Quick Answers to FAQs =
on
Processing Claims for Dual Eligible Beneficiaries
·
Wha=
t if a
dual eligible beneficiary (Medicare and Medicaid) presents at the pharmacy =
and
does not know what plan he or she has been auto enrolled in?
The pharmacist should send an E1 query to determine Part D plan
enrollment. If the E1 query r=
eturns
the RxBIN-RxPCN-RXGrp-RxID (the "4Rx" data) and 800 number of a P=
art
D plan, the pharmacist should bill the plan. If the E1 query returns just the 8=
00
number of the plan, the pharmacist should call the 800 number to obtain the
billing information from the plan. <=
/span>If
the E1 query returns no match, the pharmacist should check for Medicare
eligibility by submitting an expanded E1 query and Medicaid eligibility thr=
ough
the patient history, a Medicaid card, or a current Medicaid letter. Pharmacists can also call a dedica=
ted
pharmacy eligibility line at 1-866-835-7595. The pharmacist may use the Point
of Sale facilitated enrollment solution once dual eligibility is determ=
ined
and plan enrollment cannot be identified (see last bullet).
·
Wha=
t if a
dual eligible beneficiary who has been auto enrolled presents at a pharmacy
with a plan acknowledgement letter indicating that the beneficiary has swit=
ched
plans?
If the person does have their plan acknowledgement letter in hand, that let=
ter
should include the RxBin, RxPCN, RxGrp and RxID, generally in the upper left
hand area above the greeting. The
pharmacist should use that information for billing or, if the letter does n=
ot
include this information, the pharmacy should call the plan to get the
information needed to send in a claim.
·
Wha=
t if a
dual eligible beneficiary who has been auto enrolled presents at a pharmacy
without a plan acknowledgement letter, but indicates that he or she has
switched plans?
The pharmacist should send an E1 query or call the dedicated pharmacy
eligibility line at 1-866-835-7595 to determine Part D plan enrollment.
·
Wha=
t if a
beneficiary presents at a pharmacy with a Medicaid card and appears to be
Medicare eligible, but the pharmacist cannot determine that the beneficiary=
has
been auto-enrolled in any plan?
Once the E1 query has failed and the pharmacist has reasonable basis for
believing the beneficiary is dually eligible, the POS Contractor (Anthem) s=
hould
be billed. This will allow fo=
r the
prescription to be filled and begin the process of enrolling the dual eligi=
ble
beneficiary into a Part D plan.
Please see “What If Scenarios for Pharmacy” for a more detailed list of FAQs.