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Pursuant to Governor Ridge’s Executive Order 1996-1, agencies under the jurisdiction of the Governor must catalog and publish all non-regulatory documents such as policy statements, guidance manuals, decisions, rules and other written materials that provide compliance related information. The following compilation is the third list of the Administration’s non-regulatory documents. This list will be updated and published annually on the first Saturday in August.

This catalog is being provided to insure that the public has complete access to the information necessary to understand and comply with state regulations. Facilitating access to information is a critical component of the Ridge Administration’s initiative to enhance the partnership between the regulated community and the state.

INTERNAL GUIDELINES

BULLETINS: 2014

January 31, 2014 - PROGRAM UPDATES: NCPDP ERROR  41 "SUBMIT BILL TO OTHER PROCESSOR / PAYER":  Listings of the Part D plan chosen for cardholders and a Provider Bulletin have been distributed to the pharmacy the cardholder uses most often. Web R/A pharmacies were sent lists; FTP R/A providers had their list posted on the FTP site. The Provider Bulletin stressed the need to "update the Other Payer ID (the BIN) in the Coordination of Benefits (COB) segment, Field 340-7C" when updating the primary payer information. Claims without the new PART D BIN were processed during January, to permit pharmacies to update their primary payer information.

 

CRDP PROVIDER BULLETINS: 2010

December 17, 2010 -- 340B PRICING Retraction: Effective immediately, the Department of Aging is withdrawing the June 21, 2010 Bulletin mandating that providers submitting claims using pharmaceuticals purchased through the 340B Drug Discount Program bill the Program a Usual and Customary price that reflected the 340B discounted price.

CRDP PROVIDER BULLETINS: 2011

January 4, 2011 -- Medicare Part D Partner Plan Assignments: Each year during the Medicare Part D open enrollment period, the PACE, CRDP and SPBP Programs solicit qualified Prescription Drug Plans who are interested in partnering with the Programs to provide a coordinated benefit.

January 6, 2011 -- Medicare Part D Additional Cardholders: Enclosed is an ADDITIONAL list of Medicare Part D cardholders.

January 14, 2011 -- PART D PARTNER PLAN UPDATE: WELLCARE PCN: The WellCare Classic PCN of 01410000 included on the cardholder Medicare Part D plan lists that were previously distributed omitted the leading (or first) zero (0). The BIN/PCN combinations accompanying each member’s ID should have been BIN 603286;01410000; not 603286;1410000. Claims submitted to WellCare without the leading zero in the PCN will deny.

January 21, 2011 -- OTHER PAYER BIN: When submitting a claim to PACE/CRDP/SPBP as the secondary payer, be sure the BIN entered in the primary claim is the same as the BIN entered in the COB segment.

January 28, 2011 -- PART D PRIMARY PLAN EDIT: Effective Tuesday, February 1, 2011, claims billed to the cardholder’s incorrect primary plan will deny with NCPDP Reject Code 7C: Missing / Invalid Other Payer ID.

May 16, 2011 -- Chain Provider Voids: The PACE processing system will be implementing a change effective October 1, 2011, that may impact chain providers.

May 16, 2011 -- Same Cycle Voids: The PACE processing system will be implementing

July 15, 2011 -- PRIMARY PRESCRIPTION PLAN INFORMATION: This is a reminder that state auditors may request information to verify primary plans’ responses for claims submitted to PACE, which includes PACE and PACENET claims as well as eight other state pharmacy benefits administered by PACE. In addition, the auditors may request documentation pertaining to other state agency pharmacy benefits for which they have auditing responsibilities.a change effective October 1, 2011, affecting claims paid and voided within the same processing cycle. PACE processing cycles begin 7AM Friday and ends 10PM Thursday.

July 22, 2011 -- Provider Payment Specifications Information: Provider reimbursement requirements are reflected in this bulletin

September 9, 2011 -- NCPDP VERSION 5.1 PROCESSING CHANGES: Effective Saturday November 12, 2011, claims for PACE and all of the ancillary programs administered by the Department of Aging will by adjudicated through the Magellan FirstRx claims processing system. This upgrade from the current mainframe is in preparation for the January 2012 transition to NCPDP vD. Ø

October 14, 2011 -- NCPDP VERSION D.Ø: NCPDP VERSION DØ specifications are being emailed to all PACE software vendors. This mailing will be completed by Monday October 17, 2011.

November 4, 2011 -- NOVEMBER 12, 2011 IMPLEMENTATION POSTPONED: The implementation of the PACE new processing system for processing v.5.1 claims originally scheduled for Saturday, November 12, 2011 has been postponed.

