PACE

Provider Bulletin

Will Call Bin

Spot-Check

May 2, 2008

 

The Department is conducting unannounced spot-checks of pharmacies’ “Will Call Bins” to insure that claims paid for by the Commonwealth of Pennsylvania have been received by the cardholder.

 

      Claims submitted to PACE for prescriptions not received by the cardholder violate   Section   22.82. False or fraudulent claims by providers of 6 PA Code, Chapter 22, subsection (6) the Rules and Regulations governing the PACE Program. This section states,

“An enrolled provider submits a false or fraudulent claim if the provider directly or indirectly commits one or more of the following acts:

(6) Submits a claim for prescription drugs dispensed which were not dispensed by the provider at the provider’s principal place of business or were not dispensed to a claimant.”

 

The Provider Manual informs providers that if claims have been submitted to the Program and paid for, and the prescriptions have not been dispensed to the cardholder, providers are to submit an on-line reversal.  

 

The Department of Aging representatives will provide appropriate identification and will endeavor not to disrupt the Provider’s course of business during these random checks.

 

It is expected that Providers will cooperate fully with Department personnel as agreed to in their Provider Agreement (cited below).

 

I.   PROVIDER RESPONSIBILITIES

 

D. “The Provider agrees to furnish the Department of Aging or its agents with any information it may request regarding prescription records and payments claimed by the Provider.  These records must be readily available for review, inspection and photocopying by the PACE Compliance Unit at the Provider’s principal place of business.  The Provider further agrees to fully cooperate with the Program or its agents in the conduct of the Program’s drug utilization review responsibilities.  The Provider further agrees to respond in a complete manner to inquiries made as part of the PACE Utilization Review process within seven (7) business days of a request.  Failure to cooperate with the Program or its agents in these areas constitutes a breach of this Agreement and grounds for termination …”

 

 

Questions may be directed to the Provider Services Manager or Supervisor at

1-800-835-4080.