Managed Care Organization (MCO) Out-of-Network Providers – The MCO is not required to pay for covered services if the MCO member received services from an out-of-network Medicaid provider that is also out-of-network under the MCO member’s third-party insurance coverage.
    • Note: For MCO members who do not have other insurance, the MCO is required to pay an out-of-network provider in accordance with the HHSC’s administrative rules regarding out-of-network payment (1 T.A.C. §353.4)

5. If the primary insurance denies for Coordination of Benefits (COB), then BCBSTX will uphold the primary decision to deny and the provider will not get a payment from Medicaid.

Also make sure you’re aware of the instances that BCBSTX will pay as a secondary payer:

1. If primary insurance pays, then BCBSTX will apply Medicaid benefits:

  • If over the Medicaid allowable we would not make a payment, or
  • If not over the Medicaid allowable we will make a payment for the difference

2. If a provider is non-participating with Medicare and there is documentation on file, and is participating with Medicaid, then BCBSTX will apply Medicaid Benefits; COB is not required.

3. For Long Term Services and Support (LTSS) services, COB is not required and BCBSTX will pay Medicaid benefits for:

  • Personal Care Services
  • Durable Medical Equipment (incontinent supplies / items found in the restroom)
  • Respite
4. If a provider bills a service and Medicare doesn’t cover the service, but Medicaid does, then BCBSTX will pay as the primary.