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Pursuant to Governor Ridge’s Executive Order 1996-1, agencies under the jurisdiction of the Governor must catalog and publish all non-regulatory documents such as policy statements, guidance manuals, decisions, rules and other written materials that provide compliance related information. The following compilation is the third list of the Administration’s non-regulatory documents. This list will be updated and published annually on the first Saturday in August.

This catalog is being provided to insure that the public has complete access to the information necessary to understand and comply with state regulations.

INTERNAL GUIDELINES

PACE PROVIDER BULLETINS: 2014

  • January 31, 2014 - Program updates: NCPDP Error 41" Submit Bill to Other Processor/Payer:" Listings of the Part D plan chosen for cardholders and a Provider Bulletin have been distributed to the pharmacy the cardholder uses most often. Web R/A pharmacies were sent lists; FTP R/A providers had their list posted on the FTP site. the Provider Bulletin stressed the need to "update the Other Payer ID (the BIN) in the Coordination of Benefits (COB) segment, Field 340-7C" when updating the primary payer information. Claims without the new PART D BIN were processed during January, to permit pharmacies to update their primary information.

 

PACE PROVIDER BULLETINS: 2013

  • March 18, 2013 - New ProDUR Edits (Prospective Drug Utilization Review): Effective immediately the following pharmaceuticals are subject to ProDUR edits. Claims will reject with NCPDP Error Code 75 accompanied by "Call Help Desk" in the DUR Free Text Message field.
  • March 29, 2013 -- IMPLEMENTATION: REJECT 7C M/I OTHER PAYER ID: In January, listings of the Part D plan chosen for cardholders were distributed to the pharmacy the cardholder most often used. The lists were sent to non chain provider pharmacies and were made available to chain providers via FTP.
  • May 10, 2013 -- Compound Claims Processing Enhancement: Effective Monday, May 13, 2013 new messaging has been incorporated into the processing of compound claims that deny for NCPDP Error 70, "Product/Service Not Covered."
  • May 10, 2013-- FUL (Federal Upper Limit) Reprocessing and New FUL August Pricing-- FUL REPOROCESSING: The incorrect prices received from Medical Economics (Red Book) pricing files and applied to claims in June through October 2012 have been identified and are being reprocessed.-- NEW FUL AUGUST PRICING: The Department of Health and Human Services, Centers for Medicare & Medicaid Services has announced on their website that 42 CFR Part 447[CMS2345:P], Covered Outpatient Drugs of the Affordable Health Care Act, will become effective August 2013. These Covered Outpatient Drugs are subject to the new FUL prices.
  • May 31, 2013 -- NON-PARTICIPATING MANUFACTURERS: The following three manufacturers have notified the PACE program that they will be terminating their participation in the rebate program. Listed below are the effective dates of their termination and some of their pharmaceuticals.

  • July 1, 2013--NON-PARTICIPATING MANUFACTURERS: Effective Monday July 1, 2013, the following manufacturers are being terminated from participation in the Commonwealth of Pennsylvania Drug Manufacturers' rebate program for failure to comply with their rebate agreement. PACE, CDRP and SPBP will no longer be permitted to reimburse for these products.

  • July 2, 2013--***REVISED*** NON-PARTICIPATING MANUFACTURERS: ***REMOVED: Apotex, lebeler 60505, has notified the Program of its intent to comply with the Commonwealth's rebate agreement. Therefor, effective immediately, Apotex pharmaceuticals are removed from this list and WILL BE accepted for reimbursement. ***DATE CHANGE: Effective Thursday August 1, 2013, the floowing manuafcturers are being terminated from participation in the Commonwealth of Pennsylvania Drug Manufacturers' rebate program for failure to comply with their rebate agreement. PACE, CRDP and SPBP will no longer be permitted to reimburse for these products.

  • July 25, 2013 -- ***UPDATE*** NON-PARTICIPATING MANUFACTURERS: The Non-Participating Manufacturers Bulletin dated July 2, 2013 listed ten (10) labelers that were being terminated on Thursday August 1, 2013 for failing to comply with the Commonwealth of Pennsylvania's Drug Manufacturers' rebate program agreement. ***Two (2) manufacturers, Apotex, labeler 60505 and Ascend, labeler 67877, have since been removed from this list. Only 8 remain on the list.

