Pace Provider Bulletins
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
PACE PROVIDER BULLETINS: 2001
January 26, 2001 Prescription Records: Notified Providers that the Department of Aging will accept the “daily hardcopy record” identified in Section 22.62, (c),(3) of Chapter 22, Pharmaceutical Assistance Contract for the Elderly, as being a certification statement which will contain verbiage clearly identifying the prescriptions and stating that the pharmacist, identified by his or her signature, attests to the identified prescriptions’ validity, accuracy and completeness. Reminder that Section 22.62 (c) and (d) state that “hardcopy prescriptions” and “other records necessary to disclose the full nature and extent of prescription drugs … dispensed by a provider shall be retained for 4 years…”.
February 23, 2001 - Sarafem®: Effective February 26, 2001, the PACE Program will deny all claims for Sarafem®. This action is being taken based on the manufacturer’s package insert which states, “Sarafem® is indicated for treatment of premenstrual dysphoric disorder (PMDD).”
March 9, 2001 – Immunosuppressants: Notified Providers that effective April 1, 2001, Medicare has eliminated the time limitation for Medicare recipients receiving immunosuppressant drug benefits. This change re-establishes coverage for disabled Medicare recipients as well as Medicare recipients over age 65 who had previously exceeded the Medicare time limit for immunosuppressant drug coverage. Effective April 1, 2001, all medical exceptions for immunosuppressants will calculate the PACE reimbursement based on the percentage NOT reimbursable by Medicare, which is currently 20%.
March 16, 2001 – Mandatory Substitution Coumadin®: Notified Providers that effective April 16, 2001, the PACE Program will mandate substitution for all new claims for Coumadin®.
March 16, 2001 – Ketoprofen Reminder: Notified Providers that as stated on page V.20 of your PACE Provider Manual, section m, “Ketoprofen being compounded for off-label use to treat arthritis will be disallowed when identified in utilization review reports.”
March 23, 2001 – PACE – CRDP Cardholders Reminder: Notified Providers that PACE is payor of last resort.
March 30, 2001 - Renagel®: Notified Providers that effective Monday, April 9, 2001, PACE will deny all claims for Renagel®. No additional medical exceptions will be approved prior to the receipt of supporting diagnostic and treatment information.
April 20, 2001 – Non-Participating Manufacturers: Notified Providers of manufacturers not participating in the PACE Program.
April 20, 2001 – Mandatory Substitution for Coumadin® Clarification: Notified Providers that Cardholders whose prescription history contains Coumadin® usage and therefore received a Medical Exception should submit the Coumadin® claim to PACE with a DAW code of “1”. PACE will not disallow Coumadin® claims on future audits in those instances in which a medical exception was granted to continue Coumadin® therapy even in the absence of Brand Medically Necessary documentation. Cardholders with no history of Coumadin® usage are subject to the Program’s mandatory substitution regulations unless a Medical Exception is authorized.
May 11, 2001 - Imitrex®: Notified Providers that effective May 14, 2001, PACE Will Deny Claims for all forms of sumatriptan (Imitrex®). No medical exceptions will be approved prior to the receipt of a cardiovascular evaluation stating the patient is free of cardiovascular disease.
May 25, 2001 - TOBI®: Notified Providers that effective June 4, 2001 PACE will deny claims for TOBI®. Only approved FDA indication is for the “management of cystic fibrosis patients with Pseudomonas aeruginosa.” Off label indications will be denied. Medical Exceptions granted only upon confirmation from prescriber of a diagnosis of cystic fibrosis.
June 26, 2001 - PACENET Expansion: Notified Providers that effective July 1, 2001 PACENET eligibility income limits have been increased. No change in PACE income limits.
June 26, 2001 - PACENET Expansion: Pharmacy poster with details of program changes.
June 26, 2001 - Legislative Changes: PACE Moratorium: Notified Providers that PACE cardholders whose eligibility was terminated in 2001 solely because of a Social Security cost-of-living-adjustment would be reinstated automatically in PACE. An automated process to be established to address PACENET claims for cardholders reinstated into PACE.
July 6, 2001 - GLEEVECä: Notified Providers that Novartis Pharmaceutical’s anti-cancer drug added to PACE drug file. Approved only for treatment of chronic myelogenous leukemia(CML) and not currently covered by medicare. Provider should understand that PACE will ensure that drug is for approved FDA indication and is prescribed in the approved dosage before authorizing payment.
July 13, 2001 - Cardholders with July 15, 2001 Ending Eligibility Dates: Notified providers of an extension of eligibility to August 21, 2001.
July 20, 2001 - Renagel®: Notified Providers that effective immediately, only Medical Exception documentation received from prescriber verifying calcium phosphate products of 70 or greater will be considered for the granting of medical exceptions.
August 10, 2001 - Baycol: Notifies Providers that effective August 9, 2001, PACE no longer reimburses for Baycol because of a voluntary manufacturer withdrawal of the product.
August 24, 2001 - PACE Moratorium Agreements: Notifies Providers of agreement mailings and of process involved in the provider refunding the cardholder and PACE reimbursing the provider due to the Moratorium.
September 21, 2001 - Bronchodilator Drugs: Notifies Providers that effective October 1, 2001 the restriction of denying at point-of-sale the reimbursement of these agents has been removed. Medicare remains primary payor. PACE continues to reimburse at 20%, the part not covered by Medicare.
September 28, 2001 – Miscellaneous Agents, Maximum Dosing Edit: Notifies providers that effective October 8, 2001 PACE will review several new agents. Patients whose prescribing regimen exceeds PACE maximum daily dose will have their prescriber contacted to obtain documentation to support dosing therapy.
November 30, 2001 - National Drug Code (NDC) Accuracy: Reminds Providers of their responsibilities in accurately reporting NDCs. Discusses prohibited acts. Providers with error rates greater than 50% may be subject to recovery audit and termination.
December 14, 2001 - Other Prescription Coverage Edit: Specifies proper use of “Other Coverage Code” field and identifies NCPDP claim denial responses in the event of improper submission.
PACE PROVIDER BULLETINS: 2002
January 18, 2002 - Important Cardholder Information: Please post this provider bulletin. It summarizes general guidance for the cardholder regarding the major conditions under which PACE assistance can and cannot be used.
