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 Version D.0 Plan setups for ECSS and CE2000 available for download!  (01/12/2019)
In order to provide our customers with the latest information on all Commercial, State Medicaid and Medicare Part D plan setups, we have made our entire automated database available for download! If you are an existing DayTech customer currently supported under annual maintenance and want to be able to download the latest Plan Setup list for your ECSS or CE2000 system from the Web, just contact us and we will provide you with the instructions on how to do it!  
The Electronic Plan List was last updated on 01/12/2019 and contains  2,170 Version D.0 Plan setups
The download also contains the NCPDP D.0 Data Dictionary as of 01/2019 and External Code List as of 9/2018
Integrated support for the Version D.0 Automated Plan List is supported in ECSS and CE2000 Version 9.3.1 and later.
Contact DayTech at 916.687.7500 if you need help with your ECSS or CE2000 Plan List update.
The information included in these setups is provided by the Payers to the Switches and then to DayTech. DayTech provides this information as-is, without warranty as to either its accuracy or timeliness. All DayTech claim submission products provide the User with the ability to set up new Insurance Plans from scratch and are not in any way dependent upon the use of automated plan setups. These automated setups are provided as a convenience only.

 Relay Health Public Internet Transmitter (08/01/2017)
Relay Health has released their new eClaims internet transmitter which is included in Version 9.4.1 of our products. The eClaims Transmitter uses enhanced encryption.

 RSI Public Internet Transmitter (08/01/2017)
RSI has released a new version of their Internet Transmitter which is included in Version 9.4.1 of our products. The RSI Transmitter uses enhanced encryption.

 Version 9.4.1 for CE2000 and ECSS is now available  (08/01/2017)
Supports the Version 3.1 RSI Public Internet Transmitter with enhanced encryption
Supports a new Relay eClaims Public Internet Transmitter with enhanced encryption
Supports Report Engine databases up to the year 2024
Includes the latest HIPAA-approved NCPDP Data Dictionary and External Code List
Includes the latest Electronic Plan List which contains automated setups for over 2,000 plans
The following features apply to Version 9.4.0 and higher:
Supports the new Version 2.5 RSI Internet Transmitter
Supports a new option to warn if a claim that is about to be transmitted still contains ICD9 Diagnosis Codes after the use of ICD10 Codes is required
Allows the User to receive Help on all screen objects using right-mouse clicks and by using the ? character in all text fields
Supports the new Medicare Part D LICS fields returned in the TrOOP Eligibility Transaction
Includes the latest NCPDP Data Dictionary and External Code List
Includes the latest Electronic Plan List which contains automatic setups for over 1,700 plans including the ACA Exchange Plans
Supports new Claims Import options (applies to CE2000 with Claims Import feature only)
control over the amount of CPU consumed during real-time claims imports
conversion of transmission aborts to time-out rejects
monitoring of the health & status of real-time claim imports
monitoring of the performance of real-time claim imports

The following features apply to Version 9.3.1 and higher:

Supports optional printing the CMS Right of Appeal Notice for rejected drugs
Supports the addition of Version D.0 plans through the Electronic Plan List feature
Provides enhancements to the Login and Password process
Provides several enhancements to the Claims Import feature
Optionally converts Aborted claims into Timeout Rejects
Optionally erases and recreates receiving CE2000 batches before importing to them
Optonally stops and restarts a stalled Internet Transmitter
Captures new Medicare Part D response data, Benefit Stage data and Approved Message data to the RTB file
Expands the Report Engine to include all years up to 2020
Displays the current usage of CE2000 databases as a percent of the maximum
Warns CE2000 System Admins if a database reaches 80% of its maximum capacity
Adjusts Y2K date windowing to 1800-1919 (mm/dd/ccyy) and 1920-2099 (mmddyy)
Allows the addition of new concurrent Clients to CE2000 without touching existing Clients


The following features apply to Version 9.2 and higher:

All Version D.0 Transaction Types are supported
E1 - Eligibility (Medicare Part D Troop Facilitation)
B1, B2 and B3 Claim Billing
S1, S2 and S3 Service Billing
D1 Predetermination of Benefits
P1, P2, P3 and P4 Prior Authorization (both Claims and Services)
N1, N2 and N3 Information Reporting (both Claims and Services)
C1, C2 and C3 Controlled Substance Reporting

New Version 5.1 plans can be added using the Electronic Plan List and then converted to Version D.0 with a single mouse click!

Existing Version 5.1 plans can be converted to Version D.0 with a single mouse click as well!

Version 5.1 Batch Claims and Claim Images will convert to Version D.0 on-the-fly the next time they are used after their parent Plan is converted to Version D.0!

The CE2000 Import feature has been enhanced to fully support Version D.0. All of the Transaction Types listed above can be imported!

The CE2000 Import feature can now map Superset Imports automatically! This feature allows you to define the field mapping for your SuperSet one time and then apply it to your Plans with a single mouse click! This feature supports both Versions 5.1 and D.0.

All Version D.0 Response fields are supported.

Both ECSS and CE2000 continue to support NCPDP Versions 32, 3A, 3B, 3C and 5.1 as well as Version D.0.

Note:    DayTech began shipping Version 9.3 on 3/1/2010. Existing systems will be updated per their normal annual maintenance schedule.


 The following features apply to Version 8.0 and higher:

The ECSS underlying database structure has been expanded to accomodate new NCPDP standards expected to be adopted in the next round of HIPAA regulations.
The management of User Accounts, IDs and Passwords in ECSS Version 8.0 has been enhanced to support the requirements of the Gramm-Leach Bliley Act as well as the Sarbanes-Oxley Act.
The ECSS Print Audit reporting capabilities have been enhanced.
ECSS Version 8 is now a 32 bit product designed to support both older and new versions of Microsoft Windows. It is compatible with Windows XP and higher.
The CE2000 underlying database structure has been expanded to accomodate new NCPDP standards expected to be adopted in the next round of HIPAA regulations.
CE2000 now supports ODBC database connectivity in addition to the previous DAO connectivity. This allows CE2000 to support Microsoft Sequel Server databases in addition to Microsoft Access databases.
The CE2000 Print Audit reporting capabilities have been enhanced.

 The  following features apply to Version 7.5 and higher:
The Enhanced Medicare Part D Eligibility transaction is now supported in the Medicare Part D message area.
New Medicare Part D structured reject codes approved by the NCPDP in November of 2006 have been added to the Data Dictionary.
Users can now define any batch as their "default" batch and change it as required.
New fields and functionality have been added to the Claims Import feature of CE2000.
New fields have been added to the CE2000 Report Engine.
Details regarding all of these features and updated documentation pages are included with the 7.5 Update package.

