When a member has Medicare as their primary insurance and Health Choice Utah Medicaid as secondary, it's important to understand how statutorily excluded codes affect claim submission and coordination of benefits.

WHAT ARE STATUTORILY EXCLUDED CODES?

Statutorily excluded services are those that Medicare does not cover under any circumstances. Because these services are excluded by law, Medicare will not process or reimburse claims tied to these codes.

HEALTH Choice Utah AS THE PRIMARY PAYER

If a service is statutorily excluded from Medicare and the patient has Health Choice Utah coverage, providers can bypass Medicare altogether. In these cases, Health Choice Utah becomes the primary payer, and the claim can be submitted directly to Health Choice Utah without first billing Medicare.

WHEN CLAIMS INCLUDE BOTH COVERED AND EXCLUDED CODES

Billing becomes more nuanced when a claim includes a mix of services:

• Statutorily excluded codes, and
• Services that are covered by Medicare

In these situations, you have two options:

OPTION 1: SUBMIT ENTIRE CLAIM TO MEDICARE FIRST

Send the full claim to Medicare as the primary payer, with the appropriate modifiers. Medicare will:

• Process and pay for covered services
• Deny the statutorily excluded codes

Once Medicare has processed the claim, you can then submit the secondary claim to Health Choice Utah.

OPTION 2: SPLIT THE CLAIM

Alternatively, you may:

• Submit only the Medicare-covered codes to Medicare
• Submit the statutorily excluded codes directly to Health Choice Utah as the primary payer

This approach can help streamline reimbursement and avoid unnecessary delays tied to Medicare denials.

KEY TAKEAWAY

Understanding how to handle statutorily excluded codes ensures accurate billing and faster reimbursement. When Medicare does not cover a service, Health Choice Utah may be billed as the primary payer—but when covered services are included, providers must either bill Medicare first or split the claim appropriately.