April 1, 2002 - Non-Participating Manufacturers: Manufacturers are required to extend a rebate to PACE for medications purchased through the program. This bulletin lists all labelers that choose not to participate in extending the required rebate to PACE.
April 19, 2002 - ProDUR Additions: Specifies several new additions to PACE Prospective Drug Utilization Review System. Included are: Prozac Weekly, Rivastigmine, Galantamine, Perindopril, Meloxicam, Doxycycline, Acetaminophen, Propoxyphene Napsylate and Propoxyphene HCL.
May 3, 2002 - PACE Moratorium Information: Provides for a readjustment of the COLA factor used by PACE to reprocess enrollments that were affected by a 2000 Social Security COLA adjustment in mid 2001.
May 24, 2002 - Tracleer: Specifies the addition of Actelion Pharmaceutical's bosentan product to the PACE drug file. Describes the only approved diagnosis and explains the mandatory medical exception processing claims for Tracleer must undergo.
August 23,2002 - PACE Moratorium Information. A supplemental PACE moratorium reprocessing project announcement. All affected cardholders and providers are being notified. A toll-free phone number is provided for additional information.
September 6, 2002 - Remodulin: A treatment for pulmonary arterial hypertension(PAH), Remodulin(treprostinil) injection has been added to PACE program coverage but only for this diagnosis. Claims for this medication must go through the medical exception process to be considered for payment.
November 8, 2002 - HIPAA Compliance: Lists software vendors that will be contacted regarding the requirements of the HIPAA initiative and requests contact information from providers for vendors not included on the list.
December 27, 2002 - Mandatory Substitution of Prilosec: Identifies manufacturers that will be a source for the generic version of Prilosec, omeprazole.
PACE PROVIDER BULLETINS: 2003
January 24, 2003 - PACE Software Vendor List: Updates list of known software vendors that will be contacted regarding the requirements of the HIPAA initiative during the testing phase regarding NCPDP 5.1 and requests contact information from providers for vendors not included on the list.
January 24, 2003 - Requests to Void Prescriptions: The PACE Provider Manual, page IV.24, states that providers are responsible for voiding claims for prescriptions paid for by the Program but never received by the cardholder. This bulletin specifies costs and conditions involved with submitting voided claims.
January 31, 2003 - Important Cardholder Information Poster: Please post this provider bulletin. It summarizes general guidance for the cardholder regarding the major conditions under which PACE assistance can and cannot be used.
February 14, 2003 - Lumigan® (bimatoprost): Describes dosing restrictions recommended by the manufacturer Allergan and describes subsequent PACE claim handling procedures regarding this medication.
February 14, 2003 - Avage® and Botox Cosmetic®: PACE legislation prohibits payment for “drugs prescribed for wrinkle removal…”. This bulletin includes these medications in the category and removes them from PACE coverage.
February 14, 2003 - Medical Exception Processing for Lotronex,® Forteo® and Humira®: Specific guidance for these medications.
March 28, 2003 - Early Refill Edit: Effective Monday, April 14, 2003, PACE cardholders must use 85% of their medication, based on the previous prescription’s days supply, before the Program will consider the refill for reimbursement.
April 4, 2003 - HIPAA Information: This bulletin is in response to inquiries regarding the responsibility of the Department of Aging, PACE Program and its contractor, First Health in achieving HIPAA (Health Insurance Portability and Accountability Act of 1999) compliance.
April 11, 2003 - Cardholder Information for Early Refill Edit Poster: Illustrated poster describing that effective Wednesday, May 14, 2003, PACE cardholders must use 85% of their medication, based on the previous prescription’s day’s supply, before the Program will consider the refill for reimbursement.
May 23, 2003 - Provider Manual Insert: PACE legislation was amended in 1992 to require that cardholders be informed of the Usual and Customary price of the prescription they received under the PACE Program.
June 6, 2003 - Early Refill Edit: Delaying implementation of the March 28, 2003 - Early Refill Edit: provider bulletin. A new implementation date will be announced when further information is available.
August 1, 2003 - Relocation: First Health Services announces its office relocation details. New address becomes effective August 11, 2003.
August 8, 2003 - Pro-DUR Edit Revisions: New drug classes to be added effective August 19, 2003.
August 22, 2003 – Important Telephone Numbers: Lists retained and changed general access telephone numbers, as well as, new address of First Health Services/PACE.
November 28, 2003 – Program Changes: Changes pursuant to House Bill 888 become effective January 1, 2004. This bulletin specifies the most notable changes applicable to providers.
December 26, 2003 – New Legislation Cardholder Impact: Further description of changes to PACE/PACENET detailing Income Limit Increases Co-pays, Generics, PACENET Claims Processing and Potential PACE/PACENET Applicants.
PACE PROVIDER BULLETINS: 2004
January 9, 2004 – Federal Upper Limits (FUL) Pricing for A-Rated Multiple Source Products – Pending additional review, effective January 20th, 2004, the Department of Aging is temporarily suspending FUL reimbursement pricing on A-rated multiple source products.
January 23, 2004 – Provider Telephone Calls: Changes in PACE/PACENET Legislation have the potential for lessening the program’s ability to address phone calls in a timely manner. The potential for thousands more to be enrolled in the program requires some interim information to be presented.
February 6, 2004 – Manufacturers’ Rebate NON-PARTICIPATION NOTICE FOR: MYLAN AND UDL Labs. Effective February 9, 2004.
February 13, 2004 – Clarifications: This memo provides examples of the possible situations involved with helping people understand the use of the PACENET $40 deductible.
February 20, 2004 – Manufacturers’ Rebate REINSTATEMENT NOTICE FOR: MYLAN AND UDL Labs
February 27, 2004 – Timoptic XE Days Supply Permissions: Merck was last manufacturer of 0.25% strength in 2ML size. Only 5ML size is available from Merch and Falcon. Days supply requirement is listed.
March 12, 2004 - Lorazepam/Clorazepate Assistance Program: On March 29, 2004, the Department of Aging will implement the Lorazepam/Clorazepate Assistance Program known as the PA (Pennsylvania) Patient Assistance Program. This new program reimburses for generic formulations of lorazepam and clorazepate.
