PACE

Provider Bulletin

May 12, 2006

June 20, 2006 PACE Payer Specification Revision

Please replace page 8 and 9 of your PACE NCPDP v5.1 PAYER SPECIFICATIONS with the accompanying revision.

Although this information is being sent to all known PACE software vendors,

it remains the provider’s responsibility to ensure their software vendor is aware of this future change.

Effective Tuesday, June 20, 2006 all claims submitted to PACE, CRDP, Spina Bifida, Cystic Fibrosis, MSUD, PKU, and SPBP as the secondary payer must contain:

• the BIN of the primary payer in Field 340-7C—Other Payer ID
• the deny code, if the Other Coverage Code is 3,5,6 or 7, received from the primary payer in Field 472-6E—Other Payer Reject Code.

Secondary claims received with an OCC of 03, 05, 06 or 07 without a deny code will reject with NCPDP Error 6E, “Missing/Invalid Other Payer Reject Code.”

IMPORTANT: Claims submitted to PACE with a questionable or correctable deny code received from the primary, may be rejected at point of sale or disallowed upon further review.

Examples:

• NCPDP Error 1C – “M/I Smoker/Non-Smoker Code” received from the primary payer is correctable. Claim will be denied or disallowed.
• NCPDP Error 75 “Prior Authorization Required.” The Primary Plan’s prior authorization policy is to be followed. Claim will be denied or disallowed.

Other Coverage Codes affected:

Ø3 = Other coverage exists – claim not covered.

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.

Questions should be directed to Provider Services at

1-800-835-4080.