Medicare prescription drug benefit
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Medicare Prescription Drug Benefit PowerPoint PPT Presentation


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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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Medicare prescription drug benefit

Medicare Prescription Drug Benefit

Billing of Claims


Transaction types

Transaction Types

  • Pharmacy

    • E1 – Eligibility Transaction

      • Must process through TrOOP Facilitator (NDC Health)

    • Standard Message Format


E1 response

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


E1 response continued

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


Standard message format rules

Standard Message Format Rules

  • Displayed in field 504-F4

  • Overflow in 526-FQ

  • Should not split messages

  • Truncate whenever possible

    • Follow NCPDP rules


Standard message format rules continued

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


Standard message format

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


Standard message format continued

Standard Message Format (continued)

  • Abbreviations:

    • BN = BIN

    • PN = PCN

    • GP = Group Number

    • ID = Cardholder ID Number

    • PC = Person Code

    • PH = Help Desk Phone Number


Standard message format continued1

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


Processing the claim

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.


Secondary claim processing

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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