March 26, 2004 - Renagel®: Effective Monday, March 29, 2004 all claims for sevalamer hydrochloride (Renagel®) will be denied at the point of sale.
March 26, 2004 - ProDUR Edit Revisions: Effective March 29, 2004, the following list shows the recommended initial maximum dose, maximum daily dose and duration criteria have been added to the Department of Aging’s Prospective Drug Utilization Review Program for the following class of drugs.
May 14, 2004 - Non-Participating Drug Manufacturers: Manufacturer Rebate Program requires manufacturers’ whose products are paid for by PACE, to pay a rebate to continue having PACE pay for their products. Attached is the latest information on non-participants.
May 28, 2004 – PACE Medicare Discount Program Specifications: Updated claims submission instructions and corrections for claims applied to the federally mandated prescription assistance subsidy.
August 13, 2004 – PACE Program Updates: Submission Time Limits, deductible accrual begin date and co-payment disparities are discussed.
October 1, 2004 – PACE Processing of Medicare Discount Card Claims: MDP claims submitted to PACE must contain the correct amount in the PATIENT PAID AMOUNT SUBMITTED FIELD --Field 433-DX-- to be adjudicated correctly.
October 8, 2004 – PACE DUR Edits: Effective October 18, 2004, several new initial therapy , appropriate diagnosis , maximum quantity, initial quantity, maximum duration, maximum quantity and duplicate therapy criteria will be added to the PACE ProDUR Program.
PACE PROVIDER BULLETINS: 2005
January 28, 2005 -- PACE & Generic Substitution: Senate Bill 1167 permits PACE to continue reimbursing for brand name products if the brand name drug is determined to be “less expensive to the Program” than the newly introduced A-Rated generically equivalent drug.
January 28, 2005 -- MDP Transitional Assistance (T/A): The 2005 $600 T/A benefit for Medicare Discount Program (MDP) cardholders began January 1, 2005.
January 28, 2005 -- Optometrist's Prescribing Privileges: Notifies of updated list of drugs established by the Department of Health on October 9, 1998, when The Department of Health promulgated the amending of §6.1 of the regulations of the Department, 28 Pa. Code Chapter 6, to permit the prescribing of certain medications by optometrists certified to prescribe and administer pharmaceutical agents under §4.1 of the Optometric Practice and Licensure Act.
January 28, 2005 -- Optometrists Allowable Pharmaceutical Products: Updated list for PACE providers.
February 11, 2005 -- Prospective Drug Utilization (ProDur) Additions: Effective Monday, February 14, 2005 this criteria will be applied to the following listed drugs
February 18, 2005 -- Payer Specifications NCPDP 5.1 FUTURE EDITS: (PLEASE WATCH FOR REVISIONS) The fields listed below are contained in the current version of PACE/PACENET NCPDP v5.1 Payer Specifications dated June 1, 2004. Currently these data fields are not edited. Effective March 22, 2005, PACE will begin editing these fields. Providers are encouraged to contact their software vendors to ensure that valid data is being submitted to PACE in the data fields listed below:
March 11, 2005 -- PACE Patient Location Definitions: (PLEASE WATCH FOR REVISIONS) At the request of PACE Providers, we are providing the following definitions to assist in the determining the number to be entered in NCPDP v5.1 field 307-C7, Patient Location.
March 18, 2005 -- Non-Participating Manufacturer: Eli Lilly
April 1, 2005 – REVISED PAYER SPECIFICATIONS NCPDP 5.1 FUTURE EDITS (Part 1 of 2): The fields listed below are contained in the current version of PACE/PACENET NCPDP v5.1 Payer Specifications dated June 1, 2004.
April 1, 2005 -- Payer Specifications NCPDP 5.1 Future Edits Reminder (Part 2 of 2): Explanatory Materials for Part 1
April 8, 2005 – Bextra: Effective April 7, 2005: PACE no longer reimburses for Bextra. The FDA announced that effective April 7, 2005, Pfizer Inc. was voluntarily withdrawing Bextra at the request of the Food and Drug Administration.
May 6, 2005 -- Payer Specifications NCPDP 5.1 Future Edits Reminder (Part 1 of 2): The fields listed below are contained in the current version of PACE/PACENET NCPDP v5.1 Payer Specifications dated June 1, 2004. PACE is monitoring these fields and is returning the paid claim with an E.O.B. (Explanation Of Benefits) message whenever Missing or Invalid Data has been entered. Claims containing incorrect or invalid data in these fields will continue to be paid and returned with these EOB’s until September 27, 2005. Effective September 27, 2005, claims with missing or invalid data in these fields will deny.
May 6, 2005 -- Payer Specifications NCPDP 5.1 Future Edits Reminder (Part 2 of 2): Explanatory Materials for Part 1
May 13, 2005 -- Medicare Outpatient Drug Benefit Cardholder Information: The Department of Aging recognizes that many PACE cardholders are worried that this new Medicare benefit will diminish their current PACE coverage. This letter is intended to assure PACE cardholders that the new Medicare outpatient benefit will assist, not replace, PACE.
June 3, 2005 -- Payer Specifications NCPDP 5.1 Future Edits REMINDER (Part 1 of 2): The fields listed below are contained in the current version of PACE/PACENET NCPDP v5.1 Payer Specifications dated June 1, 2004. PACE is monitoring these fields and is returning the paid claim with an E.O.B. (Explanation Of Benefits) message whenever Missing or Invalid Data has been entered. Claims containing incorrect or invalid data in these fields will continue to be paid and returned with these EOB’s until September 27, 2005 . Effective September 27, 2005, claims with missing or invalid data in these fields will deny.
June 3, 2005 -- Payer Specifications NCPDP 5.1 Future Edits REMINDER (Part 2 of 2): Explanatory Materials for Part 1
June 3, 2005 – Eli Lilly & Company: Reconsideration of Rebate Participation.
July 1, 2005 -- Payer Specifications NCPDP 5.1 Future Edits REMINDER (Part 1 of 2): The fields listed below are contained in the current version of PACE/PACENET NCPDP v5.1 Payer Specifications dated June 1, 2004. PACE is monitoring these fields and is returning the paid claim with an E.O.B. (Explanation Of Benefits) message whenever Missing or Invalid Data has been entered. Claims containing incorrect or invalid data in these fields will continue to be paid and returned with these EOB’s until September 27, 2005 . Effective September 27, 2005, claims with missing or invalid data in these fields will deny.
