Prior to submitting claims to Wisconsin SeniorCare, providers are required to submit claims to Medicare Part D for SeniorCare participants who are also enrolled in a Medicare Part D Prescription Drug Plan (PDP). A PDP includes not only the stand-alone Medicare Part D PDPs, but also Medicare Advantage prescription drug plans (MA-PDs). For dual eligibles enrolled in a PDP, providers may only submit claims to Wisconsin Medicaid for excluded Medicare Part D drugs. Under certain circumstances, claims may have been reimbursed by Wisconsin Medicaid or Wisconsin SeniorCare without reimbursement having been obtained from a Medicare Part D PDP.

Beginning April 1, 2007, Wisconsin Medicaid and Wisconsin SeniorCare will initiate a monthly process of recouping payment for claims for recipients and participants enrolled in Medicare Part D. Providers will receive adjustments to previously paid claims for dates of service (DOS) on and after March 1, 2007. As a reminder, providers may not bill recipients for services that are adjusted and should seek reimbursement from the recipient’s Medicare Part D PDP.

Claim Responses

Providers may identify claims adjusted for Medicare Part D eligibility if they receive the Explanation of Benefits (EOB) messages below.

Providers will receive the following informational EOB message 508 on adjustments to previously paid claims:

“Recipient or participant identified as enrolled in a Medicare Part D Prescription Drug Plan (PDP). Please bill appropriate PDP.”

One of the following EOBs will be included with informational EOB message 508:

• On SeniorCare claims, EOB 268 (“Participant is enrolled in Medicare Part D for DOS. Submit claim to participant’s PDP prior to SeniorCare. PDP payment/denial information required on claim to SeniorCare.”).
• On Wisconsin Medicaid claims, EOB 545 (“Denied. Recipient eligibility file indicates Medicare Part D coverage. Please submit claim to Medicare Part D insurance carrier.”).

Excluded Drugs

Wisconsin Medicaid will continue to cover drugs that are excluded from Part D coverage for dual eligibles, including barbiturates, benzodiazepines, over-the-counter drugs, agents used for the symptomatic relief of cough and cold, prescription vitamins and minerals (except prenatal vitamins and fluoride), and weight loss agents.

Drugs excluded from Medicare Part D for SeniorCare participants include barbiturates and benzodiazepines, agents used for the symptomatic relief of cough and cold, prescription vitamins and minerals (except prenatal vitamins and fluoride), and weight loss agents.

For More Information

Providers may refer to the following sources for more information about coordination of benefits for Medicare Part D:

• The Medicare Web site at www.medicare.gov/.
• Provider Services at (800) 947-9627 or (608) 221-9883.

Information Regarding Medicaid HMOs

This Wisconsin Medicaid and BadgerCare Update contains Medicaid fee-for-service policy and applies to providers of services to recipients on fee-for-service Medicaid only. For Medicaid HMO or managed care policy, contact the appropriate managed care organization. Wisconsin Medicaid HMOs are required to provide at least the same benefits as those provided under fee-for-service arrangements.