Other Coverage Code: what the primary payer did.

At the counter: Other Coverage Code (OCC), NCPDP field 3Ø8-C8, summarizes what happened with other coverage. OCC 2 means another payer paid; OCC 3 means the claim was rejected as not covered under a rule the secondary accepts; OCC 4 generally describes patient responsibility when the prior payer paid the pharmacy zero. The supporting COB fields and current payer sheet must match.

NCPDP defines the standard field and the reporting patterns. State Medicaid programs, processors, and plans decide which OCC values, reject codes, and supporting fields they accept. This directory is organized by claim scenario so each payer rule stays beside its population, source date, and caveat.

Other Coverage Code 0–8 index

NCPDP's External Code List is authoritative but licensed. The short meanings below are current payer restatements; wording varies among publications. NCPDP's public June 2026 guidance supplies the present boundary for OCC 1 and the COB reporting method.

0Not specified

No assertion about other coverage. NCPDP permits a payer to require this on a non-COB primary claim.

Do not use it to bypass a known third-party-liability record; Nevada says a known TPL record can continue to reject with 41.

1No other coverage

The pharmacy exhausted reasonable means to identify other pharmacy benefit coverage and found none.

NCPDP v73 says OCC 1 must not be a default. Colorado requires no COB or other-payer fields when OCC 1 is appropriate.

2Other coverage paid

The prior payer adjudicated and paid a positive amount.

Report the payment and any other payer-patient responsibility fields the receiving payer sheet requires.

3Claim rejected or not covered

The prior payer was billed and rejected the claim under a reason the receiving payer accepts as a coverage rejection.

Field 472-6E and its payer-specific allowlist matter; OCC 3 does not turn every primary reject into a noncoverage result.

4Payment not collected

The prior payer recognized patient responsibility, such as deductible, copay, or coinsurance, while paying the pharmacy zero.

The amount-paid and patient-responsibility repetitions must match the payer's method.

5Managed care denial

Older payer wording.

New York's later guidance directs pharmacies to use OCC 3 instead. Confirm the receiving payer's currently accepted values.

6Not a participating provider

Older payer wording for an other-coverage denial.

Some current payer instructions route accepted other-payer rejections through OCC 3. Confirm the receiving payer's currently accepted values.

7Coverage not in effect

Older payer wording for coverage not effective on the service date.

NCPDP's current public guidance uses this situation in an OCC 3 multi-payer example. Confirm the receiving payer's current method.

8Patient responsibility only

A payer-optional route for billing patient financial responsibility only.

Louisiana and New York EPIC publish support; Mississippi and Nevada explicitly do not. Optional is not universal.

NCPDP, Telecommunication Standard Version D and Above Questions, Answers and Editorial Updates, v73, June 2026; payer value restatements from the dated Mississippi, Louisiana, Colorado, Nevada, and New York publications listed below.

Scenario-first payer directory

What travels with the OCC?

The COB/Other Payments Segment is 111-AM = “Ø5.” NCPDP's payer-sheet template describes three mutually exclusive reporting scenarios: Other Payer Amount Paid repetitions; Other Payer-Patient Responsibility and Benefit Stage repetitions; or both types plus benefit stage for government programs. The receiver's payer sheet selects the method.

337-4C and 338-5C

COB/Other Payments Count and Other Payer Coverage Type identify how many other-payer loops follow and the payer's position.

339-6C, 34Ø-7C, 443-E8

Other Payer ID Qualifier, Other Payer ID, and Other Payer Date identify who adjudicated and when, when the receiver requires them.

431-DV and 342-HC

Other Payer Amount Paid and its qualifier report what another payer paid.

471-5E and 472-6E

Other Payer Reject Count and Other Payer Reject Code report an accepted prior-payer rejection.

351-NP, 352-NQ, 353-NR

Patient-responsibility qualifier, amount, and count report deductible, copay, coinsurance, or another supported responsibility type.

392-MU through 394-MW

Benefit-stage count, qualifier, and amount carry Medicare Part D stage information when required.

NCPDP, Payer Sheet Template Implementation Guide for version D.0, v18, September 2024. A payer sheet can make situational fields required; use the receiver's current version.

Why Medicaid is generally billed last

Federal law requires states to identify liable third parties and use cost avoidance where applicable. The CMS Coordination of Benefits and Third Party Liability handbook, published in 2020, explains that Medicaid is generally the payer of last resort and also describes pay-and-chase exceptions. Follow the current state and plan rule; “generally” is not “without exceptions.”

Part D coordination uses the same NCPDP framework, but older CMS manuals can contain rules superseded by later law. Under 42 CFR §423.100, the definition of incurred costs changed for 2025 and subsequent years. Do not use a 2018 COB manual to override the current regulation or payer specification.

A secondary-claim check

1. Identify the current receiving payer, population, and program, not just the state.
2. Confirm the prior payer's actual result and retain its response.
3. Select the OCC that describes that result under the receiver's current payer sheet.
4. Populate only the reporting scenario and repetitions the receiver accepts.
5. For OCC 3, validate 472-6E against the receiver's current allowlist.
6. Keep the payer sheet version or publication date with the resolution note.