05/01/06 |
INFORMATIONAL NOTICE |
| TO: |
Pharmacies |
| RE: |
Medicare Part D Copayment Billing for SLF and CILA Residents |
|
The Illinois Department of Healthcare and Family Services (HFS) has established the ability to electronically process copay-only claims for residents of SLFs and CILAs enrolled in Medicare Part D. Copay claims can only be submitted for residents of SLFs and CILAs. They may not be submitted for residents of other long term care facilities. Those residents should already be exempt from copayments in Medicare Part D.
In order to bill HFS the Medicare Part D copayments for SLF and CILA residents, the pharmacy should first bill Medicare Part D in order to determine the copay amount charged to the client for that drug. The copayment should be between $1 and $5. If the copayment exceeds $5, the pharmacy should contact the Medicare Part D Plan.
The pharmacy may then submit the claim to HFS with the appropriate copayment amount. In addition to the pharmacy and client-specific information required on the NCPDP 5.1 claim form, the claim must also contain the following elements:
NCPDP 5.1 Claim Segment field and valid value:
| Other Coverage Code value (308-C8) |
Value = 08 (Claim is billing for co-pay) |
NCPDP 5.1 Pricing Segment fields and valid values:
| Other Amount Claims Submitted Count (478-H7) |
Value = 1 |
| Other Amount Claims Submitted Qualifier (479-H8) (Other) |
Value = 99 |
| Other Amount Claimed Submitted (480-H9) |
Value = Copay amt. ($1 - $5) |
| Gross Amount Due (430-DU) |
Value = Copay amt. ($1 - $5) |
| Usual and Customary Charge (426-DQ) |
Value = 0 (Zero) |
Copay-only claims must not contain a NCPDP 5.1 COB/Other Payments Segment.
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