PACE

Provider Bulletin

February 13, 2004

CLARIFICATIONS

 

PACENET MONTHLY DEDUCTIBLE:

 

New PACENET legislation changed the annual deductible into a rolling cumulative amount. That is, the annual deductible was divided into 12 monthly accumulating deductibles of $40.00.

 

The deductible period begins on the first day of the month and ends on the last day. A PACENET cardholder’s deductible period begins the month his/her PACENET eligibility begins.

 

EXAMPLES:

 

  1. A PACENET cardholder’s coverage begins in JANUARY, 2004. The cardholder does not use the card until MARCH. The deductible for March would be $120.00. $120 must be paid (January = $40 + February = $40 + March = $40.)

 

  1. A PACENET cardholder’s coverage begins in JANUARY, 2004. Cardholder uses and meets the deductible in JANUARY. Cardholder doesn’t use the card again until JULY when they go to the pharmacy with a prescription for a drug with a U&C of $150. PACENET will direct the pharmacy to bill the cardholder for the U&C of $150. That $150 will be applied toward the deductible of $240 that kept accumulating during the months the card wasn’t used and the deductible wasn’t met—February through July (6 months X $40 = $240). The remaining amount of $90 will be carried over and added to the deductible amount for August.

 

  1. A PACENET cardholder’s coverage begins in JANUARY, 2004. They receive 2 single source prescriptions with a total U&C of $183.95 on January 31st. Cardholder pays $40 monthly deductible + the single source copays of $15 each ($40+$15+$15) for a total of $70 on January 31st. The same cardholder returns the next day on February 1st with a prescription for a generic medication having a U&C of $28.33 Cardholder pays $28.33 because prescription is dispensed on February 1, which begins a new deductible month.  They would have a remaining deductible amount of $11.67 for February.

 

SUBMISSION TIME

 

PACE providers have been required to submit claims on-line prior to dispensing the medication since 1991. Until January 1, 2004, however, the Program permitted original claims to be billed up to  90 days from the date of service of the claim. Effective January 1, 2004 the submission time for original claims submission was reduced to 30 days. The 30-day submission time for original claims still allows for software interruptions or processing anomalies.

 

NOTE: Providers can use the NCPDP re-bill transaction (Transaction B3) to re-bill claims up to 90 days from the date of service. The re-bill transaction accesses the previously adjudicated claim and permits the provider to modify the earlier submission in one transaction.  

Providers voiding a claim (B2 transaction) over 30 days from the service date, then submitting it again (B1 transaction) will have the claim denied. B1 transactions identify the submission as an original claim. Original claims must be received within 30 days from the date of service.    

 

Questions may be directed to Provider Services at 1-800-835-4080.

PPB-04-004