  • July 26, 2013 -- MEDICARE PART D 90 DAY SUPPLY PRESCRIPTION REFILL EDIT: Currently the Program permits a prescription to be refilled five (5) times within six (6) months, whichever occurs first, from the date of the original fill. Cardholders using only PACE or having a primary that only permits a thirty day supply, usually have their chronic medication prescriptions last six months.

  • July 29, 2013 -- Rewards/Loyalty/Gas Points Programs: Questions have been received by the Department of Aging regarding the OIG's position on rewards programs in respect to Federal health care programs.

  • August 14, 2013 -- DUR ADDITION: Effective Tuesday September 2, 2013, QSYMIA® will deny at the point of sale with NCPDP Error 75 accompanied by the message of "Medical Exception required;" the Provider Services telephone number and the additional message of "Please Call Help Desk." Upon review of the cardholder's history, the Representative may be able to grant one (1) time medical exception.

  • August 22, 2013 - Perforomist Inhalation Solution: Effective, Monday August 26, 2013, Providers are advised that Perforomist Inhalation Solution has been added to the PACE list of inhalation Solutions that are billable to Medicare Part B.

  • September 20, 2013 -- Program Compliance Reminder: Providers are reminded that claims will be disallowed on audit if...

  • September 25, 2013 -- Coordination of Benefits (COB) Edit Logic Enhancement: Effective October 5, 2013, PACE will be enhancing the processing system logic to ensure that all D.Ø COB validation edits are applied according to NCPDP guidance. A review of paid claims identified two (2) submission instances that will deny on October 5, 2013.

  • November 27, 2013 -- NON-PARTICIPATING MANUFACTURER - Labeler Code 00064: Healthpoint Ltd., and Smith & Nephew Inc., Biotherapeutics, labeler code 00064 have notified the PACE, CRDP and SPBP programs that they will be terminating their participation in the Commonwealth’s rebate program effective December 6, 2013. Providers may wish to advise cardholders using medications manufactured by this company that beginning Friday, December 6, 2013, PACE, CRDP and SPBP will no longer be permitted to reimburse for any of their products.

  • November 27, 2013 -- Re: Mandate January 1, 2014: Covered Entities must comply with CAQH Phase III CORE® EFT and ERA Operating Rules per Section 1104 of the ACA (Affordable Healthcare Act). This letter is to inform you that Magellan Health Services is presently seeking to comply with the new CMS (Centers for Medicare & Medicaid Services) requirements effective January 1, 2014, as communicated through the CAQH (Committee for Affordable Quality Healthcare) Phase III CORE® EFT and ERA Operating Rules section 1104. The required changes apply to covered entities that use, conduct, or process the v5010 835 transaction and EFT.

  • December 20, 2013 -- Medicare Part D Lists: In early January, listings of the Part D plan chosen for cardholders will be distributed to the pharmacy that the cardholder uses most often. Providers receiving their Remittance Advices by FTP will have the lists posted to the FTP site. Providers using Web RA will have these lists sent to their pharmacy. The intent is to help providers update their records as easily and as accurately as possible.

  • December 20, 2013 -- CAQH (Committee for Affordable Quality Healthcare) CORE® (Committee on Operating Rules for Information Exchange) EFT and ERA UPDATE: On November 27, 2013 all providers were notified that the Program was in the process of making minor changes to the Electronic Funds Transfer (EFT) and the Electronic Remittance Advice (ERA) to comply with the new CMS (Centers for Medicare & Medicaid Services) requirements.

  • January 10, 2014 - Medicare Part D Lists: Listings of the Part D plan chosen for cardholders are being distributed to the pharmacy that the cardholder uses most often. The intent is to help providers update their records as easily and as accurately as possible.

