PACE

PROVIDER BULLETIN

February 24, 2006

MEDICARE PART D PRESCRIPTIONS

and

PACE/PACENET

CMS has identified 62,000 PACE/PACENET Cardholders currently enrolled in a Medicare Part D Plan. The majority of these cardholders have been enrolled by Highmark.

Virtually all PACE/PACENET cardholders will eventually be enrolled in both PACE/PACENET and a Medicare Part D plan.

To avoid claims being disallowed on audit, Providers must bill Medicare Part D plans before billing PACE/PACENET.

PACE should only be receiving claims for:

• Co-pays higher than PACE/PACENET co-pays

(Submit the claim to PACE/PACENET as the secondary payer with the Medicare Plan D co-pay in field 433- DX)

• Cardholders not eligible for Medicare Part D
• Cardholders not yet enrolled in a Medicare Part D plan
• Prescriptions received during a plan’s deductible if there is a deductible
• Claims not on the Medicare Part D plan’s formulary
• Claims excluded for payment by Part D
• Prescriptions received during the “donut hole.”

Providers unsure if a cardholder is enrolled in a Medicare Part D plan should use the E1—Eligibility Transaction.

The electronic query (E1) will go through the pharmacy's usual switch to NDCHealth, which the Centers for Medicare & Medicaid Services selected to be the facilitator to keep track of beneficiaries' eligibility and their true out-of-pocket (TrOOP) costs. The query will include patients' date of birth, first name, last name, sex, zip code, and cardholder identification, which can be their Medicare Part A or B number or the last four digits of their Social Security number.

Providers should ask their software vendors if they support the E1 transaction and whether a new agreement is needed to use the system,

Questions may be directed to PACE Provider Services at

1-800-835-4080