July 1, 2005 -- Payer Specifications NCPDP 5.1 Future Edits REMINDER (Part 2 of 2): Explanatory Materials for Part 1
July 2005 -- IMPORTANT INFORMATION FOR PACE PROVIDERS: Serving PACE Cardholders with MDP Cards.
August 5, 2005 -- Payer Specifications NCPDP 5.1 Future Edits REMINDER (Part 1 of 2): The fields listed below are contained in the current version of PACE/PACENET NCPDP v5.1 Payer Specifications dated June 1, 2004. PACE is monitoring these fields and is returning the paid claim with an E.O.B. (Explanation Of Benefits) message whenever Missing or Invalid Data has been entered. Claims containing incorrect or invalid data in these fields will continue to be paid and returned with these EOB’s until September 27, 2005 . Effective September 27, 2005, claims with missing or invalid data in these fields will deny.
August 5, 2005 -- Payer Specifications NCPDP 5.1 Future Edits REMINDER (Part 2 of 2): Explanatory Materials for Part 1
September 16, 2005 -- State Worker's Insurance Fund(SWIF): All PACE Providers have been mailed packets of information inviting their participation as an on-line pharmacy provider in the state’s worker’s compensation program.
September 23, 2005 -- Denying MDP Claims at Point of Sale: Details regarding the MDP claims submissions process.
October 14, 2005 -- MDP Claim Submission: On Tuesday October 4, claims submitted for First Health MDP cardholders who never used this benefit began DENYING with NCPDP error 41 “Submit bill to Primary Payer”; PACE error 44 “Bill MDP” when submitted with:
November 4, 2005 -- Payer Specifications NCPDP 5.1 Future Edits REMINDER (Part 1 of 2): The fields listed below are contained in the current version of PACE/PACENET NCPDP v5.1 Payer Specifications dated June 1, 2004. PACE is monitoring these fields and is returning the paid claim with an E.O.B. (Explanation Of Benefits) message whenever Missing or Invalid Data has been entered. Claims containing incorrect or invalid data in these fields will continue to be paid and returned with these EOB’s until September 27, 2005 . Effective September 27, 2005, claims with missing or invalid data in these fields will deny.
November 4, 2005 -- Payer Specifications NCPDP 5.1 Future Edits REMINDER (Part 2 of 2): Explanatory Materials for Part 1 · December 9, 2005--Office of Health Care Reform Policy: The Office of Health Care Reform and the affected agencies, after consultation with the State Board of Pharmacy, and the State Board of Medicine, have reached the following policy decisions:
December 9, 2005 -- PACE/PACENET CARD CHANGES: As a result of privacy concerns, the program has decided to remove the PACE/PACENET cardholder’s social security number from the PACE/PACENET card.
December 16, 2005 -- PACE PROVIDER BULLETIN: Non-Participating Drug Manufacturers UPDATED LIST
Title PACE PROVIDER BULLETINS: 2006
January 13, 2006 -- State Worker’s Insurance Fund (SWIF) Program: This Bulletin is to clarify the recent PACE/PACENET/SWIF communication you may have received regarding the processing of pharmacy claims for workers’ compensation injured workers.
January 20, 2006 -- Medicare Part D and PACE/PACENET: After January 1, 2006, PACE/PACENET Providers may be presented with both a PACE/PACENET card and a Medicare Part D prescription card.
January 27, 2006 -- DATE PRESCRIPTION WRITTEN EDIT: A CD containing the revised PACE Provider Manual and revised NCPDP v5.1 Payer Specifications is currently being prepared for distribution. The revised specifications contain the following fields that will be edited effective February 28, 2006:
February 17, 2006 -- MEDICARE PART D PRESCRIPTIONS and OTHER COVERAGE CODES
February 24, 2006 -- MEDICARE PART D PRESCRIPTIONS and PACE/PACENET: CMS has identified 62,000 PACE/PACENET Cardholders currently enrolled in a Medicare Part D Plan. The majority of these cardholders have been enrolled by Highmark
March 10, 2006 -- BILLING MEDICARE PART D CLAIMS: Providers are to bill PACE for Medicare Part D plans following the same procedure used for the various Medicare Discount plans.
March 24, 2006 -- MANUFACTURERS’ REBATE NON-PARTICIPATION: Bajamar Chemical Company Inc. Labeler Code 44184
April 14, 2006 -- MEDICARE PART D Logic Revisions: Effective Thursday, April 20, 2006, PACE is implementing 2 edits to assure the accuracy of data received from Providers submitting Part D claims to PACE as the secondary payer. Providers should be aware that these edits will also apply to all other Programs under the auspices of the Department of Aging.
April 21, 2006 -- Date the Prescription is Written Edit Questions: Effective February 28, 2006, the Date the Prescription is written is compared against the “Date of Service” on original and refilled prescriptions. Original or refill prescriptions whose date of service exceeds 6 months from the date the prescription was written deny with an NCPDP Error M4, PACE Error 724, “Prescription Time Limit Exceeded.”
April 21, 2006 -- OTHER COVERAGE CODES: Effective immediately, providers are advised that claims submitted to PACE/PACENET with Other Coverage Codes are subject to a desk level audit.
April 28, 2006 -- MANUFACTURERS’ REBATE NON-PARTICIPATION: NABI (North American Biological Inc) Labeler Code – 59730
May 5, 2006 -- SECURITY BLUE AND FREEDOM BLUE PRESCRIPTION PLANS: pace HAS BEEN ADVISED THAT effective January 1, 2006, cardholders having either Security Blue or Freedom Blue health plans as their primary payer AND who have any oral pharmaceutical prescribed that was previously billable to Medicare Part B MUST now use MEDMARK.
May 12, 2006 -- June 20, 2006 PACE Payer Specification Revision: Please replace page 8 and 9 of your PACE NCPDP v5.1 PAYER SPECIFICATIONS with the accompanying revision.