November 23, 2011 -- NCPDP VERSION D.Ø UPDATE: The acceptance of PACE D.Ø claims originally scheduled to begin on December 5, 2011 has been delayed. Claims submitted to PACE and all programs administered by the Department of Aging are to continue to be submitted on NCPDP version 5.1. Claims submitted to PACE version D.Ø will deny. A new date for accepting version D.Ø has not been finalized.

November 23, 2011 -- Pennsylvania PACE and Ancillary Programs D.0 Payer Specification: NCPDP Version D Claim Billing/Claim Re-bill Template - Request Claim Billing/Claim Re-bill Payer Sheet Template 

December 16, 2011 -- NCPDP VERSION D IMPLEMENTATION UPDATE: Claims for PACE, SPBP, CRDP and all plans administered by the Department of Aging are to continue to be submitted on NCPDP version 5.1 beyond January 1, 2012.

CRDP PROVIDER BULLETINS: 2012

January 12, 2012 -- Medicare Part D Plans with Premium Agreements: The following Part D plans have premium agreements with the PACE program.

March 6, 2012 -- March 31, 2012 D.Ø POSTPONEMENT: Claims submitted for PACE, CRDP, SPBP and all ancillary programs administered by the Department of Aging must continue to be submitted in NCPDP v5.1 past the March 31, 2012 CMS deadline.

March 16, 2012 - April 21, Implemetation: On Saturday, April 21, 2012, PACE will begin accepting NCPDP vD.Ø on its new processing platform. Claims submitted for PACE, CRDP, SPBP and all ancillary programs administered by the Department of Aging are to continue to be submitted in NCPDP v5.1 until that date. Claims submitted in D.Ø before April 21, 2012 will deny.

April 10, 2012 -- April 21, 2012 IMPLEMENTATION REMINDER: As stated in an earlier bulletin, on Saturday April 21, 2012, PACE will begin accepting claims in NCPDP vD.Ø for PACE, CRDP, SPBP and all ancillary programs. Claims submitted in version D.Ø before April 21, 2012 will deny.

April 16, 2012 -- PACE Portal: On Saturday, April 21, 2012, the Pennsylvania Department of Aging is introducing a new website: papaceportal.magellanhealth.com. The Pennsylvania PACE portal is designed to assist cardholders, pharmacies, and physicians by providing information about PACE and other pharmacy programs it administers, as well as providing links to Pennsylvania governmental websites.

May 4, 2012 -- NCPDP v5.1 Claims: Effective Monday May 7, 2012, claims submitted in NCPDP version 5.1 will deny with NCPDP Error "Ø2: Missing / Invalid Version Number" for the following programs...:

May 14, 2012 -- Prescriber NPI Edit: PACE D.Ø specifications require the prescriber's NPI (Prescriber ID field 411-DB) for all claims unless the cardholder's primary plan requires the prescriber's DEA.

September 28, 2012 -- NON-PARTICIPATING MANUFACTURERS: The manufacturers identified below have declined to sign a rebate agreement with the Commonwealth of Pennsylvania. Effective Tuesday October 2, 2012 claims submitted for their products will no longer be considered for reimbursement by PACE or CRDP.

October 3, 2012 -- FUL (Federal Upper Limit) Pricing: The Program has discovered that the Medical Economics (Red Book) pricing files received in June and July 2012 contained some incorrect FUL prices that impacted reimbursement for PACE, CRDP and SPBP claims. The Program is currently in the process of analyzing these pricing files to identify which FUL prices were incorrect. When this process is complete and the pricing is corrected, all affected claims will be adjusted by the Program.

December 11, 2012--Pharmacy's NPI submitted as the Prescriber's NPI: On April 21, 2012, PACE began accepting only NCPDP version D.Ø. In conjunction with this version change, PACE required the prescriber's NPI, not the physician's state license number be submitted in the prescriber field. Note: The DEA number is accepted only when PACE is the secondary payor.

December 12, 2012--FUL (Federal Upper Limit) Pricing UPDATE: As explained in the October FUL Bulletin, the Program discovered the Medical Economics (Red Book) pricing files received in June and July 2012 contained some incorrect FUL prices that impacted PACE, CRDP and SPBP claims reimbursement.

 

CRDP PROVIDER BULLETINS: 2013

 

May 10, 2013-- FUL (Federal Upper Limit) Reprocessing and New FUL August Pricing-- FUL REPOROCESSING: The incorrect prices received from Medical Economics (Red Book) pricing files and applied to claims in June through October 2012 have been identified and are being reprocessed.-- NEW FUL AUGUST PRICING: The Department of Health and Human Services, Centers for Medicare & Medicaid Services has announced on their website that 42 CFR Part 447[CMS2345:P], Covered Outpatient Drugs of the Affordable Health Care Act, will become effective August 2013. These Covered Outpatient Drugs are subject to the new FUL prices.