 The following feature applies to Version 7.4 and higher:
Reject messages, considered critical to Medicare Part D, that cannot currently be included in the NCPDP Standard due to HIPAA constraints are now supported using the 'structured messaging' methodology approved by the NCPDP in June of 2006.

 The following feature applies to Version 7.3 and higher:
Automated Medicare Part D plan setups are now included in the Plan List feature of both ECSS and CE2000.

 The following feature applies to Version 7.2 and higher:
The standard Medicare Part D response to a TrOOP Eligibility inquiry or from a PDP contains information about the patient's insurance plans. This information, includes the BIN#, PCN, Group ID, Cardholder ID and Plan Help Desk Phone number in a highly compressed format. While it is readable in this format, it is not very user-friendly. Version 7.2 removes this information from the text message area and places it in its own section of the audit page in a format that can be easily read and understood. Any other messages from the Payer are retained in the Message field.

 The following features apply to Version 7.1 and higher:
When Medicare Part D takes effect in January of 2006, Providers using ECSS and CE2000 will be able to submit prescription drug claims for Medicare Beneficiaries. They will also be able to check the eligibility of their Medicare patients as well as determine any other prescription drug insurance coverage that the patient has available. This information is provided by the Medicare Part D TrOOP Facilitator in response to an Eligibility Request submitted by the Provider.
Users will be able to redisplay their plans in order by BIN# and PCN as well as by Plan ID. This will assist in locating plans because the TrOOP Facilitator and PDP's return only the BIN# and PCN on Medicare Part D responses.
Providers will also be able to bill up to 9 additional payers using the Coordination of Benefits screen.
Both ECSS and CE2000 have the ability to save multiple copies of a claim making it easy to submit refill billing to multiple plans in the COB scenario.

The following features apply to Version 7.0 and higher:
The new Report Engine feature introduced in Version 7.0 allows users and/or management to create customized reports from the data collected during claims processing. These reports can be displayed, printed or exported to text files. Custom report layouts can be created, saved and reused as necessary. Reports are created using industry standard Structured Query Language (SQL).
All of the previous reporting functions of ECSS and CE2000 are still supported.
Additional information about the Report Engine can be found in the Product description area.
Version 7.0 expands the number of modem communications ports from 4 to 9.
Version 7.0 also supports the use of negative numbers in all currency fields. Negative number capability is now required by some plans and we anticipate that more will require this capability in the near future.
All documentation has been rewritten and converted to Adobe PFD format which can be viewed or printed directly from the User's desktop.

 Social Security Number Removal Initiative (01/01/2017)
With the implementation of ICD-10 under their belt, CMS has now turned their attention to what is being called the Social Security Number Removal Initiative. This initiative is intended to assign new ID numbers to all Medicare Beneficiaries by April of 2019.  By removing the Social Security from the current Medicare Health Care ID Number (HCIN), CMS hopes to better protect private health and financial information as well as federal health care benefit and service payments.

Additional information is available at: https://www.cms.gov/Outreach-and-Education/Look-Up-Topics/Medicare/SSNRI-Message.html

 ICD-10 Diagnosis Codes replace ICD-9  (10/01/2015)
Effective today prescription drug claims that previously required the use of ICD-9 Diagnosis Codes now require the use of ICD-10 codes.
The NCPDP Strategic National Implementation Process (SNIP) created an important white paper to assist the industry in the implementation of the ICD-10 code sets. The white paper and other information is available at http://www.ncpdp.org/Resources/HIPAA
Version 9.4 or both ECSS and CE2000 offer a new feature to help identify claims that contain ICD-9 codes at point-of-sale allowing the submitter to change them to ICD-10 before transmission. See the release notes that come with your Version 9.4 update for more details.

 HHS holds to 10/1/2015 ICD-10 compliance date  (06/04/2015)
The Department of Health and Human Services (HHS) issued a rule on July 31, 2014 finalizing October 1, 2015 as the new compliance date for healthcare providers, health plans, and healthcare clearinghouses to transition to ICD-10, the tenth revision of the International Classification of Diseases. This deadline allows providers, insurance companies and others in the healthcare industry time to ramp up their operations to ensure their systems and business processes are ready to go on October 1, 2015.
For more information on the rule, view the press release.
The NCPDP Strategic National Implementation Process (SNIP) created an important white paper to assist the industry in preparing for the implementation of the ICD-10 code sets. The white paper and other information is available at http://www.ncpdp.org/Resources/HIPAA under ICD-10 banner.


 Copaxone 20mg. Billing Unit Changes effective Q4 2014   (10/17/2014)

A new package configuration for Copaxone® 20mg NDC 68546-0317-30, which no longer contains alcohol swabs or any other
prepping supplies, was introduced in Q1 2014. A new National Drug Code (NDC) was not required by the FDA; however per
section 5.2.2 of the NCPDP Billing Unit Standard, the billing unit will be changed from 1 EA kit to 1 ML per syringe (package
size of 30).

Due to the significance of this change to the pharmacy industry, the drug compendia will make the changes
within the September/October 2014 timeframe and NCPDP has provided guidance on how to price this product correctly.

Additional Information may be found at:  http://ncpdp.org/NCPDP/media/pdf/UploadLinks/Copaxone-Billing-Unit-Changes.pdf

 Congress sets new date for ICD-10 implementation  (08/15/2014)
The requirement to use ICD-10 codes has now been set to 10/01/2015. The original date was supposed to be 10/01/2014 but President Obama signed H.R. 4302 Protecting Access to Medicare Act of 2014 which, among other things, delayed the conversion by at least a year.
Information on ICD-10 may be found at:   http://www.gpo.gov/fdsys/pkg/BILLS-113hr4302eh/pdf/BILLS-113hr4302eh.pdf

 CMS requires additional fields starting January 1, 2014 (12/27/2013)
Starting January 1st, CMS will require the following 3 fields on every Medicare Part D claim whether PDP or supplemental:
147-U7  Pharmacy Service Type
307-C7  Place of Service
384-4X  Patient Residence
You will need to add these fields to all of your active Medicare Part D plans prior to January 1st. All three are currently supported by ECSS and CE2000 and available in the Data Dictionary. New plans added using the current Electronic Plan List will automatically include these fields.

