Eligibility Verification

On January 1, 2006, the Centers for Medicare and Medicaid Services (CMS) implemented the Medicare Part D outpatient drug benefit for Medicare beneficiaries.

Providers may verify Medicare Part D enrollment for a Wisconsin SeniorCare participant through the Medicaid Eligibility Verification System (EVS) or the Automated Voice Response (AVR) system. The EVS or AVR will state only that a participant is in a Medicare Part D Prescription Drug Plan (PDP). It will not indicate the name of the specific PDP.

To determine the specific PDP in which a participant is enrolled, providers should first check with the participant. If the participant does not know the PDP in which he or she is enrolled, providers may send an online eligibility transaction through Medicare's E1 query. If the E1 transaction does not return Medicare Part D plan information, providers may call the Medicare Pharmacy Hotline, available 24 hours a day, seven days a week, at (866) 835-7595. Providers may also call Wisconsin Medicaid's Provider Services at (800) 947-9627 or (608) 221-9883 to determine the PDP in which a participant is enrolled.

Wisconsin SeniorCare participants who are not enrolled in a Medicare Part D PDP will continue to receive drug coverage from SeniorCare. Pharmacy providers should continue to use participants' SeniorCare cards to submit drug claims to SeniorCare. Possession of a SeniorCare card does not guarantee eligibility.

Submitting Claims for SeniorCare Participants

Effective for dates of service on and after January 1, 2006, providers are encouraged to submit claims to Medicare Part D first for SeniorCare participants who are also enrolled in a Medicare Part D PDP. If a pharmacy provider cannot reasonably determine the PDP in which a participant is enrolled (e.g., the participant does not present a Medicare Part D PDP card and the PDP cannot be identified through Medicare's eligibility system), the provider may submit the claim to SeniorCare without first obtaining a Medicare Part D payment determination. Wisconsin SeniorCare will allow this on a temporary basis and will announce an enddate to allowing claims to be submitted without a Medicare Part D payment determination for SeniorCare participants in a future Wisconsin Medicaid and BadgerCare Update.

If a participant's PDP is identified, providers should submit claims to Wisconsin SeniorCare after claims have been submitted to Medicare for drugs that are covered by the Medicare Part D PDP. This will allow payments by SeniorCare participants to be applied to Wisconsin SeniorCare spenddown and deductible requirements and for Wisconsin SeniorCare to determine applicable cost sharing.

If the provider can determine and submit a claim to a SeniorCare participant's Medicare Part D PDP, providers are required to submit the Medicare determination using National Council for Prescription Drug Programs (NCPDP) fields on the claim to SeniorCare. As required by Wisconsin SeniorCare coordination of benefits (COB) billing instructions, providers are required to indicate the amount paid by a Medicare Part D PDP in the "Other Payor Amount" field and the amount paid by the participant in the "Patient Paid Amount" field. When a Medicare Part D PDP denies a claim (e.g., for a noncovered drug, a non-formulary drug, or a non-network pharmacy), providers are required to indicate the other coverage code in the "Other Coverage Code" field.

Providers should follow existing claims submission procedures for SeniorCare participants who are not enrolled in a Medicare Part D PDP.

Refer to the Pharmacy Handbook for additional information about NCPDP fields, other coverage codes, and COB for SeniorCare.

Prior Authorization Requests

Wisconsin SeniorCare will continue to accept prior authorization (PA) requests for Medicare Part D covered and excluded drugs (i.e., barbiturates and benzodiazepine drugs, insulin, agents that are used for the symptomatic relief of cough and cold, prescription vitamins and mineral products except prenatal vitamins and fluoride, and weight loss agents) for SeniorCare participants in all levels of participation who are enrolled in a Medicare Part D PDP. Providers should follow current policies and procedures for the submission of PA requests for SeniorCare participants who are not enrolled in a Medicare Part D PDP.

For More Information

For more information about Medicare Part D, refer to the CMS Web site at www.cms.hhs.gov/. Providers may also contact Provider Services at (800) 947-9627 or (608) 221-9883 with questions about submitting claims for SeniorCare participants.

Providers may refer SeniorCare participants to the following resources:

• The Medicare program at (800) MEDICARE ([800] 633-4227) or www.medicare.gov/.
• The Wisconsin Prescription Drug Helpline at (866) 456-8211 for Medicare beneficiaries age 60 and older with questions about Medicare Part D. This helpline is sponsored by the Coalition of Wisconsin Aging Groups' Elder Law Center.
• The Disability Drug Benefit Helpline at (800) 926-4862 for persons under age 60 who receive Medicare coverage as a result of a disability. This helpline is sponsored by the Wisconsin Coalition for Advocacy.
• A county/tribal social or human services agency if the participant is age 60 or older and would like to speak to a benefit specialist for the elderly.