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 payers.

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.

Action Required:

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.

Helpful Information when Billing:

 If 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 claim.

Sometimes 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 4Rx information.

SAVE THE DATE - Information Webinar:

WHEN:            June 20, 2012

TIME:               12:00 pm - 1:00 pm CST

WHO:              Hosted by your Centers for Medicare & Medicaid Services (CMS) Regional Office.

WHAT:            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

*         Operational Concerns

*         Future of EDI Communications

*         Resources and Contact Information

More 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 Sheets

Sources:

Prime Therapeutics’ - Medicare Part D Processing Update. 05/12

CVS/Caremark – Fax on Medicare Part D Providers, Verificiation of Eligible Persons Reminder. Sent 05/21/12

Websites:

http://www.hapnetwork.org/medicare-drug-coverage/helpful-info-for-rph.html

https://medifacd.relayhealth.com/pharmacies/overview_partab.html