 CMS ICD-10 FAQ Site Announcement (06/20/2013)
The Centers for Medicare & Medicaid Services (CMS) has released three new FAQs about submitting ICD-10 claims around the October 1, 2014, deadline. These FAQs update previous information about submitting claims and explain how to split claims for services that span the October 1, 2014, transition date. The three new FAQs on ICD-10 billing discuss these topics:
    How do I report ICD-10 codes on claims when the dates of service span from prior to October 1, 2014 to on or after October 1, 2014? (#8246)
    If I submit or process a transaction with an ICD-9 code for a date of service after October 1, 2014, am I HIPAA compliant? (#8248)
    How long after the October 1, 2014 ICD-10 compliance date must I continue to report and/or process ICD-9 codes? (#8252)
You can find these questions and many other FAQs about ICD-10 at https://questions.cms.gov/.  Keep up to date on ICD-10. Visit the CMS ICD-10 website for the latest news and resources to help you prepare for the October 1, 2014, deadline. Sign up for CMS ICD-10 Industry Email Update.

 HIPPA Omnibus Privacy & Security Rule (01/24/2013)
The Department of Health and Human Services (HHS) has published its final omnibus rule to strengthen the privacy and security protections for health information established under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The changes in the final rulemaking provide the public with increased protection and control of personal health information. The changes announced expand many of the privacy and security requirements to business associates that receive protected health information, such as contractors and subcontractors. Business associates may also be liable for the increased penalties for noncompliance based on the level of negligence up to a maximum penalty of $1.5 million. The changes also strengthen the Health Information Technology for Economic and Clinical Health (HITECH) Breach Notification requirements by clarifying when breaches of unsecured health information must be reported to HHS.
Addition information regarding this rule may be found at:  https://s3.amazonaws.com/public-inspection.federalregister.gov/2013-01073.pdf

 CMS announces delay in the enforcement of the use of the ICD-10  (08/24/2012)
CMS has issued a rule delaying the enforcement of the use of ICD-10 codes until October 2014. Details of this rule may be found at the following URL:  http://www.ofr.gov/OFRUpload/OFRData/2012-21238_PI.pdf

 HIPAA Enforcement Delay Action Extended Through June 30, 2012  (03/15/2012)
(March 15, 2012)  The Centers for Medicare & Medicaid Services' Office of E-Health Standards and Services (OESS) is announcing that it will not initiate enforcement action for an additional three (3) months, through June 30, 2012, against any covered entity that is required to comply with the updated transactions standards adopted under the Health Insurance Portability and Accountability Act of 1996 (HIPAA): ASC X12 Version 5010 and NCPDP Versions D.0 and 3.0.   
On November 17, 2011, OESS announced that, for a 90-day period, it would not initiate enforcement action against any covered entity that was not compliant with the updated versions of the standards by the January 1, 2012 compliance date.  This was referred to as enforcement discretion, and during this period, covered entities were encouraged to complete outstanding implementation activities including software installation, testing and training.
Health plans, clearinghouses, providers and software vendors have been making steady progress:   the Medicare Fee-for-Service (FFS) program is currently reporting successful receipt and processing of over 70 percent of all Part A claims and over 90 percent of all Part B claims in the Version 5010 format.  Commercial plans are reporting similar numbers.  State Medicaid agencies are showing progress as well, and some have made a full transition to Version 5010.   
Covered entities are making similar progress with Version D.0.  At the same time, OESS is aware that there are still a number of outstanding issues and challenges impeding full implementation.   OESS believes that these remaining issues warrant an extension of enforcement discretion to ensure that all entities can complete the transition. OESS expects that transition statistics will reach 98 percent industry wide by the end of the enforcement discretion period.    
Given that OESS will not initiate enforcement actions through June 30, 2012, industry is urged to collaborate more closely on appropriate strategies to resolve remaining problems.  OESS is stepping up its existing outreach to include more technical assistance for covered entities.  OESS is also partnering with several industry groups as well as Medicare FFS and Medicaid to expand technical assistance opportunities and eliminate remaining barriers.   Details will be provided in a separate communication.
 The Medicare FFS program will continue to host separate provider calls to address outstanding issues related to Medicare programs and systems.  The Medicare Administrative Contractors (MAC) will continue to work closely with clearinghouses, billing vendors or health care providers requiring assistance in submitting and receiving Version 5010 compliant transactions.  If any entity is experiencing difficulty reaching a MAC, please contact Karen Jackson at Karen.Jackson1@cms.hhs.gov.   
 The Medicaid program staff at CMS will continue to work with individual States regarding their program readiness.  Issues related to implementation problems with the States may be sent to Medicaid5010@cms.hhs.gov.   
 OESS strongly encourages industry to come together in a collaborative, unified way to identify and resolve all outstanding issues that are impacting full compliance, and looks forward to seeing extensive engagement in the technical assistance initiative to be launched over the next few weeks.  
DayTech still encourages all users of ECSS and CE2000 to convert their Version 5.1 plans to D.0 as soon as Payers announce their readiness to receive transactions in the new format.
 CMS announces a 90 day delay in the enforcement of HIPAA II Transactions and Code sets rule (11/17/2011)

Today the Centers for Medicare & Medicaid Services’ (CMS) Office of E-Health Standards and Services (OESS) announced that it would not initiate enforcement action until March 31, 2012, with respect to any Health Insurance Portability and Accountability Act (HIPAA) covered entity that is not in compliance with the ASC X12 Version 5010 (Version 5010), NCPDP Telecommunication D.0 (NCPDP D.0) and NCPDP Medicaid Subrogation 3.0 (NCPDP 3.0) standards. Notwithstanding OESS’ discretionary application of its enforcement authority, the compliance date for use of these new standards remains January 1, 2012 (small health plans have until January 1, 2013 to comply with NCPDP 3.0).
CMS’ Office of E-Health Standards and Services is the U.S. Department of Health and Human Services’ (DHHS) component that enforces compliance with HIPAA transaction and code set standards.
OESS encourages all covered entities to continue working with their trading partners to become compliant with the new HIPAA standards, and to determine their readiness to accept the new standards as of January 1, 2012. While enforcement action will not be taken, OESS will continue to accept complaints associated with compliance with Version 5010, NCPDP D.0 and NCPDP 3.0 transaction standards during the 90-day period beginning January 1, 2012. If requested by OESS, covered entities that are the subject of complaints (known as “filed-against entities”) must produce evidence of either compliance or a good faith effort to become compliant with the new HIPAA standards during the 90-day period.
OESS made the decision for a discretionary enforcement period based on industry feedback revealing that, with only about 45 days remaining before the January 1, 2012 compliance date, testing between some covered entities and their trading partners has not yet reached a threshold whereby a majority of covered entities would be able to be in compliance by January 1. Feedback indicates that the number of submitters, the volume of transactions, and other testing data used as indicators of the industry’s readiness to comply with the new standards have been low across some industry sectors. OESS has also received reports that many covered entities are still awaiting software upgrades.
Links to information on Version 5010, NCPDP D.0 and NCPDP 3.0 are available at  www.cms.gov/ICD-10.
DayTech encourages all users of ECSS and CE2000 to continue to convert their Version 5.1 plans to D.0 as Payers announce their readiness. We have heard from many Payers who still intend to completely discontinue the Version 5.1 claim format effective 1/1/2012.