 

May 31, 2013 -- NON-PARTICIPATING MANUFACTURERS: The following three manufacturers have notified the PACE program that they will be terminating their participation in the rebate program. Listed below are the effective dates of their termination and some of their pharmaceuticals.

 

July 1, 2013--NON-PARTICIPATING MANUFACTURERS: Effective Monday July 1, 2013, the following manufacturers are being terminated from participation in the Commonwealth of Pennsylvania Drug Manufacturers' rebate program for failure to comply with their rebate agreement. PACE, CDRP and SPBP will no longer be permitted to reimburse for these products.

 

July 2, 2013--***REVISED*** NON-PARTICIPATING MANUFACTURERS: ***REMOVED: Apotex, lebeler 60505, has notified the Program of its intent to comply with the Commonwealth's rebate agreement. Therefor, effective immediately, Apotex pharmaceuticals are removed from this list and WILL BE accepted for reimbursement. ***DATE CHANGE: Effective Thursday August 1, 2013, the floowing manuafcturers are being terminated from participation in the Commonwealth of Pennsylvania Drug Manufacturers' rebate program for failure to comply with their rebate agreement. PACE, CRDP and SPBP will no longer be permitted to reimburse for these products.

 

July 25, 2013 -- ***UPDATE*** NON-PARTICIPATING MANUFACTURERS: The Non-Participating Manufacturers Bulletin dated July 2, 2013 listed ten (10) labelers that were being terminated on Thursday August 1, 2013 for failing to comply with the Commonwealth of Pennsylvania's Drug Manufacturers' rebate program agreement. ***Two (2) manufacturers, Apotex, labeler 60505 and Ascend, labeler 67877, have since been removed from this list. Only 8 remain on the list.

 

July 26, 2013 -- MEDICARE PART D 90 DAY SUPPLY PRESCRIPTION REFILL EDIT: Currently the Program permits a prescription to be refilled five (5) times within six (6) months, whichever occurs first, from the date of the original fill. Cardholders using only PACE or having a primary that only permits a thirty day supply, usually have their chronic medication prescriptions last six months.

 

July 29, 2013 -- Rewards/Loyalty/Gas Points Programs: Questions have been received by the Department of Aging regarding the OIG's position on rewards programs in respect to Federal health care programs.

 

 September 20, 2013 -- Program Compliance Reminder: Providers are reminded that claims will be disallowed on audit if...

 

September 25, 2013 -- Coordination of Benefits (COB) Edit Logic Enhancement: Effective October 5, 2013, PACE will be enhancing the processing system logic to ensure that all D.Ø COB validation edits are applied according to NCPDP guidance. A review of paid claims identified two (2) submission instances that will deny on October 5, 2013.

 

November 27, 2013 -- NON-PARTICIPATING MANUFACTURER - Labeler Code 00064:  Healthpoint Ltd., and Smith & Nephew Inc., Biotherapeutics, labeler code 00064 have notified the PACE, CRDP and SPBP programs that they will be terminating their participation in the Commonwealth’s rebate program effective December 6, 2013. Providers may wish to advise cardholders using medications manufactured by this company that beginning Friday, December 6, 2013, PACE, CRDP and SPBP will no longer be permitted to reimburse for any of their products.

 

November 27, 2013 -- Re:  Mandate January 1, 2014:  Covered Entities must comply with CAQH Phase III CORE® EFT and ERA Operating Rules per Section 1104 of the ACA (Affordable Healthcare Act).  This letter is to inform you that Magellan Health Services is presently seeking to comply with the new CMS (Centers for Medicare & Medicaid Services) requirements effective January 1, 2014, as communicated through the CAQH (Committee for Affordable Quality Healthcare) Phase III CORE®  EFT and ERA Operating Rules section 1104. The required changes apply to covered entities that use, conduct, or process the v5010 835 transaction and EFT.

 

December 20, 2013 -- CAQH (Committee for Affordable Quality Healthcare) CORE® (Committee on Operating Rules for Information Exchange) EFT and ERA UPDATE: On November 27, 2013 all providers were notified that the Program was in the process of making minor changes to the Electronic Funds Transfer (EFT) and the Electronic Remittance Advice (ERA) to comply with the new CMS (Centers for Medicare & Medicaid Services) requirements.

PAP (Pennsylvania Patient Assistance Program) PROVIDER BULLETINS: 2010

May 14, 2010 -- PA PAP (Pennsylvania Patient Assistance Progran) New Programs:  Effective immediately, PAP will begin enrolling eligible patients into four revised programs.

