July 27, 2007
July 31, 2007 the following edits will be implemented:
for cardholders enrolled in a Medicare Part D plan, where PACE, CRDP or
SPBP is being billed for the entire claim amount (i.e., cardholder is in
deductible, donut hole, claim denied by primary payer or CMS excluded
drug) and the claim is being submitted with an Other Coverage Code of 3
–7, the following edits have been reapplied:
maximum of 100 (tablets/capsules) for PACE and CRDP
supply maximum of 30 for PACE and CRDP; 34 for SPBP
State license numbers required for prescriber
claims submitted to PACE, CRDP or SPBP from Medicare Part D plans must
contain the PA license number UNLESS the prescriber qualifier (field
466-EZ) indicates the prescriber’s ID is his/her NPI (prescriber qualifier
= 01) or DEA (prescriber qualifier = 12.)
Part D claims submitted to PACE as the secondary payer must contain the
BIN and PCN of the Primary payer. Claims with incorrect or missing BIN’s
and/or PCN’s will reject.
- Claims rejected by Highmark
solely for NCPDP Error 76, “Plan Limitations Exceeded,” will also be
rejected by PACE, CRDP or SPBP with the same NCPDP error. This error message
will be accompanied with the text message of “SUBMIT TO HIGHMARK WITH
HIGHMARK SPECIFIC CODE”.
verify with the physician that the dosing is correct, document this fact for
their records and resubmit to Highmark with the override code of “02”. This
code is to be entered into the “submission clarification code field” also
called the “Rx denial override” field.
- As requested by the pharmacy community, claims for A-rated brand
products submitted with a DAW (Dispense As Written) Code of 5
--“Substitution Allowed, brand drug dispensed as generic,” will deny with
PACE 708 “Generic Substitution Error”;
NCPDP 70, “Product /Service
not covered” unless a medical exception is on file.
- SWIF (State Worker’s Insurance
Fund) claims are subject to the early refill edit criteria.
Questions should be directed to
Provider Services at