 DayTech NCPDP Version D.0 Trading Partner Testing and/or Certification completed (as of 07/01/2012)

AK Medicaid
American Indian Health
Argus Health
CVS/Caremark
Change Healthcare (Switch) *
FL Medicaid
Humana
ID Medicaid
IN Medicaid
KY Medicaid
LA Medicaid
Magellan Health Svcs
Maricopa
Med D TrOOP Facilitator
MedImpact
Medco Health
MGP
Michagan Epic
MI Medicaid
NE Medicaid
NH Medicaid
NJ Medicaid **
NV Medicaid
New York Epic
NY Medicaid **
NYPSP
OK Medicaid
Omnisys
PACE
PA Medicaid
Prime Therapeutics
Relay Health (Switch) *
SC Medicaid
SXC Healthcare
TX Vendor Drug
UT Medicaid
Walgreens (WHI)
WI Medicaid
CA Medi-Cal

 *Most plans only require our Switch certifications for the submission of D.0 claims. The table above includes plans that we tested with individually as well.
** Tested by one or more of our Providers - Vendor testing not provided
________________________________________________________________________________________________________________________________________________________________


 DayTech completes REMS Certification  (02/03/2011)
We are pleased to announce that DayTech software has been certified compliant with the federal Risk Evaluation Mitigation Strategy program administered by Relay Health. This blanket certification will apply to all clients using ECSS or CE2000 to submit REMS claims.

 HHS Publishes HIPAA 2 Final Rules  (01/16/09)

The Final Rules for the Transactions and Code Sets have been published in the Federal Register by the Department of Health and Human Services (HHS).
Under the transaction standards final rule, covered entities must comply with NCPDP Telecommunication Standard Version D.0 for pharmacy transactions and ASC X12 Version 5010 for some healthcare transactions on January 1, 2012.

Covered entities must comply with the standard for the Medicaid pharmacy subrogation transaction using NCPDP Medicaid Subrogation Standard Version 3.0 on Jan. 1, 2012. However, for Version 3.0, small health plans have an additional year and must comply on Jan. 1, 2013.

The ICD-10 code sets rule sets the compliance date at October 1, 2013.
Full details can be found online in the Federal Register.


 CMS clarifies use of the Prescriber NPI  (05/01/08)

CMS recently released FAQ #9100 related to NPI and the Prescriber Identifier field on the NCPDP billing transaction. This FAQ clarifies that not all prescribers are covered entities under the NPI rule and, therefore, not all prescribers are required to have an NPI. The FAQ further clarifies that if the prescriber does not have an NPI or the pharmacy cannot obtain a prescriber’s NPI, a non-NPI prescriber ID may be substituted on NCPDP pharmacy claims transactions if allowed by the payer.
CMS requires a prescriber ID for all Prescription Drug Events (PDEs), which means that Part D plans must obtain prescriber IDs on all pharmacy claims. CMS emphasizes that plans should make all reasonable efforts to obtain NPIs in the prescriber ID field. Nevertheless, given the guidance provided by the FAQ, Part D plans cannot justify putting enrollees at risk of service interruption by establishing point-of-sale edits that reject pharmacy claims that do not include the NPI in the prescriber ID field. Part D plans must avail themselves of the claims processing flexibility allowed by the FAQ by ensuring that their systems continue to accept non-NPI prescriber IDs (e.g. DEA number, State License number) on NCPDP pharmacy claims transactions. Part D plans should establish alternative policies and procedures outside of their claims processing that address potential non-compliance with NPI prescriber ID requirements on NCPDP pharmacy claims transactions.  

This guidance is expected to be used to cover exceptions. It is not intended to allow routine use of non-NPI identifiers or default identifiers in place of individual prescriber NPIs. Pharmacies are expected to make all reasonable efforts to obtain and utilize the appropriate individual NPIs for prescribers. Additionally, pharmacies still must provide their own NPI in the Service Provider ID field on all Part D pharmacy claims.


 CMS to host another NPI Roundtable (05/01/08)

CMS will host a national NPI Roundtable to address additional questions from the Medicare provider community regarding Medicare's NPI implementation. The Roundtable will be on May 14th from 2-3:30PM EDT. Providers will be able to submit questions through the online registration system at the time of sign up for the call. Registration details are available on the CMS NPI web page. Additionally, for more information on the various aspects of Medicare’s NPI implementation, the Medicare Learning Network has created a comprehensive list of MLN Matters NPI articles.


 Vaccines to be covered under Part D (11/1/07)

Beginning in 2008, certain vaccines that are not already covered under the Part A or Part B benefit, as well as the fees to administer them, will be covered under the Medicare Part D benefit. DayTech is actively participating in the NCPDP SNIP Vaccine Sub Task Group that has been charged with creating guidance for pharmacy regarding this benefit. ECSS and CE2000 will be able to support the submission of claims for vaccines and their administration fees to both primary and secondary payers. We will update this web site as we participate in industry testing and/or additional information is forthcoming.

Update: 12/6/07

DayTech has successfully tested the submission of vaccine claims to Caremark and PCS using both ECSS and CE2000.

 CMS posts NPI Frequestly Asked Questions (06/14/07)

CMS has just posted a long list of NPI Frequently Asked Questions. The entire group of questions and answers may be viewed at their web site. Just click here to link to the CMS Web Site, then type NPI into the search term box and click Search.

The entire URL is: http://questions.cms.hhs.gov/cgi-bin/cmshhs.cfg/php/enduser/std_alp.php?p_sid=GK25V7Ei

If the click-here link does not work, you can also copy and paste the entire URL shown above into your Web Browser and access the site that way.

 CMS revises Medicare Contingency Plan  (04/26/07)

CMS has just published an important revision to its Medicare Contingency Plan. The revised document can be seen at:

n Change Request: http://www.cms.hhs.gov/transmittals/downloads/R1227CP.pdf

n MLN Matters article at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5595.pdf

The change was made in response to a discrepancy found in the Medicare description of their Contingency Plan (vis-à-vis the CMS Contingency Guidance) that gave the impression that only health plans that were fully ready and capable to be compliant by May 23, 2007, would be able to invoke the contingency plan.

 CMS hosts NPI Contingency Roundtable (04/09/07)

The entire text of the announcement follows:

The Centers for Medicare & Medicaid Services (CMS) will host a National Roundtable on the recently released NPI Compliance Contingency Guidance. This toll-free call will take place from 2:30 p.m. – 4:00 p.m., EDT, on Wednesday April 18, 2007.