PAP (Pennsylvania Patient Assistance Program) PROVIDER BULETINS: 2012

December 11, 2012--NEW PAP PROGRAM--Lupron ll Settlement: Effective immediately, PAP will begin enrolling eligible patients into the PAP 5 / Lupron ll Settlement program.

PKU PROVIDER BULLETINS:  2010

September, 2010 - PKU Formulary Additions:  Effective September 1, 2010, the products listed below have been added to the PKU (Phenylketonuria) formulary:

PKU PROVIDER BULLETINS: 2011

July 15, 2011 -- PRIMARY PRESCRIPTION PLAN INFORMATION: This is a reminder that state auditors may request information to verify primary plans’ responses for claims submitted to PACE, which includes PACE and PACENET claims as well as eight other state pharmacy benefits administered by PACE. In addition, the auditors may request documentation pertaining to other state agency pharmacy benefits for which they have auditing responsibilities.

July 22, 2011 -- Provider Payment Specifications Information: Provider reimbursement requirements are reflected in this bulletin

September 9, 2011 -- NCPDP VERSION 5.1 PROCESSING CHANGES: Effective Saturday November 12, 2011, claims for PACE and all of the ancillary programs administered by the Department of Aging will by adjudicated through the Magellan FirstRx claims processing system. This upgrade from the current mainframe is in preparation for the January 2012 transition to NCPDP vD. Ø

October 14, 2011 -- NCPDP VERSION D.Ø: NCPDP VERSION DØ specifications are being emailed to all PACE software vendors. This mailing will be completed by Monday October 17, 2011.

November 4, 2011 -- NOVEMBER 12, 2011 IMPLEMENTATION POSTPONED: The implementation of the PACE new processing system for processing v.5.1 claims originally scheduled for Saturday, November 12, 2011 has been postponed.

November 23, 2011 -- NCPDP VERSION D.Ø UPDATE: The acceptance of PACE D.Ø claims originally scheduled to begin on December 5, 2011 has been delayed. Claims submitted to PACE and all programs administered by the Department of Aging are to continue to be submitted on NCPDP version 5.1. Claims submitted to PACE version D.Ø will deny. A new date for accepting version D.Ø has not been finalized.

November 23, 2011 -- Pennsylvania PACE and Ancillary Programs D.0 Payer Specification: NCPDP Version D Claim Billing/Claim Re-bill Template - Request Claim Billing/Claim Re-bill Payer Sheet Template 

December 16, 2011 -- NCPDP VERSION D IMPLEMENTATION UPDATE: Claims for PACE, SPBP, CRDP and all plans administered by the Department of Aging are to continue to be submitted on NCPDP version 5.1 beyond January 1, 2012.

PKU PROVIDER BULLETINS: 2012

January 12, 2012 -- Medicare Part D Plans with Premium Agreements: The following Part D plans have premium agreements with the PACE program.

March 6, 2012 -- March 31, 2012 D.Ø POSTPONEMENT: Claims submitted for PACE, CRDP, SPBP and all ancillary programs administered by the Department of Aging must continue to be submitted in NCPDP v5.1 past the March 31, 2012 CMS deadline.

March 16, 2012 - April 21, Implemetation: On Saturday, April 21, 2012, PACE will begin accepting NCPDP vD.Ø on its new processing platform. Claims submitted for PACE, CRDP, SPBP and all ancillary programs administered by the Department of Aging are to continue to be submitted in NCPDP v5.1 until that date. Claims submitted in D.Ø before April 21, 2012 will deny.

April 10, 2012 -- April 21, 2012 IMPLEMENTATION REMINDER: As stated in an earlier bulletin, on Saturday April 21, 2012, PACE will begin accepting claims in NCPDP vD.Ø for PACE, CRDP, SPBP and all ancillary programs. Claims submitted in version D.Ø before April 21, 2012 will deny.

April 16, 2012 -- PACE Portal: On Saturday, April 21, 2012, the Pennsylvania Department of Aging is introducing a new website: papaceportal.magellanhealth.com. The Pennsylvania PACE portal is designed to assist cardholders, pharmacies, and physicians by providing information about PACE and other pharmacy programs it administers, as well as providing links to Pennsylvania governmental websites.

May 4, 2012 -- NCPDP v5.1 Claims: Effective Monday May 7, 2012, claims submitted in NCPDP version 5.1 will deny with NCPDP Error "Ø2: Missing / Invalid Version Number" for the following programs...:

May 14, 2012 -- Prescriber NPI Edit: PACE D.Ø specifications require the prescriber's NPI (Prescriber ID field 411-DB) for all claims unless the cardholder's primary plan requires the prescriber's DEA.

