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Primary insurance and Medicaid secondary


Pittsburgh Central Pennsylvania
Best answers
Good afternoon!

Anyone out there from the state of North Carolina? I am having trouble finding clear answers regarding primary insurance and secondary Medicaid billing. I also work on billing for Pennsylvania providers and have a firm grip on Pennsylvania's rules with regard to Medicaid secondary claims. Having trouble with NC, though.

Anways, if a patient has a Blue Cross/Blue Shield primary insurance (or any non-Medicare plan-i.e. commerical-Cigna) with a $35.00 co-pay (patient does not pay co-pay at time of service) and BCBS pays at their allowable amounts (provider is in-network with BCBS and Medicaid) and the balance left is the co-pay, does Medicaid have any responsibility to pay the co-pay amount? I've talked to several representatives at Medicaid in NC and have been told that Medicaid (in NC) will consider deductible / co-insurance balances after a primary insurance pays but has no responsibility to pay co-pay balances.

If Medicaid has no responsibility to primary insurance co-pay balances, then is the patient liable for the co-pay amount or is it an adjustment?

Co-pays are in the member's contract but what happens if the member has Medicaid as their secondary?

Anyone have any insight?

Thank you in advance for your time!

Beth :confused:
Hyattsville, MD (30112)
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I am not from NC but I found this information for NC. It is the same as the MD/DC region where I am. They should cover the difference between what is paid by the commercial plan and the NC Medicaid allowed amount, including copays.


99214 Allowed $115 commercial, $35 copay, $80 paid by commercial

Say the allowed amount for the 99214 with NC Medicaid is $92.00, then Medicaid should pay the $12 as the $80+$12 would equal the Medicaid allowed amount. The remaining balance should be adjusted off after the Medicaid payment is received.
Last edited:


Durham, NC
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I'm from North Carolina, and Medicaid here rolled out a new system last July that is full of problems. I have run into this before, and the way it was explained to me is that it's a computer error on their part. Their system doesn't recognize PR3, "Copay" as a patient responsibility reason code; however, if you change the reason code to PR2, "coinsurance," and file a replacement claim, they will pay. It IS Medicaid's responsibility to pay patient copays and/or coinsurances up to their allowed amount. After they do that, the remainder is a write off.

I hope this helps! Message me if you run into any more NC payer issues; I'm happy to help.


Burlington, NC
Best answers
NC Medicaid

I am also from NC and we have struggled with getting our secondary payments paid since CSC began processing the NC Medicaid claims.

We have found that they are no longer paying secondary balances like the old company. This company has begun only paying secondary up to the Medicaid allowable. We are not, however, seeing a difference between getting paid on a Coinsurance (PR2) or Copay (PR3). Try calling the representatives at NC Tracks and ask them to review your claim. We had to do this to find out that they were not seeing our primary payment and we had to change our system formatting to accommodate them. Since we did, we are now getting our secondary's paid up to the allowable.

Good luck!