May 12, 2006 -- June 20, 2006 PACE Payer Specification Revision: Coding crosswalk grid
May 25, 2006 -- Claims Review: Beginning Friday, May 26, 2006 PACE will begin reviewing adjudicated claims with an anticipated reimbursement exceeding $500.
May 26, 2006 -- PACE Cardholders enrolled in Medicare Part D Prescription Programs: IMPORTANT INFORMATION FOR PACE PROVIDERS
June 9, 2006 -- Primary Plans With Prior Authorization: Increasing numbers of PACE and PACENET cardholders have Medicare Part D plans. As required by regulation, PACE and PACENET are billed as the secondary payer.
June 16, 2006 -- MEDICARE DISCOUNT CARDS and OTHER COVERAGE CODES: The First Health Medicare Discount Card Program (MDP) ended on May 15, 2006. Claims filled on, or before, May 15th may still be submitted to First Health MDP; claims filled after May 15th are not eligible for reimbursement.
June 30, 2006 -- NATIONAL PROVIDER IDENTIFIER (NPI): On January 23, 2004, The Centers for Medicare & Medicaid Services (CMS) announced the availability of a new identifier for use in the standard electronic health care transactions.
June 30, 2006 -- NABI Reinstatement: NABI (North American Biological Inc.) Labeler Code – 59730 has signed a rebate agreement with the PACE Program.
July 7, 2006 -- Cosopt & Trusopt: Merck has announced that the 5 ml size of Cosopt and Trusopt is being discontinued. The 10 ml size will become the smallest available container.
July 7, 2006 -- PACE Plus Medicare Legislation: PACE Plus Medicare Legislation Highlights.
July 21, 2006 -- PRIMARY PAYER REJECT CODES / BIN: Effective Thursday, August 3, 2006, PACE will accept only valid reject codes from the primary payer in Field 472-6E.
July 21, 2006 -- Part D Assignment Letters: On Tuesday, July 19, 2006 all PACE and PACENET cardholders not enrolled in a Medicare Part D plan were sent the enclosed letters informing them that the Program was requesting they enroll in a plan chosen for them.
July 21, 2006 -- Part D Letters: Two versions of the Medicare Part D Letter are included. One letter is for PACE recipients and the other is for PACENET.
July 28, 2006 -- PACE Plus Medicare: The PACE Program is recommending that cardholders using the prescription drug benefit enroll in one of the following plans if they are not currently enrolled in a Medicare Advantage Plan or an employer retiree plan.
August 18, 2006 – Billing the Primary Payer: On September 1, 2006, over 150,000 PACE/PACENET cardholders will be enrolled in the Part D plans listed below.
August 28, 2006 PACE Plus: Effective Friday September 1st, PACE will update over 150,000 PACE/PACENET cardholder files with Medicare Part D enrollment information from the seven (7) plans listed below. Under the new PACE Plus Medicare Program, many PACE and PACENET cardholders will also be enrolled in Medicare Part D plans.
September 8, 2006 - EFFECTIVE SEPTEMBER 19, 2006, to insure that the correct primary payer is being billed for those cardholders enrolled in one of the Department’s seven (7) partner plans, claims containing an OCC of 2, 3, 4, 5 or 7 must contain the valid BIN number of the primary payer in the Other Payer ID field – 340-7C. Also discusses procedures OCC 3: “Other coverage exists—claim not covered” and OCC 4: “Other coverage exists-payment not collected” in this regard.
September 29, 2006 -- Highmark Blue RX Basic Medicare Part D Transition Billing: Paid claims’ history for PACE/PACENET cardholders also enrolled in the Highmark Blue RX Basic Medicare Part D plan reveals many providers are not following Highmark’s instructions for resubmitting claims during the transition period.
October 6, 2006 -- PACE/PACENET Part D List: Activities surrounding Actual Lists of these cardholders sent to pharmacies.
PACE PROVIDER BULLETINS: 2007
January 19, 2007 -- Highmark Blue RX Basic Medicare Part D VOIDED CLAIMS: The enclosed PACE report contains voided claims that will appear on the PACE Remittance Advice of FEBRUARY 2, 2007. The Program is providing this report for those providers wishing to begin their rebilling process as soon as possible and/or to contact their software vendors for rebilling instructions.
January 26, 2007 -- PACE Plus Medicare: Listed below are the Medicare Part D plans that have partnered with PACE for 2007. Providers will notice three additional plans (identified by an asterisk *). Providers should also take note that some plans have changed their copay as well as their formulary.
January 26, 2007 -- Highmark Blue RX Basic Medicare Part D VOIDED CLAIMS: Eighty percent (80%) of providers received Highmark Void reports the week of January 21st. These reports identified voids that would appear on the Remittance Advice dated February 2, 2007.
February 2, 2007 -- Highmark Blue RX Basic Medicare Part D VOIDED CLAIMS UPDATE: The Program, in conjunction with Highmark and Medco, continues to review the voided claims that were originally scheduled to appear on the R/A of February 2, 2007.
February 8, 2007 -- IMPORTANT INFORMATION for Providers submitting claims to PACE, CRDP and SPBP: Highmark’s Medicare Part D BlueRx Prescription Program. The PACE Program is supplying the enclosed list of cardholders enrolled in Highmark’s Medicare Part D BlueRx group plan to assist Providers in billing Highmark.
February 26, 2007 -- Highmark Blue RX Basic Medicare Part D VOIDED CLAIMS: The enclosed PACE report contains voided claims that will appear on the PACE Remittance Advice of March 16, 2007.
March 2, 2007 -- Important Information: PACE will be conducting a PACE provider re-enrollment beginning in March. Pre-printed documents containing current provider information accompanied by a new PACE Provider Agreement will be mailed to all PACE providers.
March 2, 2007 -- Claim Submission Accuracy: The PACE void project identified numerous claims billed incorrectly to PACE as the primary payer. Providers were either not billing the Medicare Part D plan as the primary payer or were not billing the Medicare Part D plan correctly.
March 16, 2007 -- MEDICARE PART D VOIDED CLAIMS: As stated in the February 26 Provider Bulletin sent with the revised Void Report, the voided claims appear on the enclosed Remittance Advice. These claims were voided from the system on January 17 and identified on the original void report sent January 19, 2007.
