OTHER COVERAGE CODE EDITS
The Program has found that the submission of inaccurate data accompanying certain Other Coverage Code (OCC) values is compromising the integrity of PACE data.
Other Coverage Codes of 0: “Not Specified” and 1: “No Other Coverage Exists.”
è Claims received with an OCC of 0 or 1 and accompanied by data in the COB (Coordination of Benefits) segment will deny with NCPDP Error 13. Rationale: If no primary coverage exists, the COB segment should not contain data.
Other Coverage Code 3: “Other Coverage exists – this claim not covered.”
This value is submitted to PACE when the medication is not on the primary plan’s formulary and must be accompanied by a NCPDP reject code acceptable to the Program, such as NCPDP 70, 75, 69 or PA etc. Internal reports based on OCC 3 are generated to initiate action based on specific error codes.
Other Coverage Code 4: “Other Coverage Exists – payment not collected.”
This value is submitted to PACE when the medication is on the primary plan’s formulary, but no payment is being made by the primary plan because the cardholder is in the deductible phase and/or “Donut Hole.” Claims submitted with an OCC of 4 are accepted for processing by the Program and circumvent the reject code check. Internal tracking reports are based on OCC 4 since the (primary acceptable) claim should be credited to the cardholder’s TrOOP.
PROBLEM: Contradictory information occurs if an OCC 4 is submitted accompanied by a NCPDP reject “70” or “PA”. The program is being “told” that the primary would pay the claim if the person were not in the deductible or “donut hole” while simultaneously being “told” the primary plan rejected the claim for Product/Service not covered or a PA is needed. This contradictory information degrades the integrity of PACE data and report creation.
è SOLUTION: OCC 4 Claims accompanied with an error code will deny for NCPDP Error 13.
Other Coverage Code 6: “Other Coverage Denied, not a participating provider.”
è In 2009, PACE will access each Partner plan’s pharmacy membership roster each time an OCC of 6 is submitted. The claim will deny with NCPDP Error 13 if the provider is a plan member.
Providers may wish to review their claims submissions for accuracy and advise their software vendors of this edit implementation.
Questions may be directed to Provider Services at 1-800-835-4080.