FAQ


I am an SPAP/ADAP and CMS requires a unique BIN-PCN for my beneficiaries that are Medicare Part D Eligible. What does this mean?

All SPAPs and ADAPs must have a unique BIN or BIN/PCN combination for their Medicare Eligible beneficiaries. This means that you cannot use the same BIN-PCN for those SPAP/ADAP members who are not Medicare eligible.

In addition to this requirement, to correctly route record of supplemental payment, the SPAP/ADAP must:

  • reject claims that do not contain the same 4Rx as what was submitted to CMS, OR
  • provide a batch file of supplemental claims (when including the paid claims on the batch file, the 4Rx must match was submitted to CMS

This insures that:

  • only claims for Part D Eligible beneficiaries will be routed to the Transaction Facilitator
  • Plans are able to apply TrOOP correctly by considering these claims "other Troop"
  • Reports provided represent only business supplemental to Part D.

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I am an SPAP/ADAP, is there a report that allows me to see how many supplemental claim are being routed to the Transaction Facilitator?

Bi-monthly reports are published and loaded to the SPAP-ADAP Monthly Reports section of this website. Click on the left-hand navigation tab SPAP-ADAP Monthly Reports.

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My Supplemental Plan requires and exact 4Rx match on claims and my BIN-PCN is on the list, however the beneficiaries’ TrOOP information is not getting updated correctly, who should I contact?

You should contact the beneficiary’s plan. It is possible that N transactions are being rejected by the plan. There are many reasons why an N may be rejected. Some examples are listed below:

  • The Part D plan did not pay for the claim, therefore there is no reason to apply supplemental dollars
  • The pharmacy ID on the N was not an NPI. CMS requires all claims for Part D contain an NPI for the pharmacy provide type.
  • The Part D plan paid for the claim; however it was not a Part D drug. Supplemental benefits do not apply to non-Part D drugs because they are not TROOPable and don’t count toward drug spend.

If you are unsure who to contact, CMS provides a list of COB (coordination of benefits contacts) on its website at https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/PartDContacts.html

Look for the file titled “EOB, COB, automated TrOOP Balance Transfer (ATBT) Contact lists”

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My supplemental BIN-PCN is not on the list that the Switches uses to route Supplemental claims to the Transaction Facilitator for N generation, how do I get my information added to that list?

Contact RelayHealth at TBTSupport@relayhealth.com and request a review of your BIN-PCN. If your BIN-PCN is co-mingled with other commercial business, CMS and RelayHealth reserve the right to exclude the BIN-PCN due to the large number of non-supplemental transactions that would be forwarded to the Transaction Facilitator.

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My Supplemental Plan does not require pharmacies to submit claims with exactly the information I have provided to CMS. How do I get N transactions generated?

If you can identify all the claims that need to have an N generated, you can create a batch file that contains the corrected BIN-PCN-Cardholder ID and appropriate claim information.

Information on the Supplemental Payer batch file requirements can be found at here.

Once a batch file is received, transactions in the batch file are processed during a nightly routine. If the OHI is found with an active Part D Plan, the N transaction will be generated and forwarded to the Part D plan.

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