March 23, 2007 -- NATIONAL PROVIDER IDENTIFIER (NPI): ALL PROVIDERS SHOULD HAVE OR BE IN THE PROCESS OF ACQUIRING THEIR NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER.
April 6, 2007 -- PACE PROVIDER RE-ENROLLMENT: PHARMACY NAME: As stated in the instructions, providers must include the PHARMACY NAME in the space provided in the first paragraph of the agreement.
April 13, 2007 -- May 23, 2007 Changes: Revised PACE NCPDP v5.1 Specifications pages were mailed to all providers the week of April 9, 2007. These revised specifications were also e-mailed to all known provider software vendors and claims submission networks.
April 20, 2007 -- May 23, 2007 Changes Revised: Revised PACE NCPDP v5.1 Specifications pages were mailed to all providers the week of April 9, 2007. These revised specifications were also e-mailed to all known provider software vendors and claims submission networks.
April 27, 2007 -- May 23, 2007 Changes Revised: Revised PACE NCPDP v5.1 Specifications pages were mailed to all providers the week of April 9, 2007. These revised specifications were also e-mailed to all known provider software vendors and claims submission networks.
April 27, 2007 -- NEW PACE/PACENET CARD: Beginning May 1, 2007, the new PACE card pictured below will be sent to all PACE and PACENET cardholders.
June 1, 2007 -- Program Changes regarding AMBIEN & DESI Drugs: Effective June 5, 2007
June 22, 2007 -- BIN and PCN EDITS: In preparation for the NPI implementation on May 23, 2007, Providers were also advised to verify that the BIN (Field 101-A1) being used to submit claims to PACE/PACENET, CRDP, CF, SB, MSUD, PKU, SPBP, PAP or SWIF was BIN 002286.
July 27, 2007 -- PROGRAM CHANGES Effective Tuesday, July 31, 2007 the following edits will be implemented:
July 27, 2007 -- PATIENT ASSISTANCE PROGRAM (PAP) Effective Tuesday, July 31, 2007 Pennsylvania PATIENT ASSISTANCE PROGRAM (PAP) will begin enrolling eligible patients into a new program.
November 2, 2007 -- Part D Cardholder Letters: Because many PACE/PACENET cardholders bring letters received from the Program to the pharmacy, providers are advised that on Friday, November 2, 2007, the Program conducted another mailing.
November 30, 2007 -- PACE Plus Medicare: Listed below are the Medicare Part D plans that have partnered with PACE for 2008.
December 21, 2007 -- CHANGES FOR 2008: In January 2008, the Program will be implementing the following:
PACE PROVIDER BULLETINS: 2008
March 5, 2008 -- 2008 Part D Partner Plan List Update: To ensure that the correct Part D plan is being billed as the primary, PACE/PACENET is providing this revised cumulative list (enclosed) of all cardholders currently enrolled in the selected Medicare Part D plans who frequent your pharmacy.
March 28, 2008 -- Primary Payer Edits: Effective Monday, March 31, 2008, PACE/PACENET is implementing edits to insure providers bill the correct PACE Medicare Part D partner plan as the primary payer.
April 11, 2008 -- PA PAP (Pennsylvania Patient Assistance Program): Effective immediately, PAP will begin enrolling eligible patients into a new program.
April 25, 2008 -- Important Information About Prescriber NPI: On May 23, 2008, many primary prescription plans will accept only the prescriber’s NPI in Field 411-DB. PACE/PACENET, CRDP, SPBP and other programs administered by the Department of Aging will accept either the prescriber’s NPI or his/her Pennsylvania state license number. To avoid a denied claim, the correct Prescriber ID Qualifier must be entered in field 466-EZ. The Pennsylvania state license number qualifier is “13”; the NPI qualifier is “1”.
May 2, 2008 -- PACENET Premium for Additional IBC Plans to be collected at Point of Sale: Effective for claims with a date of service of May 1, 2008, 6,800 PACENET cardholders enrolled in the following IBC Part D plans will have the Individual Plan’s Premium, up to the monthly premium benchmark of $26.59, collected at the point of sale…
May 2, 2008 -- Will Call Bin Spot-Check: The Department is conducting unannounced spot-checks of pharmacies’ “Will Call Bins” to insure that claims paid for by the Commonwealth of Pennsylvania have been received by the cardholder.
May 16, 2008 -- Prescriber NPI: Effective Friday, May 23, 2008 PACE/PACENET, CRDP, SPBP and other programs administered by the Department of Aging will accept either the prescriber’s NPI or Pennsylvania state license number in the PRESCRIBER ID Field, number 411-DB.
June 06, 2008 -- Remittance Advice Enhancement: PACE, SPBP, CRDP and all programs under the auspices of the Department of Aging are transitioning to all electronic remittance advices. When complete, this will eliminate the current paper R/A’s.
October 3, 2008 -- PACE & E-PRESCRIBING: The number of prescribers and pharmacies utilizing e-prescribing continues to increase throughout Pennsylvania. To facilitate e-prescribing for cardholders, PACE will make eligibility data available for e-prescribing physicians beginning in November.
October 31, 2008 -- Program Updates: For AVANDIA and ACTOS, Effective January 1, 2009, all new prescriptions.
October 31, 2008 -- Program Training Information: Provider Services is currently developing a downloadable power point training presentation module that will be available to any pharmacy provider.
November 12, 2008 -- PACE and EASY PRINT: A Guide to using Medicare Remit Easy Print (MREP) with PACE
November 14, 2008 -- Medicare Part D Plans: Listed in this bulletin are the Medicare Part D plans that have been selected as partner plans with PACE for 2009, pending final execution of their Agreements with the Department of Aging.
November 21, 2008 -- PA RX PRICEFINDER: On July 22nd, the Commonwealth unveiled a website to permit the public to access usual and customary billing information. This website, www.parxpricefinder.com, enables consumers to shop around and get the best price for their medications.
December 26, 2008 -- OTHER COVERAGE CODE EDITS: The Program has found that the submission of inaccurate data accompanying certain Other Coverage Code (OCC) values is compromising the integrity of PACE data.
December 31, 2008 -- Medicare Part D Plans: Effective January 1, 2009, approximately 138,000 PACE/PACENET cardholders will be enrolled in Part D partner plans. Although 4 of the 5 Partner plans are the same as last year, some cardholders may have been moved into a different plan that better serves their needs.
