PACE
PROVIDER BULLETIN
December 2007
CHANGES FOR 2008
In January 2008, the
Program will be implementing the following:
Ø
Approximately half of the previously
assigned cardholders will be in a new or different Part D plan.
Ø
PACENET Cardholders enrolled into
one of the 5 Partner plans will have their premium (deductible) included with
the amount they pay to the provider.
Ø
PACE will upload the Part D partner
plans’ formularies into the Program’s system.
PACE Part D Partner
Plans for 2008
Effective January 1, 2008, approximately 116,000
PACE/PACENET cardholders will be moved into different Part D partner plans either
because of changes in partner plans or a cardholder’s medication needs may be
better served by a different partner plan. Nearly 16,000 new PACE/PACENET
cardholders will be assigned to a Partner plan.
To ensure that the correct Part D
plan is being billed as the primary, PACE is providing this cumulative list
(enclosed) of all cardholders currently enrolled in the selected Medicare Part
D plans who frequent your pharmacy. This list contains the PACE cardholder’s
name, PACE card number, the Medicare Part D insurer’s name, BIN and PCN and the
cardholder’s ID, when available. At the
time of this printing, PACE had not received all of the partner plans identification
numbers.
Providers may obtain this
information by using the E1 transaction or calling the appropriate Part D partner
plan at the number below:
|
Plan |
Phone
Number |
Available |
|
|
|
|
|
AmeriHealth
Advantage (IBC) Rx Option 1 |
1-888-457-3007 |
8AM--8PM;
365 days |
|
MemberHealth
Community CCRx Basic |
1-866-684-5353 |
8AM--8PM;
365 days |
|
RxAmerica Advantage
Star Plan |
1-877-GET-PACE (1-877-438-7223) |
24 hours; 365 days |
|
Silverscript |
1-888-832-6153 |
24 hours; 365 days |
|
Ovations/UHC AARP Medicare Rx
Saver |
1-877-710-5083 |
24 hours; 365 days |
PROVIDERS SUBMITTING CLAIMS CONTAINING INCORRECT PART D PARTNER PLANS’ BIN
NUMBER WILL HAVE THE CLAIMS DENIED WITH THE NCPDP REJECT CODE “41”, “BILL CLAIM
TO PRIMARY PAYER.”
§ These denials will be accompanied by
the primary plan’s name, the BIN number and PCN in response field 504-F4. The Member’s ID will also be returned IF this information has been received
from the plan.
§ Providers should ask PACE/PACENET
cardholders for their PART D information to verify if they have entered into a
new plan and to obtain their plan identification number.
§ Although all 5 partner plans have a
$275 deductible, each plan must be billed to ensure that the claim amount is
recorded for the TrOOP (True Out Of Pocket
expense.) Failure to bill the primary plan will result in the cardholder not
having the cardholder’s TrOOP accurately calculated.
§ Providers submitting invalid Other
Coverage Codes (OCC’s) and deny reasons to have the Program reimburse for the
claim could have these payments disallowed on audit.
§ PACE cardholders are continually
enrolling in Part D plans; therefore, this list cannot be all inclusive.
Providers should continue to inquire if a PACE/PACENET cardholder has a
Medicare Part D card.
PACENET Cardholders enrolled in
a Part D partner plan
Cardholders who were enrolled in a Part D Partner plan received
a letter which, in part, stated,
“If you are enrolled in PACENET and this Part D plan at the same
time, you will receive the same
benefits, but you will pay the Part D’s plan premium at the pharmacy each
month. The premium amount will be …..( the amount of the assigned plan’s
premium.)”
Some cardholders mistakenly envisioned making payments at
the pharmacy. The intended interpretation was to inform PACENET cardholders
enrolled in one of the 5 partner plans that they will have the plan’s premium collected
by including it in the amount they pay for the prescription at the
pharmacy. That is, when the claim is
submitted to the program, the cardholder will “pay” the premium by having it included
with the copay.
The following examples provide
insight into how this process will work.
§
The premium (deductible) does not
begin until the first time the PACENET card is used.
On January 1, Paula PACENET is
enrolled in Ovations which has a premium of $25.20 and a deductible of $275.00.
