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T To:IPA Members From:Heather Rodgers 2/23/06
1. MEDICARE PART D AND PAAD / MEDICAID To avoid unnecessary audits and chargebacks, please be sure you make every attempt to get a prior authorization. When you bill a Medicare Part D plan you may get a “NDC not covered” or “plan limits exceeded” rejection message. All attempts must be made to either get a prior authorization or have the MD change the Rx to a formulary medication. While you are waiting for the PDP response, you can bill a 6 day emergency supply through Medicaid / PAAD. The PDP’s have 6 days to either approve/deny the medication. The medication should only be billed though Medicaid/PAAD after the PDP has denied it. The State Should Only Be Billed as a Last Resort.
What to do if you encounter a Medicare Part D dually eligible beneficiary that does not have their Medicare Part D card info and is rejected by PAAD? If you have tried to check the patients’ eligibility through an E1 query and they do not have coverage, you should still be able to bill PAAD or Medicaid. According to PAAD, these claims should not reject because the State is already aware these beneficiaries do not yet have coverage. However, should you try to bill a Rx and PAAD rejects it and you have done everything you can to verify eligibility, you can still bill the State. You would enter a 3, 7, or 8 in the Other Coverage Code field to process the claim.
Other Coverage Codes · 03 or 3 Drug Product not covered by carrier · 07 or 7 Claim previously denied for edit 893 · 08 or 8 Payment received reflects 100% co-payment 2. Horizon NJ Health MAC Adjustment The MAC on Albuterol MDI has been adjusted to reflect the recent price increases on this product. All claims filled on or after 2/14/06 can now be reversed and resubmitted for proper payment. If you have any questions or third party issues, please contact Heather Rodgers at 800-575-2667. |