In 2025, understanding how to file a secondary payer Medicaid claim is more critical than ever. With updated CMS coordination rules, timely filing requirements, and evolving third‑party liability (TPL) procedures, billing professionals must stay current. This article explains the latest processes, requirements, and best practices for submitting Medicaid claims when Medicaid is the secondary payer.
Why Filing a Secondary Payer Medicaid Claim Matters in 2025
First, Medicaid must pay only after all primary coverage — like Medicare, commercial insurance, or workers’ compensation — has paid or denied. States enforce Coordination of Benefits (COB) and recovery through TPL rules. As of 2025, CMS and state agencies are strengthening compliance enforcement and tightening timely filing rules. You’ll learn what has changed and how to adapt.
Overview of 2025 Changes Affecting Medicaid Secondary Claims
- Updated COB rules: Federal mandates require coordination with Medicare and private insurers before Medicaid pays :contentReference[oaicite:1]{index=1}.
- Timely filing deadlines: Most states require claims submitted within 90 days of service or 30 days from when they come under provider control; all claims must be enforceable within two years of service :contentReference[oaicite:2]{index=2}.
- Medicare Secondary Payer automation: As of January and April 2025, CMS updated its Common Working File (CWF) and shared systems to automate MSP editing and cost‑avoid processing at the detail‑level :contentReference[oaicite:3]{index=3}.
Step‑by‑Step Filing Process
1. Identify Primary Coverage
Check eligibility and payer information: Medicare status, group health plans, workers’ comp, liability claims, or commercial insurers. Use SEC 111/NGHP reporting if applicable :contentReference[oaicite:4]{index=4}.
2. Wait for Primary Payer Decision or Denial
Never submit a secondary Medicaid claim until the primary insurer pays or formally denies. Document denials and responses.
3. Prepare the Medicaid Secondary Claim
- Include primary insurer payments or denials (e.g. EOBs).
- Add appropriate delay reason code if submission is beyond 90 days due to primary processing delay (e.g. code 7 for Third Party Processing Delay) :contentReference[oaicite:5]{index=5}.
- Submit electronically if possible, per state guidelines. Some states may still accept paper UB‑04 with attachments if you’re exempt.
4. Submit Within State Timeframes
Ensure filing within the allowable window. Late submissions may require a delay reason code or waiver documentation. Claims older than two years are generally non‑enforceable unless there was agency error or a court order :contentReference[oaicite:6]{index=6}.
5. Monitor for Denials and Submit Adjustments If Needed
After submission, track remittance advices or 835s. If denied, correct and resubmit with appropriate codes within the allowed timeframe.
Key Coding & Claim Entry Tips
When Medicaid is secondary, use proper value and payer codes. For example, Medicare A or B coverage should be coded with MA or MB; commercial insurance with CI; Medicaid primary with MC :contentReference[oaicite:7]{index=7}.
In 2025, CMS systems now support detail‑level edits so include all relevant services even if some fall outside MSP periods (e.g. flu shots outside ongoing responsibility for medicals) :contentReference[oaicite:8]{index=8}.
Practical Tips for Revenue Cycle Professionals
- Track eligibility updates accurately to detect new primary coverage quickly.
- Train staff on delay reason codes and documentation requirements per state.
- Use state companion guides or payer portals to understand local Medicaid rules.
- Verify whether paper claims are acceptable or if electronic submission is required.
- When Medicare is involved, use CMS Pub. 100‑05 guidelines and interactive MSP tools :contentReference[oaicite:9]{index=9}.
Internal & External Resources
For more in‑depth guidance, visit your state Medicaid companion guide or HIPAA reference documents. You may also consult:
Continue improving your billing practices by reviewing related articles on our site:
FAQ
How long do I have to file a secondary Medicaid claim?
Most states require filing within 90 days of service or 30 days from when the claim is within provider control. All claims must be payable within two years of the date of service unless an exception applies :contentReference[oaicite:10]{index=10}.
Can Medicaid be tertiary if Medicare and commercial pay?
Yes. If Medicare and a commercial insurer both pay first, Medicaid becomes tertiary. You must submit supporting EOBs and follow COB rules accordingly.
What is the Third Party Processing Delay code?
It is a delay reason code (usually code 7) used when the primary insurer processing caused submission delays. This must be documented and filed within 30 days of the delay control event :contentReference[oaicite:11]{index=11}.
Conclusion
By mastering how to file a secondary payer Medicaid claim under 2025 rules, you ensure accurate coordination of benefits, avoid denials, and optimize reimbursement. Stay current on state-specific COB policies and CMS MSP guidance. Apply these steps and your revenue cycle processes will be compliant and efficient. For more advanced billing and coding insights, explore our other articles.