SPBP PROVIDER BULLETINS: 2010

January 1, 2010 -- SPBP MA Bulletin: The SPBP MA Bulletin for the Revised Formulary has been released with an effective date of January 1, 2010.

February 19, 2010 SPBP Cardholder with Non-Part D Prescription Plans: Some SPBP cardholders may have a primary prescription plan which is not Part D coverage.

May 18, 2010 -- FORMULARY UPDATE: Act 128-1992 amending the Lottery Fund Preservation Act, in part, requires all pharmaceutical manufacturers to have in effect a rebate agreement with the PACE Program if they wish to have their products covered.

December 1, 2010 -- SP1 Cardholder - New GROUP ID: Effective January 1, 2011, the Group ID for cardholders whose SPBP Identification Number begins with SP1 is changing from SPBP to ADAP. However, the Group ID for SPBP cardholders whose SPBP Identification Number begins SP2 remains unchanged, i.e., SPBP.

December 17, 2010 -- 340B PRICING Retraction: Effective immediately, the Department of Aging is withdrawing the June 21, 2010 Bulletin mandating that providers submitting claims using pharmaceuticals purchased through the 340B Drug Discount Program bill the Program a Usual and Customary price that reflected the 340B discounted price.

SPBP PROVIDER BULLETINS: 2011

January 4, 2011 -- Medicare Part D Partner Plan Assignments: Each year during the Medicare Part D open enrollment period, the PACE, CRDP and SPBP Programs solicit qualified Prescription Drug Plans who are interested in partnering with the Programs to provide a coordinated benefit.

January 6, 2011 -- Medicare Part D Additional Cardholders: Enclosed is an ADDITIONAL list of Medicare Part D cardholders.

January 14, 2011 -- PART D PARTNER PLAN UPDATE: WELLCARE PCN: The WellCare Classic PCN of 01410000 included on the cardholder Medicare Part D plan lists that were previously distributed omitted the leading (or first) zero (0). The BIN/PCN combinations accompanying each member’s ID should have been BIN 603286;01410000; not 603286;1410000. Claims submitted to WellCare without the leading zero in the PCN will deny.

January 21, 2011 -- OTHER PAYER BIN: When submitting a claim to PACE/CRDP/SPBP as the secondary payer, be sure the BIN entered in the primary claim is the same as the BIN entered in the COB segment.

January 28, 2011 -- PART D PRIMARY PLAN EDIT: Effective Tuesday, February 1, 2011, claims billed to the cardholder’s incorrect primary plan will deny with NCPDP Reject Code 7C: Missing / Invalid Other Payer ID.

May 16, 2011 -- Chain Provider Voids: The PACE processing system will be implementing a change effective October 1, 2011, that may impact chain providers.

May 16, 2011 -- Same Cycle Voids: The PACE processing system will be implementing a change effective October 1, 2011, affecting claims paid and voided within the same processing cycle. PACE processing cycles begin 7AM Friday and ends 10PM Thursday.

July 15, 2011 -- PRIMARY PRESCRIPTION PLAN INFORMATION: This is a reminder that state auditors may request information to verify primary plans’ responses for claims submitted to PACE, which includes PACE and PACENET claims as well as eight other state pharmacy benefits administered by PACE. In addition, the auditors may request documentation pertaining to other state agency pharmacy benefits for which they have auditing responsibilities.

July 22, 2011 -- Provider Payment Specifications Information: Provider reimbursement requirements are reflected in this bulletin

September 9, 2011 -- NCPDP VERSION 5.1 PROCESSING CHANGES: Effective Saturday November 12, 2011, claims for PACE and all of the ancillary programs administered by the Department of Aging will by adjudicated through the Magellan FirstRx claims processing system. This upgrade from the current mainframe is in preparation for the January 2012 transition to NCPDP vD. Ø

October 14, 2011 -- NCPDP VERSION D.Ø: NCPDP VERSION DØ specifications are being emailed to all PACE software vendors. This mailing will be completed by Monday October 17, 2011.

November 4, 2011 -- NOVEMBER 12, 2011 IMPLEMENTATION POSTPONED: The implementation of the PACE new processing system for processing v.5.1 claims originally scheduled for Saturday, November 12, 2011 has been postponed.

November 23, 2011 -- NCPDP VERSION D.Ø UPDATE: The acceptance of PACE D.Ø claims originally scheduled to begin on December 5, 2011 has been delayed. Claims submitted to PACE and all programs administered by the Department of Aging are to continue to be submitted on NCPDP version 5.1. Claims submitted to PACE version D.Ø will deny. A new date for accepting version D.Ø has not been finalized.