The CMS announced that through May 23, 2008, CMS will not impose penalties on covered entities that deploy contingency plans to facilitate the compliance of their trading partners (e.g. those healthcare providers who bill them). The posted guidance document can be used by covered entities to design and implement a contingency plan. Details are contained in a CMS document entitled, “Guidance on Compliance with the HIPAA National Provider Identifier (NPI) Rule.” To view this guidance, visit
http://www.cms.hhs.gov/NationalProvIdentStand/Downloads/NPI_Contingency.pdf on the CMS website.

The final rule establishing the NPI as the standard unique health provider identifier for health care providers was published in 2004 and requires all covered entities to be in compliance with its provisions by May 23, 2007, except for small health plans, which must be in compliance by May 23, 2008.

CMS encourages health plans to assess the readiness of their provider communities and determine the need to implement contingency plans to maintain the flow of payments, while continuing to work toward compliance.

The call will open with a presentation on the Contingency Guidance announced on April 2, and it should be of particular interest to health plans that are developing their own contingency plans. Following the presentation, callers will have an opportunity to ask questions of CMS subject matter experts.

A second Roundtable will be scheduled following the Medicare Fee-for-Service announcement of its contingency plan. This call will be of particular interest to Medicare providers and trading partners. Information on this call will be announced shortly and posted on www.cms.hhs.gov/NationalProvIdentStand.

The CMS guidance and resultant contingency plans that may be implemented by covered entities does not remove the requirement and expectation for health care providers to acquire an NPI. Getting an NPI is easy and free. Go to www.cms.hhs.gov/NationalProvIdentStand for more information.

April 18, 2007 conference call details:

Date: April 18, 2007
Conference Title: NPI Contingency Guidance Roundtable
Time: 2:30 – 4:00 p.m. EDT

In order to receive the call-in information, you must register for the call. It is important to note that if you are planning to sit in with a group, only one person needs to register to receive the call-in data. This registration is solely to reserve a phone line, NOT to allow participation.
Registration will close at 1:00 p.m. EST on April 17, 2007. No exceptions will be made, so please be sure to register prior to this time.

1. To register for the call participants need to go to:
https://ww4.premconf.com/webrsvp/register?conf_id=7749423
2. Click "Continue" to be taken to the registration screen.
3. Fill in all required data.
4. Click "Submit".
5. You will be taken to the confirmation screen where the call-in number will be given.
6. To view the time the call will start, you will need to select your time zone in the drop down box under "Time" on the confirmation screen.
7. Click "Confirm Registration" to receive a confirmation email.

For technical issues with web registration for this Roundtable, please call 1-800-289-0579.

For those individuals who are unable to attend, an audio file of the conference will be posted at http://www.cms.hhs.gov/NationalProvIdentStand/04_education.asp on the CMS website


 CMS allows NPI implementation delay  (04/02/2007)

CMS has announced that Covered Entities may delay using the National Provider ID until May of 2008 provided that they act in good faith during that time to implement it. The entire text of the announcement follows:

Department of Health & Human Services
Centers for Medicare & Medicaid Services
Room 303-D
200 Independence Avenue, SW
Washington, DC  20201

Public Affairs Office

MEDICARE NEWS

FOR IMMEDIATE RELEASE                CONTACT: CMS Public Affairs
April 2, 2007                                            (202) 690-6145

CMS CLARIFIES GUIDELINES FOR NATIONAL PROVIDER IDENTIFIER (NPI) DEADLINE IMPLEMENTATION

Today, the Centers for Medicare & Medicaid Services (CMS) announced that it is implementing a contingency plan for covered entities (other than small health plans) who will not meet the May 23, 2007, deadline for compliance with the National Provider Identifier (NPI) regulations under the Health Insurance Portability and Accountability Act (HIPAA) of 1996.

The final rule establishing the NPI as the standard unique health provider identifier for health care providers was published in 2004 and requires all covered entities to be in compliance with its provisions by May 23, 2007, except for small health plans, which must be in compliance by May 23, 2008.
“The enforcement guidance released today clarifies that covered entities that have been making a good faith effort to comply with the NPI provisions may, for up to 12 months, implement contingency plans that could include accepting legacy provider numbers on HIPAA transactions in order to maintain operations and cash flows.” said CMS Acting Administrator Leslie V. Norwalk, Esq.  
The NPI is an identifier that will be used by covered entities to identify health care providers, eliminating the current need for multiple identifiers for the same provider.  The NPI replaces all “legacy” identifiers that are currently being used, such as Medicaid provider IDs, individual plan provider IDs, UPINs, etc., and will be required for use on health care claims and other HIPAA transactions.
CMS made the decision to announce this guidance on its enforcement approach after it became apparent that many covered entities would not be able to fully comply with the NPI standard by May 23, 2007.  This guidance would protect covered entities from enforcement action if they continue to act in good faith to come into compliance, and they develop and implement contingency plans to enable them and their trading partners to continue to move toward compliance. HHS recognizes that transactions often require the participation of two covered entities and that non-compliance by one covered entity may put the second covered entity in a difficult position.
The enforcement process is complaint driven and will allow covered entities to demonstrate good faith efforts and employ contingency plans. If a complaint is filed against a covered entity, CMS will evaluate the entity's "good faith efforts" to comply with the standards and would not impose penalties on covered entities that have deployed contingencies to ensure that the smooth flow of payment continues.  Each covered entity will determine the specifics of its contingency plan.  Contingency plans may not extend beyond May 23, 2008, but entities may elect to end their contingency plans sooner.  Medicare will announce its own contingency plan shortly.
CMS encourages health plans to assess the readiness of their provider communities to determine the need to implement contingency plans to maintain the flow of payments while continuing to work toward compliance.  Likewise, we encourage health care providers that have not yet obtained NPIs to do so immediately, and to use their NPIs in HIPAA transactions as soon as possible.  Applying for an NPI is fast, easy and free.  Visit the National Plan/Provider Enumeration System (NPPES) website at https://nppes.cms.hhs.gov/.   
A critical aspect of implementing the NPI is the ability for covered entities to match a provider's NPI with the many legacy provider identifiers that have been used to process administrative transactions.  CMS plans to make data available from the NPPES system that will assist covered entities in developing these “crosswalks.”

Further information concerning this issue is available on the CMS Web-site at http://www.cms.hhs.gov.  The site also contains contingency plan guidance for the industry in a document titled “Guidance on Compliance with the HIPAA National Provider Identifier Rule.”

