Medicare Part D Claim Processing

Medicare Part D Pharmacy Notice

Please visit the CMS web site: http://www.cms.hhs.gov to obtain the Model Pharmacy Notice entitled, "Medicare Prescription Drug Coverage and Your Rights" CMS-10147. Once there, you will need to navigate to Sept. 30th listings. This standard notice, CMS-10147, advises enrollees to contact their Medicare Part D Plans to obtain coverage determination or ask for a formulary exception if the enrollee disagrees with the information relayed by the Pharmacist (CMS Requirement 423.562). All participating pharmacies in our Medicare Part D Program must either post this notice in a conspicuous area or hand the notice to CIGNA members.

Claim processing information PDP BIN AND PCN:

All CIGNATURE-Rx claims for PDP members should be submitted under BIN 012353 and PCN 03490000.

Claim processing information:

The member id is alpha-numeric with a maximum of 9 characters and a two digit suffix code (usually 01).

Claim processing information for Part B vs. Part D drugs:

Please reiterate to your staff to check the free text message fields for additional processing information.

The following categories of Part B vs. Part D drugs will initially reject as "PRIOR AUTH REQUIRED - DETERMINE B OR D DRUG STATUS" with additional free text message and override information. The Pharmacy Help Desk does not need to be contacted for these overrides. Your pharmacy staff may enter the override codes communicated online for the four drug categories with confirmed Part D approved indications.

Oral anti-cancer drugs:
Claim will be initially rejected with error code 195 "PRIOR AUTH REQUIRED - DETERMINE B OR D DRUG STATUS", Under the free form text field, you can find online message: "Not Medicare Transplant use PAC 34902". Dispensing pharmacist can resubmit claim using override code PAC 34902 if the prescription is not used for Medicare covered transplant.

Immunosuppressives:
Claim will be initially rejected with error code 195 "PRIOR AUTH REQUIRED - DETERMINE B OR D DRUG STATUS", Under the free form text field, you can find online message: "Not Medicare Transplant use PAC 34902". Dispensing pharmacist can resubmit claim using override code PAC 34902 if the prescription is not used for Medicare covered transplant.

Anti-emetics:
Claim will be initially rejected with error code 195 "PRIOR AUTH REQUIRED - DETERMINE B OR D DRUG STATUS", Under the free form text field, you can find online message: "Not w/in 48 hrs of chemo use PAC 34904". Dispensing pharmacist can resubmit claim using override code PAC 34904 if the prescription is not used within 48 hours of chemotherapy.

Nebulizer solutions:
Claim will be initially rejected with error code 195 "PRIOR AUTH REQUIRED - DETERMINE B OR D DRUG STATUS", Under the free form text field, you can find online message: "If in hospital/SNF w/o Part A use PAC 34905". Dispensing pharmacist can resubmit claim using override code PAC 34905 if the prescription is used for a participant in hospital or SNF without Medicare Part A coverage.

Claim processing information - Patient Location Code:

Please enter the appropriate Patient Location Code for each claim.

Incorrect patient location code submissions may result in "Pharmacy not in network" denials.

Retail Pharmacies:
Please enter the appropriate Patient Location Code for each claim.
Incorrect patient location code submissions may result in "Pharmacy not in network" denials.

LTC Pharmacies:
00 or 01 indicates retail claim and can only be submitted by retail pharmacies.
05 indicates ALF claim that can only be submitted by LTC pharmacies.

Home Infusion claims can only be submitted by Home Infusion pharmacies with:
Patient Location Code 01 with level of service 06.
Patient Location Code 05 with level of service 06.

Claim processing information standard benefit exclusions:

Standard Benefit Exclusions

Drugs excluded under Medicare Part D:

   a.

Agents for Anorexia, Weight Loss, or Weight Gain

   b.

Agents used to promote fertility

   c.

Agents used for cosmetic purposes or hair growth

   d.

Agents used for the symptomatic relief of cough and cold

   e.

Prescription vitamins and mineral products; except prenatal vitamins and fluoride preparations

   f.

Nonprescription drugs

   g.

"Less than effective" Medicaid drugs

   h.

Barbiturates

   i.

Benzodiazepines