June 9, 2006


Primary Plans


Prior Authorization


Increasing numbers of PACE and PACENET cardholders have Medicare Part D plans. As required by regulation, PACE and PACENET are billed as the secondary payer.


Some Part D plans have formularies requiring a prior authorization for the primary plan to reimburse the pharmacy. This requirement causes concern for both the cardholder and the provider.


To address this issue, PACE is requesting that providers call Provider Services when a claim is denied by the primary payer for NCPDP Errors 75, “Prior Authorization Required” or 3W, “Prior Authorization in Progress.”


The provider will be asked to confirm the prescriber’s name and the Part D Plan being billed. We will also ask for the prescriber’s telephone number.


Providers will be instructed to dispense the medication and bill PACE with an Other Coverage Code of 3, “Other Coverage Exists, Claim not Covered”


PACE will act on behalf of the cardholder to facilitate the Prior Authorization process to insure that the cardholder does not go with out medication.  


This new policy will insure that cardholders receive their medications that providers avoid claims being disallowed on PACE audits and that Part D plans reimburse when appropriate.


Providers should call 1-800-835-4080 with any questions about this policy.