- How is supplemental coverage to Medicare Part D information acquired?
- What is the process if a beneficiary has lost their card?
- How is the Medicare eligibility information acquired from CMS by the Transaction Facilitator?
- How are the Medicare Part A and/or B eligibility information acquired?
- What is the process when the claim rejects with the information provided on the E1?
- How is the LIS/LICS (Low income subsidy/low income cost share level) information acquired?
- How is coverage determination acquired?
- What is the process if a DOB (Date of Birth) reject is received on a Medicare Part D claim?
- How is an override acquired? (Vacation, lost medications, etc.)
- How is a prior authorization acquired?
- What if the pharmacy is presented with BAE (Best Available Evidence)?
- What types of CMS eligibility are in the file sent to the Transaction Facilitator?
- How is the Medicaid eligibility information acquired?
- How is the Medicare Part D eligibility information acquired?
- How is the date of birth used for matching?
- What is BAE (Best Available Evidence)?
- How are the submitted fields used to find the beneficiary?
- Are all of the beneficiary data fields required?
- What can be submitted in the Cardholder ID field?
- What beneficiary demographic information is required in the E1 Transaction?
How is supplemental coverage to Medicare Part D information acquired?
- If filed with CMS, supplemental coverage information will be returned on the Medicare Part D E1 response transaction
- Beneficiary's card
What is the process if a beneficiary has lost their card?
- If it is a Medicare Part D card, the beneficiary must call their Medicare Part D plan. Use the help desk number from the E1 response field; 127-UB OTHER PAYER HELP DESK NUMBER to provide to the beneficiary if they do not have access to the contact number.
- If it is a Medicare card (card issued to all Medicare patients) the beneficiary must call the Medicare number.
How is the Medicare eligibility information acquired from CMS by the Transaction Facilitator?
- The Transaction Facilitator receives a CMS Eligibility file with daily updates directly from CMS
How are the Medicare Part A and/or B eligibility information acquired?
The only methods available for pharmacies to obtain Medicare Part A and/or Medicare Part B eligibility are:
- E1 for Medicare Part A or Medicare Part B (different BIN/PCN on submission)
- Beneficiary's card
What is the process when the claim rejects with the information provided on the E1?
- Validate that an E1 request was sent, if not send an E1 request and re-verify that what is returned is exactly what was sent on the claim.
- If the E1 response and claim match (4Rx, (BIN, PCN, Group ID, Cardholder ID), DOB, Gender), but the claim was rejected;
- Check the reject to see if reject codes, 01, 04, 06, 07 check OHI (Other Health Insurance) fields populated in Response Coordination of Benefits/Other Payers Segment. If there is OHI present, that is the information the Part D Plan is telling the pharmacy should be used.
990-MG OTHER PAYER BIN NUMBER
991-MH OTHER PAYER PROCESSOR CONTROL NUMBER:
992-MJ OTHER PAYER GROUP ID
356-NU OTHER PAYER CARDHOLDER IDReprocess the claim with information from the above fields. If the claim still rejects, contact the Plan's phone number in the E1 response transaction field; 127_UB OTHER PAYER HELP DESK NUMBER associated with the Medicare Part D Plan.
- Check the reject to see if reject codes, 01, 04, 06, 07 check OHI (Other Health Insurance) fields populated in Response Coordination of Benefits/Other Payers Segment. If there is OHI present, that is the information the Part D Plan is telling the pharmacy should be used.
- If the reject codes are for anything else then what is listed above, contact the plan; check the reject to see if the Plan help desk number is returned.
How is the LIS/LICS (Low income subsidy/low income cost share level) information acquired?
- An indicator (value = Yes/No) is provided to identify whether or not the beneficiary is eligible for LICS. This value is available on the E1 response field: 138-UQ CMS LOW INCOMECOSTSHARING (LICS) LEVEL
- The actual LICS level is not available to pharmacies in any form other than as designated by the co pay returned from the Part D Plan.
How is coverage determination acquired?
- The only method to obtain a coverage determination is to contact the beneficiary's Plan. You may need to submit an E1 request to contact the Plan. The Plan's phone number is in the E1 transaction response field; 127_UB OTHER PAYER HELP DESK NUMBER.
What is the process if a DOB (Date of Birth) reject is received on a Medicare Part D claim?
