PACE
PROVIDER BULLETIN
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 |
|
|
|
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.