Submitting Paid and Partially Paid Claims to Medicaid

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