- If the date of birth returned on the E1 is not the DOB the pharmacy has on file or what the beneficiary has stated, the only resolution for this is for the beneficiary to correct their DOB with the SSA (Social Security Administration).
- In the interim, the DOB must be used that is on file with SSA/Medicare Part D. This information can be acquired by submitting the E1 request. If the E1 processing is not available, contact the beneficiary's Medicare Part D plan.
How is an override acquired? (Vacation, lost medications, etc.)
- The pharmacy will have to contact the beneficiary's plan. An E1 request can be done to obtain the E1 response field 127-UB OTHER PAYER HELP DESK NUMBER to obtain the contact number.
How is a prior authorization acquired?
- The only method to obtain a prior authorization is to contact the beneficiary's plan; check the claim if a prior authorization reject is returned, included with the reject should be a phone contact for the plan specific to the prior authorization reject returned.
What if the pharmacy is presented with BAE (Best Available Evidence)?
- If a beneficiary disputes the cost-share at the pharmacy and presents BAE documentation, the pharmacy will need to contact the Part D sponsor to acquire their BAE policy for the next steps to obtain the accurate cost share for the beneficiary.
What types of CMS eligibility are in the file sent to the Transaction Facilitator?
- The Transaction Facilitator receives a CMS Eligibility file with daily updates from CMS. This file contains eligibility information for every beneficiary enrolled in Medicare Part A, B, and D. The CMS Eligibility file also contains information on Other Health Insurance (OHI) that the beneficiary may have supplemental to the Medicare Part D coverage.
How is the Medicaid eligibility information acquired?
Some methods available for pharmacies to obtain Medicaid eligibility are:
- Beneficiary's card
- The state Medicaid office the beneficiary resides in
How is the Medicare Part D eligibility information acquired?
The only methods available for pharmacies to obtain Medicare Part D eligibility are:
- E1 for Medicare Part D transaction
- Beneficiary's card
How is the date of birth used for matching?
- If only the last 4 digits of the SSN are submitted and the DOB in the pharmacy system does not match what is in the CMS Eligibility file, it is unlikely that a match will occur.
- If an exact MBI, RRB, or SSN is used, and the DOB does not match what is in the CMS Eligibility file, an E1 match may still be found. However, it is still likely that the claim will be rejected by the Plan due to the DOB mismatch
- The DOB in the CMS systems is the same as the Social Security Administration (SSA) DOB. Thus, when sponsors and processors have a member-reported DOB that differs from the SSA/CMSDOB, it is the (SSA) DOB that must be used.
- If the beneficiary has concerns regarding the DOB mismatch, have the beneficiary contact their Plan or SSA.
What is BAE (Best Available Evidence)?
- In certain cases, CMS systems do not reflect a beneficiary's correct low income subsidy (LIS) status at a particular point in time. As a result, the most up-to-date and accurate subsidy information has not been communicated to the Part D plan. The CMSBAE policy requires sponsors to establish the appropriate cost-sharing for low income beneficiaries when presented with evidence that the beneficiary's information is not accurate. (see the CMS Memo "Clarified BAE Guidance" for additional information)
How are the submitted fields used to find the beneficiary?
- If an exact MBI, RRB, or 9-digit SSN is submitted in the Cardholder ID field, the Last Name (exact) and First Name (partial) are used to find the beneficiary.
- If only the last 4 digits of the SSN are submitted, then a weighted match is done using First Name, Last Name, DOB (date of birth), and Zip.
Are all of the beneficiary data fields required?
Not all beneficiary fields are required. Below is a list of each the E1 transaction fields related to beneficiary information and whether they are required or optional:
|
Field Name |
Required |
Optional |
|
Cardholder ID |
X |
|
|
Full Last Name |
X |
|
|
Full First Name |
|
X |
|
First Initial of First Name |
X |
|
|
Date of Birth |
X |
|
|
ZIP/Postal Code |
X |
|
What can be submitted in the Cardholder ID field?
Any of the following can be submitted in the Cardholder ID field:
- Medicare Part A/B ID Card Number also know as the MBI (Medicare Beneficiary Identifier)
- Nine-digit Social Security Number (SSN)
- Railroad Retirement Board (RRB) number
- Last four digits of the SSN
What beneficiary demographic information is required in the E1 Transaction?
- Cardholder ID
- Patient Last Name
- At least the first character of the Patient First Name
- Patient Date of Birth
- ZIP/Postal Code