November 23, 2011 -- Pennsylvania PACE and Ancillary Programs D.0 Payer Specification: NCPDP Version D Claim Billing/Claim Re-bill Template - Request Claim Billing/Claim Re-bill Payer Sheet Template 

December 16, 2011 -- NCPDP VERSION D IMPLEMENTATION UPDATE: Claims for PACE, SPBP, CRDP and all plans administered by the Department of Aging are to continue to be submitted on NCPDP version 5.1 beyond January 1, 2012.

SPBP PROVIDER BULLETINS: 2012

January 12, 2012 -- Medicare Part D Plans with Premium Agreements: The following Part D plans have premium agreements with the PACE program.

March 6, 2012 -- March 31, 2012 D.Ø POSTPONEMENT: Claims submitted for PACE, CRDP, SPBP and all ancillary programs administered by the Department of Aging must continue to be submitted in NCPDP v5.1 past the March 31, 2012 CMS deadline.

March 16, 2012 - April 21, Implemetation: On Saturday, April 21, 2012, PACE will begin accepting NCPDP vD.Ø on its new processing platform. Claims submitted for PACE, CRDP, SPBP and all ancillary programs administered by the Department of Aging are to continue to be submitted in NCPDP v5.1 until that date. Claims submitted in D.Ø before April 21, 2012 will deny.

April 10, 2012 -- April 21, 2012 IMPLEMENTATION REMINDER: As stated in an earlier bulletin, on Saturday April 21, 2012, PACE will begin accepting claims in NCPDP vD.Ø for PACE, CRDP, SPBP and all ancillary programs. Claims submitted in version D.Ø before April 21, 2012 will deny.

April 16, 2012 -- PACE Portal: On Saturday, April 21, 2012, the Pennsylvania Department of Aging is introducing a new website: papaceportal.magellanhealth.com. The Pennsylvania PACE portal is designed to assist cardholders, pharmacies, and physicians by providing information about PACE and other pharmacy programs it administers, as well as providing links to Pennsylvania governmental websites.

May 4, 2012 -- NCPDP v5.1 Claims: Effective Monday May 7, 2012, claims submitted in NCPDP version 5.1 will deny with NCPDP Error "Ø2: Missing / Invalid Version Number" for the following programs...:

May 14, 2012 -- Prescriber NPI Edit: PACE D.Ø specifications require the prescriber's NPI (Prescriber ID field 411-DB) for all claims unless the cardholder's primary plan requires the prescriber's DEA.

October 3, 2012 -- FUL (Federal Upper Limit) Pricing: The Program has discovered that the Medical Economics (Red Book) pricing files received in June and July 2012 contained some incorrect FUL prices that impacted reimbursement for PACE, CRDP and SPBP claims. The Program is currently in the process of analyzing these pricing files to identify which FUL prices were incorrect. When this process is complete and the pricing is corrected, all affected claims will be adjusted by the Program.

December 11, 2012--Pharmacy's NPI submitted as the Prescriber's NPI: On April 21, 2012, PACE began accepting only NCPDP version D.Ø. In conjunction with this version change, PACE required the prescriber's NPI, not the physician's state license number be submitted in the prescriber field. Note: The DEA number is accepted only when PACE is the secondary payor.

December 12, 2012--FUL (Federal Upper Limit) Pricing UPDATE:  As explained in the October FUL Bulletin, the Program discovered the Medical Economics (Red Book) pricing files received in June and July 2012 contained some incorrect FUL prices that impacted PACE, CRDP and SPBP claims reimbursement.

 

SPBP PROVIDER BULLETINS: 2013

 May 10, 2013-- FUL (Federal Upper Limit) Reprocessing and New FUL August Pricing-- FUL REPOROCESSING: The incorrect prices received from Medical Economics (Red Book) pricing files and applied to claims in June through October 2012 have been identified and are being reprocessed.-- NEW FUL AUGUST PRICING: The Department of Health and Human Services, Centers for Medicare & Medicaid Services has announced on their website that 42 CFR Part 447[CMS2345:P], Covered Outpatient Drugs of the Affordable Health Care Act, will become effective August 2013. These Covered Outpatient Drugs are subject to the new FUL prices.

 

May 31, 2013 -- NON-PARTICIPATING MANUFACTURERS: The following three manufacturers have notified the PACE program that they will be terminating their participation in the rebate program. Listed below are the effective dates of their termination and some of their pharmaceuticals.

