August 18, 2006
BILLING THE PRIMARY PAYER
On September 1, 2006, over 150,000 PACE/PACENET cardholders will be enrolled in the Part D plans listed below.
PACE legislation requires that cardholders enrolled in a Part D plan must use providers in that plan’s network. Providers NOT enrolled in the Part D plans listed below and who attempt to bill PACE/PACENET instead of the Part D plan will have the claim denied.
· AmeriHealth Advantage (IBC) Option 1
· First Health Premier
· Highmark BlueRx Basic
· Humana –Standard and Enhanced
· MemberHealth Community Care Rx Basic
· Ovations: United Medicare Med Advance and AARP Medicare RX
· PacifiCare Saver
On September 1, 2006, PACE will deny claims for these 150,000 Part D cardholders and over 60,000 MA-PD cardholders if the Part D or MA-PD plan has not been billed before PACE/PACENET. These denials will be accompanied by the Primary Plan’s Member ID, the BIN number and PCN in response field 504-F4.
Providers should be able to readily access this response field to properly bill the primary payer. Any questions concerning access to this field should be directed to your software help desk.
Additionally, PACE currently edits for increasing numbers of PART D plans other than the 7 listed above. The E-1 transaction available through Per-Se’® enables providers to obtain a cardholder’s member ID. Providers unfamiliar with this transaction should contact their software provider for information.
Questions should be directed to Provider Services at: