PACE

Provider Bulletin

September 23, 2009

Valid Claim Data

 

The May 2009, Provider Bulletins (included with this transmission) reminded providers that the responsibility for the validity of their claim data lies with them.   

 

These two bulletins stated that post payment reports were showing:

 

  1. incorrect amounts appearing in the Patient Pay Amount field (field 433-DX)
  2. numerous claims submitted with false data, i.e., primary reject reasons, accompanying  claims submitted with an OCC  3, to have PACE pay the claim.

 

This submission of invalid data causes both incorrect reimbursement and overcharging of copays to the cardholders.

 

Many of the submission errors have been corrected, but PACE continues to see claims submitted for payment accompanied by error codes that are either:

  1. not being generated by the primary or
  2. are inconsistent with the information provided to PACE by the primary payer.  

 

Beginning September 28th, providers will be called when claims submitted the previous day with an OCC 3 (claim denied by the primary) and accompanied by the NCPDP Error 52Non-Matched Cardholder ID –conflicts with primary coverage information on PACE files.

 

Provider representatives will:

·       review the Program’s primary plan information with the provider

·       when necessary, request the claim be voided from PACE (as the primary payer), resubmitted to the primary, followed by resubmission to PACE as the secondary.

 

Reports will be reviewed the following day to insure provider compliance.

PACE will reverse any incorrect claim(s) that were not voided.

 

Note:

      Any incorrect copay overpayments are to be refunded to the cardholder.

      Providers are prohibited from billing cardholders if they choose not to rebill an incorrect submission resulting in a Program void.

 

PACE continues to review claim submissions. Providers with a pattern of submitting invalid data to receive a paid claim are being referred for audit.     

 

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