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
