PACE

Provider Bulletin

Highmark Blue RX Basic Medicare Part D

VOIDED CLAIMS

January 19, 2007

The enclosed PACE report contains voided claims that will appear on the PACE Remittance Advice of FEBRUARY 2, 2007. The Program is providing this report for those providers wishing to begin their rebilling process as soon as possible and/or to contact their software vendors for rebilling instructions.

• As stated in the PACE Provider Bulletin of September 29, 2006, claims that should have been billed to Highmark Blue Rx Basic as the primary payer have been voided by PACE. This is a result of transmissions of transactions failing to utilize the appropriate override code referenced below in the memo.
• Claims submitted to PACE as the secondary payer have also been voided when information from Highmark identified incorrect amounts submitted in either the amount of Highmark’s patient copay or Highmark’s payment to the pharmacy.

These claims may be re-submitted to Highmark as the primary payer following Highmark’s instructions (below) for resubmitting claims during the transition period.

In order for Providers to reprocess their claims they will need to submit claims through BIN number 610014 utilizing one of the following processes:

• For claims with a Date of Service of 90 days old or less the Provider will need to adjudicate their claims to Medco.

If Providers submitting these claims to Medco receive a reject message of rejection 70 = Product/Service Not Covered or 75 = Prior Authorization Required with an alternate message of “TEMP FILL of 34 D/S ALLOW WITH PA/MC = 11111,” the Provider needs to resubmit the claim with a PA/MC code of 11111 in the Prior Authorization field (416-DG.) If the claim of less than 90 days old continues to reject, and you are not able to resolve the rejection, contact the Medco Pharmacy Services Helpdesk at 1- 800-922-1557.

• For claims with a Date of Services over 90 days old, but less than 180 days the Provider will need to adjudicate these claims to Medco. The claim will reject for 81 = Claim Too Old. The Provider will then need to submit the “Claim Too Old” override request on the Medco Pharmacist Resource Center. The following is a overview on how to access the web site.

o To access the Pharmacist Resource Center (PRC) website go to www.medco.com/rph and enter your User ID and Password. If you do not have a user ID or password one can be obtained on the website. Simply select “Click here to register today” on the 1^st page. To set up a User ID and password you will need to enter the Pharmacies Services Provider ID (NCPDP #), Pharmacy’s Medco Account number, Retail Pharmacy’s zip code and an RX number you recently submitted to Medco within the last two days.

§ If you do not know your Pharmacy’s Medco Account number, this can be obtained through option 5, then option 1 on the Medco Pharmacy Services Automated Phone System at 1-800-922-1557

o Once logged into the Pharmacist Resource Center website select “Contact the Helpdesk” on the left side of the website. Then select “A specific prescription claim” to submit Claim Too Old override requests.

o On the “specific prescription claim” page the user will need to enter their information, the patient information and the Rx numbers that rejected for Claim Too Old for the listed patient.

§ 10 claims can be listed on each Claim Too Old override request per patient.

o The claims will be processed within 72 hours. Temporary fill override will be applied to your claim by Medco.

o A fax will be sent to the requester within one week of the website submission.

§ The status of the claim can also be obtained through the Processed Claim Inquiry and Rejected Claim Inquiry link on the Medco Pharmacist Resource Center website.

If you have difficulty submitting claims, you may contact Medco Pharmacy Services at 1-800-922-1557 for assistance.

Claims greater than 180 days old cannot be re-submitted.

• Pharmacy Providers will need to follow standard COB claims submissions procedures.

To permit PACE to be billed as the secondary payer, the Program has extended the on-line submission time for these claims up to 180 days from the date of service of the claim.

NOTE: This 180 day extension applies only to claims identifying Highmark as the primary payer.

PACE related submission questions may be directed to PACE Provider Services at 1-800-835-4080