Providers may submit paid and partially paid third party claims to Medicaid using theapproved paper or online filing methods as described in Chapter 5, Filing Claims.
The following third party-related information is required on the claim, in
addition to the other required claim data:

Claim Form Include the Following Third Party Information                In These Claim Fields
CMS-1500 • Other Insured’s name, policy number, insurance             BLOCK 9 – 9D
co.
• Was condition related to (accident)                                                   BLOCK 10                           
• TPL paid dates                                                                                 BLOCK 19
• Amount paid                                                                                     BLOCK 29