PACE PROVIDER BULLETINS: 2009
March 27, 2009 -- Pennsylvania Rx Price Finder Website: Last July, it was announced that the Commonwealth was creating a website that would permit the public to access pharmacy usual and customary pricing information.
March 27, 2009 -- Disallowed Claims: As stated in the March 6, 2009 Provider Bulletin, PACE is currently developing an edit to ensure that the Other Coverage Code (OCC) 6 “Other Coverage Denied-Not a Participating Provider” is being used correctly.
April 3, 2009 -- Other Coverage Code “6” EDIT: Effective Monday April 6, 2009, Providers submitting claims with the Other Coverage Code of “6” will have the claim(s) denied when identified as a participating pharmacy by any of the following third party plans:
April 11, 2008 -- Effective immediately, PAP will begin enrolling eligible patients into a new program.
May 1, 2009 -- Effective June 1, 2009, PACE IS GOING GREEN! The last paper Remittance Advice for PACE, CRDP, SPBP and all other Programs under the auspices of the Department of Aging will be printed May 29, 2009.
May 15, 2009 -- Payer Specification Sheet: COMPLIANCE: PACE Providers are responsible for the validity of their claims submissions data. PACE is receiving TrOOP (True Out Of Pocket) expense data indicating that the Patient Paid Amount field (Field 433-DX) reported to PACE is not matching the data returned by the primary payer. This discrepancy is appearing both when the primary payer is making payment as well as during the deductible and the “donut hole.”
May 15, 2009 -- Claim Reversal Specification Revision: PACE receives approximately 20,000 voids weekly. To insure that the PART D TrOOP (True Out Of Pocket) expenses, is calculated correctly, effective Tuesday, June 16, 2009, ALL voids / reversals for ALL Programs must include the cardholder’s Program specific identification number.
May 29, 2009 -- Validity of Claim’s Information: Providers are responsible for the validity of their claims’ data. The PACE Provider Agreement states...
May 29, 2009 -- Prospective Drug Utilization Review (ProDUR): Criteria Additions: The following list contains recommended initial maximum dose, maximum daily dose and duration criteria which have been added to the Department of Aging’s Prospective Drug Utilization Review program in the following drug classes:…
May 29, 2009 -- Future Provider Notifications: As announced, this week’s Remittance Advice is the last paper R/A for PACE, SPBP, CRDP, PAP and SWIF. To inform providers of Program changes or initiatives in the future, Provider Bulletins will continue to be e-mailed to pharmacy associations, chain corporate offices as well as being available on the Department of Aging’s website at www.aging.state.pa.us.
July 1, 2009 -- MemberHealth CCRX and First Health Premier Claim Submissions: Enclosed is a list of cardholders that frequent your pharmacy and are enrolled in either MemberHealth CCRX or First Heath Premier Part D Plans. This list contains the correct BIN, PCN, Member ID and Group for each member and is a duplicate of the list sent in early January.
July 1, 2009 -- PACE Claim Submissions: The Pennsylvania Pharmaceutical Assistance Contract for the Elderly Program (PACE) has received bulletins forwarded by Pennsylvania pharmacy providers.
September 23, 2009 -- Valid Claim Data: The May 2009, Provider Bulletins (included with this transmission) reminded providers that the responsibility for the validity of their claim data lies with them.
PACE PROVIDER BULLETINS: 2010
January, 2010 -- 2010 Medicare Part D Partner Plans: PACE is conducting its annual assignment of cardholders into Part D partner plans.
February 1, 2010 -- New PACE Cardholder ID Number: Beginning March 4, 2010, PACE will be mailing new PACE Cards to all current PACE/PACENET members.
February 2, 2010 -- NEW PACE/PACENET CARD: All Cardholders will receive a NEW PACE/PACENET card and ID number. Effective Tuesday, May 4, 2010, only the new PACE/PACENET ID will be accepted. The old number will reject with the NCPDP error 07 M/I Cardholder ID number.
February 19, 2010 New Edits: Effective February 23, 2010, PACE will implement the following edits:...
March 1, 2010 New PACE/PACENET Card Implementation Revision: The PACE/PACENET card implementation has been delayed until April.
March 10, 2010 -- CMS Termination of Fox Insurance: Effective March 9, 2010, CMS terminated Fox Insurance as a Medicare Part D plan.
March 29, 2010 -- PPI EDIT: Effective Tuesday March 30, PACE will implement a PPI edit for cardholders enrolled in either MemberHealth Community CCRX or Ovations AARP Rx Saver plans.
April 9, 2010 -- Osteopathic Assistants (OA's): The State Board of Osteopathic Medicine has amended its regulations whereby the supervising physician may delegate to the physician assistant (Osteopatic Assistant) the prescribing, dispensing, and administering of drugs and therapeutic devices.
April 23, 2010 -- Osteopathic Assistants (OA's): As stated in the previous bulletin, the State Board of Osteopathic Medicine amended its regulations whereby the supervising physician may delegate to the physician assistant (Osteopathic Assistant) the prescribing, dispensing and administering of drugs and therapeutic devices.
June 7, 2010 -- NEW PACE/PACENET CARD EDIT: The new PACE/PACENET card mailing has been completed. Distribution of pharmacy cardholder lists was completed in early April.
June 11, 2010 -- NEW PACE/PACENET CARD NCPDP Error 07 M/I Cardholder ID number EDIT Reminder: Effective Tuesday, June 15, only the new PACE/PACENET ID will be accepted. The old PACE ID number will reject with the NCPDP error 07 M/I Cardholder ID number. THE NEW ID WILL BE RETURNED IN FIELD 504 F4 IN THE RESPONSE SEGMENT WITH THE MESSAGE: NEW CH ID 9999Z9999.
June 21, 2010 -- 340B PRICING: Providers are advised that pharmaceuticals billed to the Commonwealth that are eligible for 340B pricing are being reviewed.
June 24, 2010 -- Workers’ Compensation Security Fund (WCSF) Catastrophic Loss Benefits Continuation Fund(AUTOCAT) Programs: All PACE Providers have been mailed packets of information inviting their participation as a pharmacy provider in the above mentioned Programs. Effective July 1, 2010 claims for the WCSF and AUTOCAT programs will be accepted using the PACE point-of-sale (POCAS) system.
