Medicare Part D Processing Update
The new CMS requirements for Med
The new CMS requirements for Medicare Part D plans are that each sponsor must
use a unique Bank Identification Number (RxBIN) and processor control number
(RxPCN) combination, a cardholder identification number (RxID), along with an Rx
group number (RxGRP) in order for claims to be processed correctly. If the “4Rx”
information is not submitted accurately, the claim will be rejected.
These requirements were created so that
pharmacies can identify when they are billing Part D claims, and secondary
payers can better coordinate benefits on claims. The standardization of this
billing will mean that all payers associated with the Part D benefit can all
identify and manage their Part D claims more effectively. Increases in
efficiency could lead to faster reimbursements to pharmacies from third party
On May 21, 2012, claims lacking the required
billing information started to be rejected from Part D sponsors. The
implementation date differs for each Benefit Sponsor, but all plans must have
4Rx information implemented by June 30, 2012. If information is not accurately
submitted by this date, claims will be rejected.
Every pharmacy must update the information for patients covered on Medicare Part
D plans for all new prescriptions and refills to avoid interruptions in payment.
New card information may be obtained from the acknowledgement letter that
patients will receive with all of their billing information prior to
distribution of the Part D identification cards. This letter will verify that
the patient is insured, and that you are billing their plan appropriately.
Information when Billing:
the patient has no 4Rx information available, pharmacists are able to submit an
“E1 Transaction.” The E1 Transaction is where pharmacists can use
basic information given by the patient to submit a real-time eligibility query
to the Facilitator. The Facilitator returns information needed to submit the
transaction will not come back with the information needed, and only supply the
patient’s plan name and phone number. Pharmacists can then use this number to
contact the plan to obtain that information.
If the plan
phone number is not given, then the pharmacist can call the
CMS pharmacy line at (866) 835-7595 to obtain
DATE - Information Webinar:
June 20, 2012
12:00 pm - 1:00 pm CST
Hosted by your Centers for Medicare & Medicaid Services (CMS) Regional
Please join CMS staff for an informative webinar for healthcare
providers, clearinghouses and vendors on Version 5010.
Version 5010 refers to the
standards that HIPAA-covered entities (health plans, health care clearinghouses,
and certain health care providers) must use when electronically conducting
certain health care administrative transactions, such as claims, remittance,
eligibility, and claims status requests and responses.
All covered entities should
have been fully compliant with Version 5010 by January 1, 2012; however, an
enforcement delay is in effect until June 30, 2012.
In this webinar, we'll cover:
Current Conversion Statistics
Final Preparations for 5010/D.0 Cutover
Future of EDI Communications
Resources and Contact Information
Prime Therapeutics’ Medicare Part D PDP and MA-PD payer information sheet can be
found at: PrimeTherapeutics.com > Pharmacists > D.0/
Version 5010 Pharmacy Information > D.0 Payer
Prime Therapeutics’ - Medicare Part D Processing
CVS/Caremark – Fax on Medicare Part D Providers, Verificiation of Eligible
Persons Reminder. Sent 05/21/12