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 NPI information is available via email  (03/26/07)
Users of ECSS and CE2000 who are under annual software maintenance can email us at support@daytechcorp.com for a list of specific instructions on how to include the NPI in our products as well as general information about the NPI.

 Remember to give your NPI# to your Switch  (02/08/2007)
When you receive your new NPI number you will need to contact your Switch and give them the number so that they can continue to route your claims correctly.
Currently the Switches have only your NCPDP and Medicaid ID numbers on file.
Unless you provide them with your NPI number, they will not be able to route claims that use your NPI in the Service Provider ID field.
For Change Healthcare (ENV) Switch users please call  800-333-6869
For RelayHealth (NDC) Switch users please call  800-388-2316
You will need to provide them with your NCPDP# as well as your NPI#.
 Delaware Medicaid will require early use of the NPI (01/18/2007)
We have been notified by the NCPDP that Delaware Medicaid will require the use of the NPI on all claims beginning March 24, 2007. The NPI will be required to identify both prescribers and pharmacies.

Note:

The individual prescriber's NPI should be used in the Prescriber ID field 411-DB of each claim with a value of  01 in the Prescriber ID Qualifier field 466-EZ.

Do not use the organization's NPI.

The pharmacy NPI number should be used in the Service Provider ID field of the plan definition with a  01  in the Service Provider ID Qualifier field.

Do not use the NPI of the individual pharmacist.

Pharmacy owners should register their pharmacy's NPI with NCPDP. Instructions on how to do this may be found on the NCPDP web site at:   http://www.ncpdp.org.

The official compliance date of the NPI is May 23. However, payers can,
as in the case with Delaware, decide to require its use before then.


 National Provider ID (NPI) Update (08/30/2006)

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires the implementation of a standard unique identifier for health care providers. In a Final Rule issued January 23, 2004 the National Provider ID or NPI was established to meet this requirement. All health care providers can apply for an NPI. All health care providers who are Covered Entities under HIPAA will be required to use the NPI in all HIPPA-covered transactions starting in 2007. This ID will be phased in to replace the other identifiers in use today such as the NCPDP#, DEA#, UPIN#, etc..
To get more information and obtain an NPI, visit the NPPES web site at:
http://nppes.cms.hhs.gov/NPPES       or call 1-800-465-3203.
Current versions of both ECSS and CE2000 support the use of the NPI.

 HIPAA Disaster Recovery Planning Tool available (06/29/2006)
The Department of Health and Human Services' Office for Civil Rights (OCR) has modified the HIPAA section of its web site a page on emergency preparedness planning and response. The site includes a new tool for covered entities to use in their disaster recovery planning. More information may be found at the following URL:
http://www.hhs.gov/ocr/hipaa/emergencyPPR.html

 Final Rule on HIPAA Enforcement published  (02/17/2006)

On February 16, the Final Rule on HIPAA Enforcement was published in the Federal Register. The regulation can be viewed at:

http://a257.g.akamaitech.net/7/257/2422/01jan20061800/edocket.access.gpo.gov/2006/pdf/06-1376.pdf.

The Final Rule adopts the complete regulatory structure for implementing the civil money penalty authority of the Administrative Simplification part of HIPAA (SSA, section 1176), completing the structure begun when the Privacy Rule was issued in 2000 and expanded by the interim final procedural enforcement rules issued in 2003. The Final Rule covers the enforcement process from its beginning, which will usually be a complaint or a compliance review, through its conclusion. A complaint or compliance review may result in informal resolution, a finding of no violation, or a finding of violation. If a finding of violation is made, a civil money penalty will be sought for the violation, which can be challenged by the covered entity through a formal hearing and appellate review process.
These rules apply to covered entities that violate any of the rules implementing the Administrative Simplification provisions of HIPAA.

 CMS Provides Medicare Part D "What If" Guidance (01/04/2006)
Medicare & Medicaid Full Benefit Dual Eligibles (FBDE)

Audience
What If…
Pharmacist Response
1. Medicare & Medicaid FBDE
A FBDE goes to a pharmacy and presents their Medicaid card
After December 31, 2005, prescription drug coverage for dually eligible individuals shifts from Medicaid to Medicare for both the elderly and disabled.  Therefore, prior to billing Medicaid, the pharmacist should consider the possibility that any person presenting a Medicaid card may also be eligible for Medicare.  If the person produces evidence of, or otherwise confirms, Medicare eligibility, the pharmacist can send an E1 query to determine Part D plan enrollment.

If the E1 query returns the RxBIN-RxPCN-RXGrp-RxID (the "4Rx" data) and 800 number of a Part D plan, the plan should be billed and the plan 800 number given to the person to call to obtain their new ID card and find out about their prescription drug plan.

If the E1 query returns just the 800 number of the plan, this means the person has been enrolled in a Part D plan but the "4Rx" data have not been received by the TrOOP Facilitator.  The pharmacist can call the 800 number to obtain the billing information from the plan, as well as give the plan 800 number to the person to call to obtain their new ID card and find out about their prescription drug plan.

If the E1 query returns no match, the pharmacist can check for Medicare eligibility by submitting an expanded E1 query.  If the person is eligible for Medicare, the E1 will return "A", "B" or "AB".  This means the person has not yet been enrolled in a Part D plan, but does have Medicare Part A and/or B eligibility.  If the pharmacist verifies dual eligibility, the POS Contractor (Anthem) can be billed.  Medicaid eligibility can be verified through history of current Medicaid billing in the patient profile, a Medicaid card, or a current Medicaid award letter.  Medicare eligibility can be verified through the "A or B"  E1 query, a Medicare card, a Medicare MSN Notice, or by calling a dedicated pharmacy eligibility line at 1-866-835-7595 (available Mon.-Fri. 8 AM-8PM EST), or 1-800-MEDICARE at any other time.  Pharmacists will need to obtain certain identifying information from the beneficiary or the beneficiary's record to confirm eligibility over the phone.

If the expanded E1 query does not return a match, the pharmacist can either include additional information in the E1 query and try again, if applicable, or call the dedicated pharmacy eligibility line at (1-866-835-7595) available Mon.-Fri. 8 AM-8PM EST, or call 1-800-MEDICARE to verify Medicare eligibility.   If eligibility cannot be confirmed, the person must use other coverage, if available, or pay out-of-pocket for all or some of the prescription and be referred to 1-800-MEDICARE to resolve Medicare coverage status.



2. Medicare & Medicaid FBDE
A FBDE goes to a pharmacy and they have not been assigned to a plan
If the E1 query returns no match for Part D enrollment, the pharmacist can check for Medicare eligibility by submitting an expanded E1 query.  If the person is eligible for Medicare, the E1 will return "A", "B" or "AB".  This means the person has not yet been enrolled in a Part D plan, but does have Medicare Part A and/or B eligibility.  If the pharmacist verifies dual eligibility, the POS Contractor (Anthem) can be billed.  

