PACE

 Provider Bulletin

Highmark Blue RX Basic Medicare Part D

Transition Billing

September 29, 2006

 

Paid claims’ history for PACE/PACENET cardholders also enrolled in the Highmark Blue RX Basic Medicare Part D plan reveals many providers are not following Highmark’s instructions for resubmitting claims during the transition period.

Note:  The Highmark Blue Rx Basic transition period extends from September 1, 2006 through December 31, 2006.

 

Failure to follow Highmark’s procedure results in PACE being the primary payer of the claim rather than Highmark Blue RX Basic.

 

According to the representatives at Highmark:

 

 


Providers who receive a reject message from Medco of either:

70 = Product/Service Not Covered, or
75 = Prior Authorization Required


also receive an alternate message stating:   TEMP FILL of 34 D/S ALLOW WITH PA/MC = 11111.

 

These rejected claims are to be resubmitted to Highmark for payment with the PA/MC code of 11111 in the Prior Authorization field (416-DG.)

 

Should the claim still reject, providers are asked to contact the Medco Help Desk at 1-800-922-1557 for assistance.

 

 

Providers who have not followed these instructions and have billed PACE/PACENET as the primary payer are requested to reverse and rebill these claims to Highmark.

 

PACE will review claims’ history for Highmark Blue Rx cardholders in late October. On November 1st, those remaining claims that should have been billed to Highmark will be reversed by the Program. Following this action, Providers can bill the primary payer, Highmark and then PACE as the secondary payer.

 

We appreciate your cooperation in the resubmission of these claims.  Please contact Provider Services at 1-800-835-4080 should you have any questions or concerns.