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B.1.2 Cost Avoidance Coordination-of-Benefits
Effective July 20, 2009, phase II of Cost Avoidance coordination-of-benefits (COB) for pharmacy claims was implemented. This phase includes all Medicaid clients with other known insurance coverage (adults and children). Phase I of Cost Avoidance was implemented on January 20, 2009, and only included a limited number of adults 21 years of age or older.
The Texas Medicaid VDP implemented this new process to ensure compliance with federal Centers for Medicare & Medicaid Services (CMS) regulations. Under federal rules, Medicaid agencies must be the payer of last resort. The cost avoidance model checks for other known insurance at the point of sale, preventing Medicaid from paying a claim until the pharmacy attempts to obtain payment from the client's third-party insurance.
For more information on Cost Avoidance, visit the Texas Vendor Drug website at: www.txvendordrug.com/costavoidance.html.
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