Medicaid eligibility can be verified through history of current Medicaid billing in the patient profile, a Medicaid card, or a current Medicaid award letter.  Medicare eligibility can be verified through the "A or B"  E1 query, a Medicare card, a Medicare MSN Notice, or by calling a dedicated pharmacy eligibility line at 1-866-835-7595 (available Mon.-Fri. 8 AM-8PM EST), or 1-800-MEDICARE at any other time.  Pharmacists will need to obtain certain identifying information from the beneficiary or the beneficiary's record to confirm eligibility over the phone.

3. Medicare & Medicaid FBDE
A FBDE opted out of their autoassigned plan and goes to a pharmacy and believes they still have Medicaid coverage
After December 31, 2005, prescription drug coverage for dually eligible individuals shifts from Medicaid to Medicare for both the elderly and disabled.  Therefore, prior to billing Medicaid, the pharmacist should consider the possibility that any person presenting a Medicaid card may also be eligible for Medicare.  If the person produces evidence of, or otherwise confirms, Medicare eligibility, the pharmacist can send an E1 query to determine Part D plan enrollment.

If the E1 query returns no match for Part D enrollment, the pharmacist can check for Medicare eligibility by submitting an expanded E1 query.  If the person is eligible for Medicare, the E1 will return "A", "B" or "AB".  This means the person has not yet been enrolled in a Part D plan, but does have Medicare Part A and/or B eligibility.  If the pharmacist verifies dual eligibility, the POS Contractor (Anthem) can be billed.  

Medicaid eligibility can be verified through history of current Medicaid billing in the patient profile, a Medicaid card, or a current Medicaid award letter.  Medicare eligibility can be verified through the "A or B"  E1 query, a Medicare card, a Medicare MSN Notice, or by calling a dedicated pharmacy eligibility line at 1-866-835-7595 (available Mon.-Fri. 8 AM-8PM EST), or 1-800-MEDICARE at any other time.  Pharmacists will need to obtain certain identifying information from the beneficiary or the beneficiary's record to confirm eligibility over the phone.

4. Medicare & Medicaid FBDE
A FBDE person with Medicare just qualified for Medicaid in December 2005
After December 31, 2005, prescription drug coverage for dually eligible individuals shifts from Medicaid to Medicare for both the elderly and disabled.  Therefore, prior to billing Medicaid, the pharmacist should consider the possibility that any person presenting a Medicaid card may also be eligible for Medicare.  If the person produces evidence of, or otherwise confirms, Medicare eligibility, the pharmacist can send an E1 query to determine Part D plan enrollment.

If the E1 query returns the RxBIN-RxPCN-RXGrp-RxID (the "4Rx" data) and 800 number of a Part D plan, the plan should be billed and the plan 800 number given to the person to call to obtain their new ID card and find out about their prescription drug plan.

If the E1 query returns just the 800 number of the plan, this means the person has been enrolled in a Part D plan but the "4Rx" data have not been received by the TrOOP Facilitator.  The pharmacist can call the 800 number to obtain the billing information from the plan, as well as give the plan 800 number to the person to call to obtain their new ID card and find out about their prescription drug plan.

If the E1 query returns no match, the pharmacist can check for Medicare eligibility by submitting an expanded E1 query.  If the person is eligible for Medicare, the E1 will return "A", "B" or "AB".  This means the person has not yet been enrolled in a Part D plan, but does have Medicare Part A and/or B eligibility.  If the pharmacist verifies dual eligibility, the POS Contractor (Anthem) can be billed.  Medicaid eligibility can be verified through history of current Medicaid billing in the patient profile, a Medicaid card, or a current Medicaid award letter.  Medicare eligibility can be verified through the "A or B"  E1 query, a Medicare card, a Medicare MSN Notice, or by calling a dedicated pharmacy eligibility line at 1-866-835-7595 (available Mon.-Fri. 8 AM-8PM EST), or 1-800-MEDICARE at any other time.  Pharmacists will need to obtain certain identifying information from the beneficiary or the beneficiary's record to confirm eligibility over the phone.

If the expanded E1 query does not return a match, the pharmacist can either include additional information in the E1 query and try again, if applicable, or call the dedicated pharmacy eligibility line at (1-866-835-7595) available Mon.-Fri. 8 AM-8PM EST, or call 1-800-MEDICARE to verify Medicare eligibility.   If eligibility cannot be confirmed, the person must use other coverage, if available, or pay out-of-pocket for all or some of the prescription and be referred to 1-800-MEDICARE to resolve Medicare coverage status.

5. Medicare & Medicaid FBDE
A person just aged into Medicare this month and had Medicaid already
After December 31, 2005, prescription drug coverage for dually eligible individuals shifts from Medicaid to Medicare for both the elderly and disabled.  Therefore, prior to billing Medicaid, the pharmacist should consider the possibility that any person presenting a Medicaid card may also be eligible for Medicare.  If the person produces evidence of, or otherwise confirms, Medicare eligibility, the pharmacist can send an E1 query to determine Part D plan enrollment.

If the E1 query returns the RxBIN-RxPCN-RXGrp-RxID (the "4Rx" data) and 800 number of a Part D plan, the plan should be billed and the plan 800 number given to the person to call to obtain their new ID card and find out about their prescription drug plan.

If the E1 query returns just the 800 number of the plan, this means the person has been enrolled in a Part D plan but the "4Rx" data have not been received by the TrOOP Facilitator.  The pharmacist can call the 800 number to obtain the billing information from the plan, as well as give the plan 800 number to the person to call to obtain their new ID card and find out about their prescription drug plan.

If the E1 query returns no match, the pharmacist can check for Medicare eligibility by submitting an expanded E1 query.  If the person is eligible for Medicare, the E1 will return "A", "B" or "AB".  This means the person has not yet been enrolled in a Part D plan, but does have Medicare Part A and/or B eligibility.  If the pharmacist verifies dual eligibility, the POS Contractor (Anthem) can be billed.

Medicaid eligibility can be verified through history of current Medicaid billing in the patient profile, a Medicaid card, or a current Medicaid award letter.  Medicare eligibility can be verified through the "A or B"  E1 query, a Medicare card, a Medicare MSN Notice, or by calling a dedicated pharmacy eligibility line at 1-866-835-7595 (available Mon.-Fri. 8 AM-8PM EST), or 1-800-MEDICARE at any other time.  Pharmacists will need to obtain certain identifying information from the beneficiary or the beneficiary's record to confirm eligibility over the phone.

