PACE

PROVIDER BULLETIN

April 14, 2006

MEDICARE PART D Logic Revisions

 

 

Effective Thursday, April 20, 2006, PACE is implementing 2 edits to assure the accuracy of data received from Providers submitting Part D claims to PACE as the secondary payer. Providers should be aware that these edits will also apply to all other Programs under the auspices of the Department of Aging.

 

       Field

       3Ø8-   

         C8

OTHER COVERAGE CODE

ØØ = Not specified.

Ø1 = No other coverage.

Ø2 = Other coverage exists – payment collected.

Ø3 = Other coverage exists – claim not covered.

Ø4 = Other coverage exists – payment not collected.

Ø5 = Managed care plan denial.

Ø6 = Other coverage exists payment denied- not a          participating provider.

Ø7 = Other coverage exists – not in effect on D.O.S.

 

IMPORTANT:

  Ø8 = “Claim is billing for a copay”  is not supported.

 

Claims containing dollar amounts in field 431-DV, “Other Payer Amount Paid”, (also referred to as Third Party Liability [TPL]) must have an Other Coverage Code (OCC) of “2.”  Claims with dollar amounts in the “Other Payer Amount Paid” field with an OCC of 0, 1, 3, etc., will deny with PACE Error 025, NCPDP Error 13, “Missing/Invalid Other Coverage Code”.

See the following example.

 

Provider Submitted Information

 

Program Response: Claim Denied

“M/I Other Coverage Code”

Other Coverage Code:  3

 

Usual & Customary: $125.00

Patient Paid Amount: $0.00

Other Amount Paid (TPL) $40.00

PACE Copay Amount: $0.00

 

Program Payment: $0.00

 

Note: Claims with dollar amounts in Field 433 DX and an OCC of 3 through 7, indicating that other coverage exists, but the patient is responsible for the payment, will continue to process as before.

 

See Example 2 on the back of this page.

 

 

 

 

 

-OVER-

Claims paid by all Part D prescription plans have either a fixed or percentage cardholder copay. Therefore, claims submitted to PACE as the secondary payer containing dollar amounts in field 431-DV, “Other Payer Amount Paid”, (the TPL amount), must also have a dollar amount in the “Patient Paid Amount” field, 433-DX. See Example 1.

 

Premise: The PACE allowed amount for single source Drug X is $70.00; the claimant is a PACE cardholder.

 

Example 1

Provider Submitted Information

 

Program Returned Response

Other Coverage Code:  2

 

Usual & Customary: $125.00

Patient Paid Amount: $30.00

Other Amount Paid (TPL) $40.00

PACE Copay Amount: $9.00

 

Program Payment: $21.00

 

Conversely, claims for which no money is received from the primary (there is 0 or blanks in the TPL field) will not be subject to this edit. See Example 2.

 

Example 2

Provider Submitted Information

 

Program Returned Response

Other Coverage Code:  4

 

Usual & Customary: $125.00

Patient Paid Amount: $100.00

Other Amount Paid (TPL) $0.00

PACE Copay Amount: $9.00

 

Program Payment: $61.00

(Note: Program logic calculates payment on the lower of the allowed amount [$70.00] or the Patient Paid Amount [$100.00] minus the applicable copay.)

 

The Program will process claims received with TPL amounts and no amount entered in the Patient Paid Amount Field 433-DX since it is possible that the primary plan’s copay is being waived. The claim will be adjudicated with $0.00 in this field. Program logic will result in $0.00 Program payment and $0.00 Program copay. See Example 3.

 

Example 3

Provider Submitted Information

 

Program Paid Claim Response

Other Coverage Code:  2

 

Usual & Customary: $125.00

Patient Paid Amount: Provider fails to enter any dollar amount; default is 0.

Other Amount Paid (TPL) $40.00

PACE Copay Amount: $0.00

 

Program Payment: $0.00

(Note: Program logic calculates payment on the lower of the allowed amount [$70.00] or the Patient Paid Amount [$0.00] minus the applicable copay.)