 

July 1, 2013--NON-PARTICIPATING MANUFACTURERS: Effective Monday July 1, 2013, the following manufacturers are being terminated from participation in the Commonwealth of Pennsylvania Drug Manufacturers' rebate program for failure to comply with their rebate agreement. PACE, CDRP and SPBP will no longer be permitted to reimburse for these products.

 

July 2, 2013--***REVISED*** NON-PARTICIPATING MANUFACTURERS: ***REMOVED: Apotex, lebeler 60505, has notified the Program of its intent to comply with the Commonwealth's rebate agreement. Therefor, effective immediately, Apotex pharmaceuticals are removed from this list and WILL BE accepted for reimbursement. ***DATE CHANGE: Effective Thursday August 1, 2013, the floowing manuafcturers are being terminated from participation in the Commonwealth of Pennsylvania Drug Manufacturers' rebate program for failure to comply with their rebate agreement. PACE, CRDP and SPBP will no longer be permitted to reimburse for these products.

 

July 25, 2013 -- ***UPDATE*** NON-PARTICIPATING MANUFACTURERS: The Non-Participating Manufacturers Bulletin dated July 2, 2013 listed ten (10) labelers that were being terminated on Thursday August 1, 2013 for failing to comply with the Commonwealth of Pennsylvania's Drug Manufacturers' rebate program agreement. ***Two (2) manufacturers, Apotex, labeler 60505 and Ascend, labeler 67877, have since been removed from this list. Only 8 remain on the list.

 

July 26, 2013 -- MEDICARE PART D 90 DAY SUPPLY PRESCRIPTION REFILL EDIT: Currently the Program permits a prescription to be refilled five (5) times within six (6) months, whichever occurs first, from the date of the original fill. Cardholders using only PACE or having a primary that only permits a thirty day supply, usually have their chronic medication prescriptions last six months.

 

July 29, 2013 -- Rewards/Loyalty/Gas Points Programs: Questions have been received by the Department of Aging regarding the OIG's position on rewards programs in respect to Federal health care programs.

 

 September 20, 2013 -- Program Compliance Reminder: Providers are reminded that claims will be disallowed on audit if...

 

September 25, 2013 -- Coordination of Benefits (COB) Edit Logic Enhancement: Effective October 5, 2013, PACE will be enhancing the processing system logic to ensure that all D.Ø COB validation edits are applied according to NCPDP guidance. A review of paid claims identified two (2) submission instances that will deny on October 5, 2013.

 

November 27, 2013 -- NON-PARTICIPATING MANUFACTURER - Labeler Code 00064:  Healthpoint Ltd., and Smith & Nephew Inc., Biotherapeutics, labeler code 00064 have notified the PACE, CRDP and SPBP programs that they will be terminating their participation in the Commonwealth’s rebate program effective December 6, 2013. Providers may wish to advise cardholders using medications manufactured by this company that beginning Friday, December 6, 2013, PACE, CRDP and SPBP will no longer be permitted to reimburse for any of their products.

 

November 27, 2013 -- Re:  Mandate January 1, 2014:  Covered Entities must comply with CAQH Phase III CORE® EFT and ERA Operating Rules per Section 1104 of the ACA (Affordable Healthcare Act).  This letter is to inform you that Magellan Health Services is presently seeking to comply with the new CMS (Centers for Medicare & Medicaid Services) requirements effective January 1, 2014, as communicated through the CAQH (Committee for Affordable Quality Healthcare) Phase III CORE®  EFT and ERA Operating Rules section 1104. The required changes apply to covered entities that use, conduct, or process the v5010 835 transaction and EFT.

 

December 20, 2013 -- CAQH (Committee for Affordable Quality Healthcare) CORE® (Committee on Operating Rules for Information Exchange) EFT and ERA UPDATE: On November 27, 2013 all providers were notified that the Program was in the process of making minor changes to the Electronic Funds Transfer (EFT) and the Electronic Remittance Advice (ERA) to comply with the new CMS (Centers for Medicare & Medicaid Services) requirements.

 

 

SPBP PROVIDER BULLETIN FOR 2014

 

May 15, 2014 -- SPBP REENROLLMENT AGREEMENTAt the end of May, providers enrolled in the Special Pharmaceutical Benefits Program will be sent a SPBP re-enrollment packet. Included in this packet will be the new Agreement, a cover letter from the Special Pharmaceutical Benefits Program explaining the reason for the re-enrollment and a self-addressed return envelope to facilitate its return to the Program.

 

 

SWIF PROVIDER BULLETINS: 2009

August 28, 2009 -- SWIF and Cypress Care: Providers enrolled in the SWIF program administered by the Pennsylvania Department of Aging may have learned that Medrisk was recently awarded a contract to implement a Preferred Provider Organization for SWIF policyholders.

