PACE

PROVIDER BULLETIN

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:

 

·        An OTHER COVERAGE CODE of “4”

                                                                  AND

·        NO Patient Pay Amount submitted

                                                                  AND

·        NO TPL Amount submitted.

 

Many providers receiving this edit resubmitted the claim correctly-- to First Health MDP as the primary payer with the remaining patient pay amount submitted to PACE .

 

Some providers resubmitted the claims with an OTHER COVERAGE CODE of “3”— “Other Coverage Exists –claim not covered.” The entry of this code by the provider states to the Program that the primary insurance (MDP) was billed and denied the claim.

 

Claims paid by PACE containing an Other Coverage Code of 3 for drugs that are compensable by MDP for cardholders who have not exhausted their MDP benefit are subject to disallowance.

 

 

 

Providers are to bill First Health MDP BEFORE billing PACE.

 

Questions may be directed to PACE Provider Services at

 

1-800-835-4080.

 

 

 

PPB-05-021