Paula does not use her PACENET card until June 2, 2008. On June 2nd,
Paula gets a brand prescription which
is submitted to the Program with a U&C of $125.00. She pays the PACENET copay of $15.00 plus the Ovations premium (deductible)
of $25.20 for a total of $40.20.
The next day, June 3rd,
Paula gets a second prescription for a $25.00 generic. Since the prescription
is in the same month, Paula only pays the PACENET copay of $8.00.
§
Once the deductible begins, it will
accumulate.
Paula doesn’t need any more
prescriptions until November. On November 15th, Paula has a
prescription filled for a brand which is submitted to the Program with a
U&C of $150.00. Since Paula still
has not met her $275 deductible, Ovations pays $0; PACENET will be responsible
for payment.
PACE calculates the total
reimbursement due to the Provider from all sources is $130.00.
Paula has not had any prescriptions filled
since June, therefore she has 5 months of premiums (deductibles) to pay -- July,
August, September, October and November-- totaling $126.00 ($25.20 monthly x 5
months.) Additionally, Paula also has
the PACENET copay of $15 for a brand drug.
Since the total allowed reimbursement
is $130.00, the PACENET response to the pharmacy will be that Paula only
pays $130 ($126.00 in accumulated premiums + a $4.00 copay.) The copay is $4.00,
not $15. The cardholder will not pay more than the calculated allowed amount
which is $130.00.
§
Although the deductible accumulates,
the PACENET cardholder will not pay more than the Program calculated
reimbursement.
Paul PACENET is enrolled in RxAmerica
with a $275 deductible and a monthly premium (deductible) of $20.40. Paul gets a prescription for generic Bumex
for $24.99 in January, 2008. PACE calculates the total reimbursement due the
Provider from all sources is $12.45.
Paul pays a total of $12.45 which is
credited towards the monthly deductible (premium) of $20.40. The $12.45 appears
in the Patient Pay Amount (Field 505-F5) and Amount Applied To Periodic Deductible
(Field 517-FH.) In this case the amount
returned in Amount of Copay/Coinsurance (Field 518-FI) is $0.00. The entire amount due from Paul, which is
applied to the premium (deductible), is $12.45.
In February, this prescription is refilled.
Again Paul only pays $12.45. In this
example, this is the only prescription that Paul needs and he has it filled
every month. Every month he only pays $12.45 ($8.00 + $4.45.)
PACENET
Cardholders not enrolled in a Part D partner plan
√ PACENET cardholders not
enrolled in one of the 5 partner plans will be billed by the plan. The
cardholder will pay the premium
directly to the plan.
√ PACENET cardholders
not enrolled in any Part D
plan will have the 2008 Benchmark premium of $26.59 assessed (deducted) at the
point of sale. Note: This is the same procedure currently in place.
Part D Partner Plans’ Formularies
Ø In late
December 2007, the Part D partner plan’s formularies will be uploaded (entered)
into the Program’s system.
Ø Effective
January 1, 2008, PACE will compare claims denied by the primary payer and submitted
to PACE with an Other Coverage Code (OCC) of “3” accompanied by the NCPDP error
code “70”, “NDC not on file” to the respective plans’ formulary.
Ø During
January, if the NDC submitted on the claim is found to be on the Part D plan’s
formulary, the claim will be processed for payment, but the paid response will
contain the NCPDP code “6E”, “Missing Invalid Other Payer Reject Code” as an
EOB.
Ø THIS EOB OR “SOFT EDIT” WILL BE IN EFFECT ONLY FOR JANUARY.
BEGINNING
FEBRUARY 2008, CLAIMS IDENTIFIED AS
BEING INCORRECTLY SUBMITTED TO THE PROGRAM WITH AN OCC “3” AND NCPDP ERROR CODE “70” WILL BE DENIED BY
PACE WITH NCPDP ERROR CODE “6E”-- “MISSING/INVALID OTHER PAYER REJECT CODE.”
Ø Providers
should examine their real time paid responses for this information beginning
January 1.
Ø This EOB
will appear on both the electronic and paper Remittance Advice beginning January 18, 2008.
Ø It may be
prudent for providers to inform their software vendors of this future
enhancement.
********************
PACE, CRDP, SPBP and
ancillary Plans’ BIN and PCN’s
Effective
January 1, 2008, claims containing incorrect BINs and PCNs will be denied.
Questions may be directed to Provider Services at
1-800-835-4080