PACE

PROVIDER BULLETIN

September 23, 2005

Denying MDP Claims at Point-Of-Sale

Over 10,000 First Health MDP enrolled cardholders have never used their Medicare Discount Program benefit.

PACE denies claims that should be billed to MDP with the NCPDP error code 41; PACE error code 043 — “Submit bill to Primary Payer.”

PACE claims’ history identifies claims paid by PACE as the only payer as submitted with OTHER COVERAGE CODES of “3” or “4”.

Claims submitted to PACE with an OTHER COVERAGE CODE of “3”— “Other Coverage Exists –claim not covered” are valid only when the primary insurance (MDP) denies the claim with a response that the drug is not compensable.

Claims submitted to PACE with an OTHER COVERAGE CODE of “4”---“Other Coverage Exists—payment not collected” are valid only when the primary insurance (MDP) coverage is exhausted.

Effective Tuesday October 4, claims submitted for First Health MDP cardholders who have never used this benefit will DENY if submitted with:

· An OTHER COVERAGE CODE of “4”

AND

· NO Patient Pay Amount submitted

AND

· NO TPL Amount submitted.

Claims will deny with NCPDP error 41 “Submit bill to Primary Payer”; PACE error 44 “Bill MDP”.

Providers are to bill First Health MDP BEFORE billing PACE.

Questions may be directed to PACE Provider Services at

1-800-835-4080.

PPB-05-020