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Medicare Prescription Drug Benefit

Medicare Prescription Drug Benefit. Billing of Claims. Transaction Types. Pharmacy E1 – Eligibility Transaction Must process through TrOOP Facilitator (NDC Health) Standard Message Format. E1 Response. Accepted Claim with message: MEDICARE ELIG CHECK:

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Medicare Prescription Drug Benefit

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  1. Medicare Prescription Drug Benefit Billing of Claims

  2. Transaction Types • Pharmacy • E1 – Eligibility Transaction • Must process through TrOOP Facilitator (NDC Health) • Standard Message Format

  3. E1 Response • Accepted Claim with message: • MEDICARE ELIG CHECK: • Primary and Other insurance information • Use field 504-F4 • Carry over information into 526-FQ • Help Desk number

  4. E1 Response (continued) • Rejected with message: • MEDICARE ELIG CHECK: No single match was found • Use field 504-F4 • Carry over information into 526-FQ • Reject codes if necessary • Include Help Desk number

  5. Standard Message Format Rules • Displayed in field 504-F4 • Overflow in 526-FQ • Should not split messages • Truncate whenever possible • Follow NCPDP rules

  6. Standard Message Format Rules (continued) • Field Separators • Colon : separates field name from value • Semi colon ; separated different fields • & separates different messages • Processor messages • Field 526-FQ on PAID response • Brand/Generic messages • BEFORE insurance information on REJECT response

  7. Standard Message Format • E1 Response • PRIMARY;BN:123456;PN:1234567890;GP:123465789012345;ID:12345678901234567890;PC:001;PH:8001234567;& • ADDINS:1;BN:123456;PN:1234567890;GP:123465789012345;ID:12345678901234567890;PC:001;PH:8001234567;& • Continue messaging with all insurance information known

  8. Standard Message Format (continued) • Abbreviations: • BN = BIN • PN = PCN • GP = Group Number • ID = Cardholder ID Number • PC = Person Code • PH = Help Desk Phone Number

  9. Standard Message Format (continued) • Similar messaging on a PDP paid claim • When PDP is secondary: • Reject with code 41: Submit Bill to Other processor or Primary Payer: • Followed by same message

  10. Processing the Claim • All necessary information is returned in message • Set up cross reference list for pharmacists to look up plan code and BIN/PCN or • Use BIN/PCN as plan code (or description) • Process primary claim according to instructions on payer sheet. • Message will indicate if plan is primary or secondary.

  11. Secondary Claim Processing • Process secondary (Add Ins. Message) as regular COB claim • 2 types of processing • COB billing to include COB segment • Copay only billing • Refer to payer sheet for plan set up

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