PACE

PROVIDER BULLETIN

April 21, 2006

OTHER COVERAGE CODES

Effective immediately, providers are advised that claims submitted to PACE/PACENET with Other Coverage Codes are subject to a desk level audit.

The Provider Agreement, Section I, Provider Responsibilities, states:

“C. The Provider agrees to maintain all records necessary to disclose the extent of services the Provider furnishes to Cardholders.

D. The Provider agrees to furnish the Department of Aging or its agents with any information it may request regarding prescription records and payments claimed by the Provider.”

Additionally, the Audit Section of PACE Provider Manual, page VIII.1 states,

“D. Maintenance of Other Records

1. Other records necessary to disclose the full nature and extent of prescription drugs, both covered and not covered by the PACE Program, which were dispensed by a provider shall be retained for four (4) years and shall be available for review and copying by authorized Commonwealth officials or their authorized agents within seven (7) business days of a request for the records. These records include purchase orders and invoices, billing records, computer user manuals and computer security information.”

The Program will be conducting random desk level audits requesting documentation to support the use of Other Coverage Codes of:

• “03” Other Coverage Exists – claim not covered

· “04” Other Coverage Exists – payment not collected

• “05” Managed care plan denial

· “06” Other Coverage Exists – payment denied -- not a participating provider

· “07” Other Coverage Exists – not in effect on date of service

The preferred documentation will be a copy of the Other Coverage plan’s response either denying payment (OCC’s of 03, 05, 06 or 07) or identifying the amount due from the cardholder (OCC 04).

Questions may be directed to Provider Services at

1-800-835-4080