Quick Answers to FAQs on Processing Claims for Dual Eligible Beneficiaries

 

·        What if a dual eligible beneficiary (Medicare and Medicaid) presents at the pharmacy and does not know what plan he or she has been auto enrolled in?

The pharmacist should send an E1 query to determine Part D plan enrollment.  If the E1 query returns the RxBIN-RxPCN-RXGrp-RxID (the "4Rx" data) and 800 number of a Part D plan, the pharmacist should bill the plan.  If the E1 query returns just the 800 number of the plan, the pharmacist should call the 800 number to obtain the billing information from the plan.  If the E1 query returns no match, the pharmacist should check for Medicare eligibility by submitting an expanded E1 query and Medicaid eligibility through the patient history, a Medicaid card, or a current Medicaid letter.  Pharmacists can also call a dedicated pharmacy eligibility line at 1-866-835-7595.  The pharmacist may use the Point of Sale facilitated enrollment solution once dual eligibility is determined.

 

·        What if a dual eligible beneficiary who has been auto enrolled presents at a pharmacy with a plan acknowledgement letter indicating that the beneficiary has switched plans?

If the person does have their plan acknowledgement letter in hand, that letter should include the RxBin, RxPCN, RxGrp and RxID, generally in the upper left hand area above the greeting.  The pharmacist should use that information for billing or, if the letter does not include this information, the pharmacy should  call the plan to get the information needed to send in a claim.

 

·        What if a dual eligible beneficiary who has been auto enrolled presents at a pharmacy without a plan acknowledgement letter, but indicates that he or she has switched plans?

The pharmacist should send an E1 query or call a dedicated pharmacy eligibility line at 1-866-835-7595 to determine Part D plan enrollment (or 1-800-MEDICARE between 8 PM and 8 AM ET).

 

·        What if a beneficiary presents at a pharmacy with a Medicaid card and appears to be Medicare eligible, but the pharmacist cannot determine that the beneficiary has been auto-enrolled in any plan?

Once the E1 query has failed and the pharmacist has reasonable basis for believing the beneficiary is dually eligible, the POS Contractor (Anthem) should  be billed.  This will allow for the prescription to be filled and begin the process of enrolling the dual eligible beneficiary into a Part D plan.

Please see “What If Scenarios for Pharmacy” for a more detailed list of FAQs.