PACE

PROVIDER BULLETIN

March 10, 2006

BILLING MEDICARE PART D CLAIMS

 

Medicare Part D plans:

·        may or may not have a deductible

·        may have a fixed or predetermined copay for brands or generics

·        may have a percentage of the price returned as the cardholder copay.

 

When a primary Medicare Part D plan is billed, the claim will be either paid or denied.

 

Providers are to bill PACE for Medicare Part D plans following the same procedure used for the various Medicare Discount plans.

 

PAID CLAIM

 

PAID Response contains:

·        the amount to collect from the cardholder

·        the amount the plan is paying.

 

1) To bill PACE/PACENET as secondary payer when payment is received:

·        Enter Other Coverage Code of “2”

·        Enter the amount returned by the primary payer to be collected (the Medicare Part D plan’s copay) from the cardholder in the Patient Paid Amount Field (Note: Software vendors: This field is 433-DX)

·        Enter the amount paid by the other payer.

 

QUESTION:  Do I have to bill PACE as the secondary if the PART D’s plan is less than the PACE copay?

 

ANSWER: No. If the Part D plan’s copay is less than $6.00 (generic) or $9.00 (brand/single source), there is no reason to bill PACE. However, if PACE is billed, the Medicare Part D plan’s copay must appear in the Patient Paid Amount Field in addition to the Medicare Part D plan’s payment appearing in the Other Payer Amount field.

 

IMPORTANT: When a Medicare Part D claim is billed to PACE with an amount entered in the OTHER PAYER AMOUNT PAID field (Field 431-DV), the Part D plan’s copay MUST be entered in the Patient Paid Amount field (field number 433-DX).

 

 

--OVER--


 

QUESTION:  Do I have to bill PACENET as the secondary if the Medicare Part D’s copay is less than the PACE copay?

 

ANSWER: Yes. To accurately accumulate the cardholder’s PACENET deductible, the program must receive a record of the out of pocket expense. During the deductible phase, this amount will be recorded. The PACENET response will be that the Part D copay is to be collected. 

 

2) To bill PACE/PACENET as Secondary payer when no payment is received because the cardholder is in the deductible phase or the person has reached the “donut hole,” your system (depending on your software) should:

 

EXAMPLE A

 

·        Enter an Other Coverage Code of “4” –“Other Coverage Exists-payment not collected”

·        Enter the amount to be collected from the PACE/PACENET cardholder in the Patient Paid Amount field. This should be the amount the provider billed to the Part D plan. (Note: Software vendors: This field is 433-DX.)

 

or

 

EXAMPLE B

 

·        Enter an Other Coverage Code of “4” –“Other Coverage Exists-payment not collected”

·        Enter your Usual and Customary.

 

DENIED CLAIM

 

Bill PACE/PACENET as secondary payer when the claim is denied because:

·        the pharmaceutical is not on the plan’s formulary,

·        the request for the Plan’s prior authorization was denied or

·        the provider does not participate with the Part D plan.

 

You or your system should:

·        Enter the applicable Other Coverage Code – 3,5, 6 or 7

·        Enter your Usual and Customary.

 

 

 

Questions should be directed to Provider Services at

1-800-835-4080.