PACE

PROVIDER BULLETIN

May 15, 2009

Payer Specification Sheet

COMPLIANCE

 

PACE Providers are responsible for the validity of their claims submissions data.

 

PACE is receiving TrOOP (True Out Of Pocket) expense data  indicating  that the Patient Paid Amount field  (Field 433-DX) reported to PACE is not matching the data returned by the primary payer. This discrepancy is appearing both when the primary payer is making payment as well as during the deductible and the “donut hole.” 

 

This incorrect data is causing:

·        cardholders to pay higher primary copays (Patient Paid Amounts)

·        TrOOP to be incorrect 

·        PACE to pay higher reimbursement.

  

PRICING SEGMENT

 

Segment MANDATORY for these transactions: B1 and B3.

Field

Field Name

VALUES

USED= Y

EDITED= E

PACE VALUES SUPPORTED

COMMENTS

111-AM

SEGMENT IDENTIFICATION

11

Y

Pricing Segment

*4Ø9-D9

INGREDIENT COST SUBMITTED

 Y

                * E

 

*Edited if compound code of 2 is used.

412-DC

DISPENSING FEE SUBMITTED

 

Y

 

433-DX

PATIENT PAID AMOUNT SUBMITTED

 

E

Enter amount/copay  indicated by payer(s) i.e. other third party prescription drug plans/ Part D plans, that cardholder is to pay.

 

Review your claim submissions to be certain that the amount appearing in Field 433-DX, PATIENT PAID AMOUNT SUBMITTED is correct. The number appearing in this field is the dollar amount due from the cardholder as specified in the response from the primary payer.

 

In the deductible and the “donut hole” this amount may be identical to the providers submitted U&C OR may be a lower, discounted amount. In the coverage and catastrophic phases, this value will be the primary’s copay.  

 

Because of the discrepancy in CMS reporting data, the amount that appears in this field must match what the primary payer returned in the response in both deductible and coverage phases.

 

Claims identified as being paid with incorrect amounts may be voided. Providers will be expected to refund any overpayments to cardholders due to incorrect Patient Paid Amounts.

 

Providers whose claims submissions demonstrate a consistent pattern of incorrect submissions will be contacted. Incorrect submissions caused by a software programming error may result in suspension of all payments to the provider until either the problem is corrected or a new vendor retained.

 

Software vendors identified as having programming errors causing these incorrect submissions may be decertified until the error is corrected and data submitted verifying the correction.

 

ALL Providers using decertified vendors will be notified that payments may be suspended until the vendor has corrected the problem or a new software vendor retained.

 

Questions may be directed to Provider Services at 1-800-835-4080.