January
4, 2006
Medicare Q & As
Part VII
The following message came from CMS.
“CMS deeply appreciates the significant role pharmacists play in the
implementation of the new Medicare Part D benefit, especially during the early
stages of implementation. To assist you with new procedures associated with
processing prescriptions for Medicare Part D beneficiaries, CMS will sponsor a
teleconference for pharmacists tomorrow, January 5th, at 11:00 a.m.
Please call (800) 798-2796, passcode 51906156, to join the call.”
Where can I find the CCRX formulary?
The CCRX formulary is located on
the APA website at
www.arpharmacists.org in the Medicare Madness Center.
How can I access the Wellpoint instructions for dual-eligible patients
that are not enrolled in a plan?
The Wellpoint instructions are
located on the APA website at
www.arpharmacists.org in the Medicare Madness Center in the Medicare Part D
Q&As Part IV dated December 9, 2005.
The Wellpoint telephone number is
1-800-928-6201.
How do I adjudicate 1927 drugs?
Medicaid Billing for Non-Covered Part D Drugs for Dual Eligibles
1) First, bill the part D plan.
If the drug is not covered, the claim will be rejected by the plan.
2) If the rejection code is Y701, the drug is covered by Medicaid for
dual eligibles.
3) Bill Medicaid using the TPL (Third Party Liability) billing.
4) Using the TPL billing, enter the date the claim was denied in the
other payor date.
5) If unable to locate this field, you may have to contact your software
vendor. Tell him the NCPDP field you need is “E8”, the field for other
payor.
FYI according to Pam Ford: Coverage by Medicaid on drugs not covered by
Part D for dual-eligible patients will be the same as under the Medicaid
program. For example, if a drug has a days limit, such as Xanax XR, that is
what is allowed on the non-covered Part D drug.
Note: List of 1927 drugs may be found on the APA Website at
www.arpharmacists.org in the Medicare Madness Center.
Dual-eligible Patients with Status Not Verified with CCRx
Medicaid/Medicare dual-eligible patients have been loaded
incorrectly; therefore, their claims are adjudicating with a copay or the amount
being applied to the $250 deductible. They are working to resolve this problem
as quickly as possible. In order to facilitate this correction for your
patients, you can fax your dual-eligible patients to CCRx at 1-866-684-5441.
Please include patient’s name, Medicaid number, and CCRx ID number. Please put
“Attention Dual Eligibles with Wrong Copays” at the top.
This problem has increased their call volume tremendously; therefore, you
may receive a busy signal or be put on hold for an extended amount of time.
This should decrease as the issues are resolved and beneficiaries begin
receiving their enrollment receipt letters and/or ID cards.
When will CCRx patients that enrolled before December 31, 2005, at
11:50 p.m. become eligible?
If CCRx received the
enrollment application prior to 11:59 p.m. on December 31, 2005, eligibility
will be retroactive to January 1, 2006. Most likely these beneficiaries will
not be loaded into the system by January 1st and will not appear on
an E1 eligibility transaction. The CCRx Provider Help Desk will not have a
record of them, and because they will not have a record of these patients, they
will need to initially pay cash for their prescriptions. Once the system
records their information, they will be assigned a CCRx Number, and the pharmacy
can then resubmit those claims that were filled prior to their enrollment record
with fill dates back to January 1st. The amount paid by the
beneficiary will count toward TrOOP and any applicable deductible.
Some beneficiaries are receiving letters from CCRx with the incorrect
claims processing information. Please use BIN: 012304 and PCN: MPD
How do I handle dual-eligible patients and claims not
adjudicating?
Suggestions from other pharmacists:
1) Give patient a 10- day supply of medication and try to
adjudicate again.
2) Ask the patient to write a check for the cost of the medication and
hold the check until the claim is successfully adjudicated.
When can dual-eligible patients change their plans?
Dual-eligible patients may change their plans anytime, but whichever
plan is in effect on the 1st day of the month will be in effect for
the entire month.
When can regular Medicare beneficiaries change their enrollment plans?
Regular Medicare beneficiaries that have chosen their own plans may not
change their plans until open enrollment begins again on November 15, 2006.
However, because there is an Initial Enrollment Period (IEP) and an Annual
Enrollment Period (AEP), the patient has one sign-up with each enrollment
period. So, technically, the patient can change plans one time.
For instance, if a patient enrolls in Plan A in November of 2005, this
would satisfy the IEP. Then, if the patient decides that this plan is not the
best plan for them and wants to change in March of 2006 to Plan B, this would
satisfy the patient’s AEP. This will not be the case in subsequent years
because the IEP and the AEP will not run concurrently as they do during this
early period, November 15, 2005 – May 15, 2006.
Is there another number at CCRX that I can call?
Not that we know of
Beneficiary Help Desk 1-866-684-5353
Practitioner Help Desk 1-866-684-5395
We realize these numbers may involve long holds and possible disconnections.
How do I know where to file a claim for a dual-eligible patient that
has not yet received a letter from CMS?
This is accomplished through the use of E1 transmission. Instructions
must come from your software vendor. We know at this time that problems with
this process have been occurring.
How do I handle claims where I only have an ID number but no group
number for CCRx?
CCRx Group Numbers for Arkansas are as follows:
PDA19 basic
PDB19 choice
PDC19 gold