PACE

Provider Bulletin

July 27, 2007

PROGRAM CHANGES

Effective Tuesday, July 31, 2007 the following edits will be implemented:

• Claims 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:
• Quantity maximum of 100 (tablets/capsules) for PACE and CRDP
• Day supply maximum of 30 for PACE and CRDP; 34 for SPBP
• Pennsylvania State license numbers required for prescriber
• ProDUR edits.

• Secondary 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.)

• Medicare 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”.

Pharmacists should 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

1-800-835-4080.