PACE

MEDICARE DISCOUNT PROGRAM SPECIFICATIONS

UPDATE

 

May 28, 2004

 

Providers: Due to the recent redefinition by NCPDP of Field 433-DX, “Patient Paid Amount Submitted,”  we are revising the previously distributed Medicare Discount Program (MDP) specifications.

 

Providers filling prescriptions for PACE cardholders enrolled in the Medicare Discount Program (MDP) will be sent complete updated v5.1 specifications to replace those dated May, 2004.

 

In the interim, PACE Providers are advised that effective June 1, 2004, claims received for any PACE cardholder presenting both a Medicare Discount Card and a PACE card will process as follows: 

 

To bill PACE for the amount indicated by the primary payer (the Discount Program in which the cardholder is enrolled), providers should access the following data fields:

 

Claim Segment

·        Until the $600.00 Medicare benefit is exhausted, providers are to enter “2” --“Other Coverage exists -- payment collected,” in NCPDP Field 308-C8,  “Other Coverage Code”.

·        Upon notification from the Primary Payer that the $600.00 Medicare benefit is expended, providers should change the “Other Coverage Code” to “4” – “Other Coverage exists - payment not collected.”

 

COB Segment

·        Enter “03” In NCPDP Field 339-6C, “Other Payer ID Qualifier”.

·        Enter the BIN number received from the primary payer.

 

Pricing Segment

·        When using the “Other Coverage Code” value of “2” or “4”, enter the

Co-pay amount indicated by the MDP response in NCPDP Field 433-DX, “Patient Paid Amount Submitted.”

 

NOTE:

Providers submitting claims for PACE cardholders who are eligible for the Medicare $600.00 benefit and who are enrolled in the First Health Services discount card plan will receive a response from PACE indicating that $0.00 is due from the cardholder until the $600.00 is exhausted.  Claims received from other Discount plans will contain the appropriate PACE copay.

 

 

PPB-04-011