August 23, 2010 -- REMITTANCE ADVICE NAME CHANGE: In September the sender ID value and the electronic R/A file name will be changing. This will affect all PACE, CRDP, SPBP, PA PAP, AutoCat and WCSF providers.
September 14, 2010 -- Prescription Imaging: At the request of providers, the Department has reviewed the practice of scanning (imaging) a prescriber’s original written order into pharmacy computer systems thereby serving as a readily available electronic record.
October, 2010 -- Prescription Records: The "Prescription Imaging" Bulletin dated September 14, 2010 addressed prescriptions received by the pharmacy as an "original handwritten order."
October 1, 2010 -- NON-PARTICIPATING MANUFACTURERS: Effective immediately, the manufacturers and labeler codes listed below are not reimbursed by PACE:
November 23, 2010 -- Propoxyphene (Darvon®, Darvocet®): Xanodyne Pharmaceuticals is withdrawing propoxyphene. The FDA recommends that healthcare professionals stop prescribing propoxyphene; contact patients currently taking propoxyphene related products; ask them to discontinue taking the medication and inform patients of the risks and discuss pain management alternatives.
December 14, 2010 -- Prospective Drug Utilization Review (ProDUR)- Criteria Additions: Effective December 14, 2010 the following maximum daily dose, duration, age and step therapy criteria have been added to the Department of Aging’s Prospective Drug Utilization Review program in the following drug classes:
December 17, 2010 -- 340B PRICING Retraction: Effective immediately, the Department of Aging is withdrawing the June 21, 2010 Bulletin mandating that providers submitting claims using pharmaceuticals purchased through the 340B Drug Discount Program bill the Program a Usual and Customary price that reflected the 340B discounted price.
December 28, 2010 -- Medicare Part D Partner Plans: As in previous years, PACE is sending lists of PACE cardholders and their Part D partner information to the cardholder’s pharmacy to enable cardholder primary payer information to be updated as quickly as possible. This task will involve the verifying or updating of over 100,000 PACE cardholder primary payer records.
PACE PROVIDER BULLETINS: 2011
January 4, 2011 -- Medicare Part D Partner Plan Assignments: Each year during the Medicare Part D open enrollment period, the PACE, CRDP and SPBP Programs solicit qualified Prescription Drug Plans who are interested in partnering with the Programs to provide a coordinated benefit.
January 6, 2011 -- Medicare Part D Additional Cardholders: Enclosed is an ADDITIONAL list of Medicare Part D cardholders.
January 14, 2011 -- PART D PARTNER PLAN UPDATE: WELLCARE PCN: The WellCare Classic PCN of 01410000 included on the cardholder Medicare Part D plan lists that were previously distributed omitted the leading (or first) zero (0). The BIN/PCN combinations accompanying each member’s ID should have been BIN 603286;01410000; not 603286;1410000. Claims submitted to WellCare without the leading zero in the PCN will deny.
January 21, 2011 -- OTHER PAYER BIN: When submitting a claim to PACE/CRDP/SPBP as the secondary payer, be sure the BIN entered in the primary claim is the same as the BIN entered in the COB segment.
January 28, 2011 -- PART D PRIMARY PLAN EDIT: Effective Tuesday, February 1, 2011, claims billed to the cardholder’s incorrect primary plan will deny with NCPDP Reject Code 7C: Missing / Invalid Other Payer ID.
April 1, 2011 -- NON-PARTICIPATING MANUFACTURER: Effective April 1, 2011, FRESENIUS MEDICAL CARE, labeler code 49230, has terminated its manufacturer’s rebate agreement with the Commonwealth.
May 16, 2011 -- Chain Provider Voids: The PACE processing system will be implementing a change effective October 1, 2011, that may impact chain providers.
May 16, 2011 -- Same Cycle Voids: The PACE processing system will be implementing a change effective October 1, 2011, affecting claims paid and voided within the same processing cycle. PACE processing cycles begin 7AM Friday and ends 10PM Thursday.
July 15, 2011 -- PRIMARY PRESCRIPTION PLAN INFORMATION: This is a reminder that state auditors may request information to verify primary plans’ responses for claims submitted to PACE, which includes PACE and PACENET claims as well as eight other state pharmacy benefits administered by PACE. In addition, the auditors may request documentation pertaining to other state agency pharmacy benefits for which they have auditing responsibilities.
July 22, 2011 -- Provider Payment Specifications Information: Provider reimbursement requirements are reflected in this bulletin
September 9, 2011 -- NCPDP VERSION 5.1 PROCESSING CHANGES: Effective Saturday November 12, 2011, claims for PACE and all of the ancillary programs administered by the Department of Aging will by adjudicated through the Magellan FirstRx claims processing system. This upgrade from the current mainframe is in preparation for the January 2012 transition to NCPDP vD. Ø
October 14, 2011 -- NCPDP VERSION D.Ø: NCPDP VERSION DØ specifications are being emailed to all PACE software vendors. This mailing will be completed by Monday October 17, 2011.
November 4, 2011 -- November 12, 2011 IMPLEMENTATION POSTPONED: The implementation of the PACE new processing v.5.1 claims originally scheduled for Saturday, November 12, 2011 has been postponed.
November 23, 2011 -- NCPDP VERSION D.Ø UPDATE: The acceptance of PACE D.Ø claims originally scheduled to begin on December 5, 2011 has been delayed. Claims submitted to PACE and all programs administered by the Department of Aging are to continue to be submitted on NCPDP version 5.1. Claims submitted to PACE version D.Ø will deny. A new date for accepting version D.Ø has not been finalized.
November 23, 2011 -- Pennsylvania PACE and Ancillary Programs D.0 Payer Specification: NCPDP Version D Claim Billing/Claim Re-bill Template - Request Claim Billing/Claim Re-bill Payer Sheet Template
December 16, 2011 -- NCPDP VERSION D.Ø IMPLEMENTATION UPDATE: Claims for PACE, SPBP, CRDP and all plans administered by the Department of Aging are to continue to be submitted on NCPDP version 5.1 beyond January 1, 2012.