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.

 

 

Ø     Providers submitting PACE, PACENET, CRDP, SPBP1 and SPBP2 claims must use the Processor Control Number (PCN) (Field 104-A4) of  ØØØØ1Ø2286.

 

 

Ø     Claims submitted to CF, SB, MSUD, PKU, PAP or SWIF are to use Processor Control Number (PCN) of ØØØØ6822Ø1.

 

 

Ø     Claims submitted to PACE/PACENET, CRDP, CF, SB, MSUD, PKU, SPBP, PAP or SWIF MUST contain the BIN of 002286.

 

 

Ø     Auditors will be examining records to insure the date the prescription was written does not exceed six months from the dispensing date.

 


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. 

 

 

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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