SWIF PROVIDER BULLETINS: 2010

February 25, 2010 TERMINATION OF AGREEMENT: In accordance with Section IV, subsection A, of the SWIF Provider Agreement cited below, the Pennsylvania Department of Aging hereby notifies all enrolled SWIF Providers that their SWIF Provider Agreements are terminated effective 10 PM, Wednesday, March 31, 2010.

SWIF PROVIDER BULLETINS: 2011

July 15, 2011 -- PRIMARY PRESCRIPTION PLAN INFORMATION: This is a reminder that state auditors may request information to verify primary plans’ responses for claims submitted to PACE, which includes PACE and PACENET claims as well as eight other state pharmacy benefits administered by PACE. In addition, the auditors may request documentation pertaining to other state agency pharmacy benefits for which they have auditing responsibilities.

July 22, 2011 -- Provider Payment Specifications Information: Provider reimbursement requirements are reflected in this bulletin

September 9, 2011 -- NCPDP VERSION 5.1 PROCESSING CHANGES: Effective Saturday November 12, 2011, claims for PACE and all of the ancillary programs administered by the Department of Aging will by adjudicated through the Magellan FirstRx claims processing system. This upgrade from the current mainframe is in preparation for the January 2012 transition to NCPDP vD. Ø

October 14, 2011 -- NCPDP VERSION D.Ø: NCPDP VERSION DØ specifications are being emailed to all PACE software vendors. This mailing will be completed by Monday October 17, 2011.

November 4, 2011 -- NOVEMBER 12, 2011 IMPLEMENTATION POSTPONED: The implementation of the PACE new processing system for processing v.5.1 claims originally scheduled for Saturday, November 12, 2011 has been postponed.

November 23, 2011 -- NCPDP VERSION D.Ø UPDATE: The acceptance of PACE D.Ø claims originally scheduled to begin on December 5, 2011 has been delayed. Claims submitted to PACE and all programs administered by the Department of Aging are to continue to be submitted on NCPDP version 5.1. Claims submitted to PACE version D.Ø will deny. A new date for accepting version D.Ø has not been finalized.

November 23, 2011 -- Pennsylvania PACE and Ancillary Programs D.0 Payer Specification: NCPDP Version D Claim Billing/Claim Re-bill Template - Request Claim Billing/Claim Re-bill Payer Sheet Template 

December 16, 2011 -- NCPDP VERSION D IMPLEMENTATION UPDATE: Claims for PACE, SPBP, CRDP and all plans administered by the Department of Aging are to continue to be submitted on NCPDP version 5.1 beyond January 1, 2012.

SWIF PROVIDER BULLETINS: 2012

January 12, 2012 -- Medicare Part D Plans with Premium Agreements: The following Part D plans have premium agreements with the PACE program.

March 6, 2012 -- March 31, 2012 D.Ø POSTPONEMENT: Claims submitted for PACE, CRDP, SPBP and all ancillary programs administered by the Department of Aging must continue to be submitted in NCPDP v5.1 past the March 31, 2012 CMS deadline.

March 16, 2012 - April 21, Implemetation: On Saturday, April 21, 2012, PACE will begin accepting NCPDP vD.Ø on its new processing platform. Claims submitted for PACE, CRDP, SPBP and all ancillary programs administered by the Department of Aging are to continue to be submitted in NCPDP v5.1 until that date. Claims submitted in D.Ø before April 21, 2012 will deny.

April 10, 2012 -- April 21, 2012 IMPLEMENTATION REMINDER: As stated in an earlier bulletin, on Saturday April 21, 2012, PACE will begin accepting claims in NCPDP vD.Ø for PACE, CRDP, SPBP and all ancillary programs. Claims submitted in version D.Ø before April 21, 2012 will deny.

April 16, 2012 -- PACE Portal: On Saturday, April 21, 2012, the Pennsylvania Department of Aging is introducing a new website: papaceportal.magellanhealth.com. The Pennsylvania PACE portal is designed to assist cardholders, pharmacies, and physicians by providing information about PACE and other pharmacy programs it administers, as well as providing links to Pennsylvania governmental websites.

May 4, 2012 -- NCPDP v5.1 Claims: Effective Monday May 7, 2012, claims submitted in NCPDP version 5.1 will deny with NCPDP Error "Ø2: Missing / Invalid Version Number" for the following programs...:

May 14, 2012 -- Prescriber NPI Edit: PACE D.Ø specifications require the prescriber's NPI (Prescriber ID field 411-DB) for all claims unless the cardholder's primary plan requires the prescriber's DEA.