PACE PROVIDER BULLETINS: 2012

  • January 12, 2012 -- Medicare Part D Plans with Premium Agreements: The following Part D plans have premium agreements with the PACE program.
  • March 6, 2012 -- March 31, 2012 D.Ø POSTPONEMENT: Claims submitted for PACE, CRDP, SPBP and all ancillary programs administered by the Department of Aging must continue to be submitted in NCPDP v5.1 past the March 31, 2012 CMS deadline.
  • March 16, 2012 - April 21, Implemetation: On Saturday, April 21, 2012, PACE will begin accepting NCPDP vD.Ø on its new processing platform. Claims submitted for PACE, CRDP, SPBP and all ancillary programs administered by the Department of Aging are to continue to be submitted in NCPDP v5.1 until that date. Claims submitted in D.Ø before April 21, 2012 will deny.
  • March 30, 2012 - Part D Plan BINS: Most PACE/PACENET cardholders have a primary Part D plan. Each year, cardholders have the opportunity to change plans resulting in plan membership updates
  • April 10, 2012 -- April 21, 2012 IMPLEMENTATION REMINDER: As stated in an earlier bulletin, on Saturday April 21, 2012, PACE will begin accepting claims in NCPDP vD.Ø for PACE, CRDP, SPBP and all ancillary programs. Claims submitted in version D.Ø before April 21, 2012 will deny.
  • April 16, 2012 -- PACE Portal: On Saturday, April 21, 2012, the Pennsylvania Department of Aging is introducing a new website: papaceportal.magellanhealth.com. The Pennsylvania PACE portal is designed to assist cardholders, pharmacies, and physicians by providing information about PACE and other pharmacy programs it administers, as well as providing links to Pennsylvania governmental websites.
  • May 4, 2012 -- NCPDP v5.1 Claims: Effective Monday May 7, 2012, claims submitted in NCPDP version 5.1 will deny with NCPDP Error "Ø2: Missing / Invalid Version Number" for the following programs...:
  • May 14, 2012 -- Prescriber NPI Edit: PACE D.Ø specifications require the prescriber's NPI (Prescriber ID field 411-DB) for all claims unless the cardholder's primary plan requires the prescriber's DEA.
  • June 1, 2012 -- Part D 4Rx Identifier Edit: CMS has mandated that by July 1, 2012, all Aprt D sponsors require pharmacies to use current 4Rx data for Medicare Part D drug claim submissions.
  • September 28, 2012 -- NON-PARTICIPATING MANUFACTURERS: The manufacturers identified below have declined to sign a rebate agreement with the Commonwealth of Pennsylvania. Effective Tuesday October 2, 2012 claims submitted for their products will no longer be considered for reimbursement by PACE or CRDP.
  • October 3, 2012 -- FUL (Federal Upper Limit) Pricing: The Program has discovered that the Medical Economics (Red Book) pricing files received in June and July 2012 contained some incorrect FUL prices that impacted reimbursement for PACE, CRDP and SPBP claims. The Program is currently in the process of analyzing these pricing files to identify which FUL prices were incorrect. When this process is complete and the pricing is corrected, all affected claims will be adjusted by the Program.
  • November 2, 2012 - Medicare Part D Plans: Listed below are the Medicare Part D Plans that have been selected as partner plans with PACE for 2013, pending final execution of their Agreements with the Department of Aging
  • November 23, 2012 -- ProDUR Edits: Effective December 3, 2012 claims for cardholders receiving the following pharmaceuticals for the first time will be rejected with NCPDP Error 88.
  • December 11, 2012--Pharmacy's NPI submitted as the Prescriber's NPI: On April 21, 2012, PACE began accepting only NCPDP version D.Ø. In conjunction with this version change, PACE required the prescriber's NPI, not the physician's state license number be submitted in the prescriber field. Note: The DEA number is accepted only when PACE is the secondary payor.
  • December 12, 2012--FUL (Fedderal Upper Limit) Pricing UPDATE: As explained in the October FUL Bulletin, the Program discovered the Medical Economics (Red Book) pricing files received in June and July 2012 contained some incorrect FUL prices that impacted PACE, CRDP and SPBP claims reimbursement.

 

 

Available PACE PROVIDER BULLETINS  for  years 2001-2011