If the expanded E1 query does not return a match, the pharmacist can either include additional information in the E1 query and try again, if applicable, or call the dedicated pharmacy eligibility line at (1-866-835-7595) available Mon.-Fri. 8 AM-8PM EST, or call 1-800-MEDICARE to verify Medicare eligibility.   If eligibility cannot be confirmed, the person must use other coverage, if available, or pay out-of-pocket for all or some of the prescription and be referred to 1-800-MEDICARE to resolve Medicare coverage status.

6. Medicare & Medicaid FBDE
FBDE was not autoenrolled and shows up at pharmacy, but doesn't have appropriate proof of identification
Pharmacists should follow established practices for verifying identity and coverage.

Medicaid eligibility can be verified through history of current Medicaid billing in the patient profile, a Medicaid card, or a current Medicaid award letter.  Medicare eligibility can be verified through the "A or B"  E1 query, a Medicare card, a Medicare MSN Notice, or by calling a dedicated pharmacy eligibility line at 1-866-835-7595 (available Mon.-Fri. 8 AM-8PM EST), or 1-800-MEDICARE at any other time.  Pharmacists will need to obtain certain identifying information from the beneficiary or the beneficiary's record to confirm eligibility over the phone.


7. Medicare & Medicaid FBDE
A  FBDE was autoenrolled and needs a drug that's not on their plan's formulary
All Part D plans cover a temporary first fill of up to 30 days of a non-formulary drug under their mandatory new enrollee transition policies.  The pharmacist may contact the plan to discuss any transitional issues.  The pharmacist may also discuss switching the prescription to a generic or therapeutic alternative that is on the plan's formulary with the person and his/her prescribing physician consistent with current industry practice.


Low Income Subsidy Non Full Benefit Dual Eligible (LIS NFBDE)

Audience
What If…
Pharmacist Response
1. LIS NFBDE
A person goes to a pharmacy and the pharmacy cannot confirm enrollment, although the individual has an enrollment acknowledgment letter and proof of LIS
If billing instructions for a person's Part D plan cannot be confirmed through a Plan ID card or E1 query, but the person does have their plan acknowledgement letter at hand, that letter should include the RxBin, RxPCN, RxGrp and RxID, generally in the upper left hand area above the greeting.  If the letter does not include this information, the pharmacy can call the plan to get the information needed to send in a claim.

If the person's letter or other documentation indicates that the person has qualified for low-income subsidy (LIS) extra help, but the Part D plan adjudicates the claim with greater than $2/$5 copays, the pharmacist can contact the Plan to discuss the LIS documentation.  Plan member service staff should take note of the description of the documentation, and should instruct the pharmacist to collect no more than $2/$5 copays, and to rebill the claim once the Plan's billing system has been updated.  Plan staff should expedite correction of the member record so that the claim can be rebilled within 24-48 hours.
2. LIS NFBDE
A person who has applied and been approved for LIS but who has not yet enrolled in a plan shows up at a pharmacy thinking they have enrolled in a plan
If there is no evidence of Medicaid coverage, but the expanded E1 query returns an "A or B" match, or a call to the dedicated pharmacy eligibility line at (1-866-835-7595) available Mon.-Fri. 8 AM-8PM EST, or 1-800-MEDICARE confirms Medicare eligibility, the pharmacist should advise the person that they need to enroll in a Medicare drug plan to get Medicare drug coverage.  The person can be referred to 1-800-MEDICARE to get information and compare the plans that are available to them. Staff at 1-800-MEDICARE can also help the person enroll in a plan of their choice.   

In the meantime, the person must use other coverage, if available, or pay out-of-pocket for all or some of the prescription.

3. LIS NFBDE
A person with LIS accidentally joins a Medicare drug plan where they will have to pay part of the premium

N/A
4. LIS NFBDE
A person is waiting for decision about the LIS to join a plan
Part D plans will generally adjudicate claims at the non-LIS cost sharing level until official confirmation of LIS status has been received from CMS.  Beneficiaries will be reimbursed for any excess cost sharing they incur after the date of their LIS eligibility.





Employer/Union

Audience
What If…
1. Employer orUnion
A FBDE is also claimed by an employer/union as RDS and they are not aware that they have been autoenrolled by Medicare in a plan
The person should be asked if they have single or family coverage.

If they have single coverage, the relative value of Medicaid health coverage and Medicare prescription coverage to their employer coverage should be reviewed.  In most cases, the combined Medicare and Medicaid coverage is likely to be better than the employer/union coverage.  If this is the case the person should stay in the Medicare drug plan.  If it is not the case, the person should opt out of the Medicare drug plan and continue with their employer coverage.

Caution:  A person with employer/union group health coverage may not be able to drop drug coverage without also dropping health coverage.  The decision of the individual may also affect coverage of family members.

If they have family coverage, their decision about continuing enrollment with a Medicare drug plan could affect the family coverage.  The individual should contact their employer to determine the effect of the decision on the family coverage.  They can also contact their local State Health Insurance and Assistance Program for assistance.  Call 1-800-MEDICARE for the number of the local SHIP.  (final 12/27)

2. Employer/Union
A person whose employer is claiming them for the RDS joins a Medicare drug plan
The plan will contact the person to confirm that they want to join a Medicare drug plan prior to enrolling them. CMS will also notify their employer that the person has attempted to enroll in a plan. They will need to make a choice. They can choose to complete the enrollment in the Medicare drug plan or continue with their retiree/union drug coverage.  (final 12/27)



Discount Card

Audience
What If…
1. Discount Card
A person has a Medicare-approved drug discount card
The person can continue to use their Medicare-approved drug discount card until they join a Medicare prescription drug plan or until May 15, 2006, whichever comes first.

If they qualified for a credit in 2005 to help pay for prescriptions, they can use any credit they have left until they join a Medicare prescription drug plan or until May 15, 2006, whichever is first.  (final 12/27)

General

Audience
What If…
Pharmacist Response
1. General
A person tries to disenroll through the Plan Finder web tool
N/A
2. General
A person enrolled in plan and goes to the pharmacy and the pharmacy has no record of the enrollment
If billing instructions for a person's Part D plan cannot be confirmed through a Plan ID card or E1 query, but the person does have their plan acknowledgement letter at hand, that letter should include the RxBin, RxPCN, RxGrp and RxID, generally in the upper left hand area above the greeting.  If the letter does not include this information, the pharmacy can call the plan to get the information needed to send in a claim.

The pharmacist can also call a dedicated pharmacy eligibility line at 1-866-835-7595 (available Mon.-Fri. 8 AM-8PM EST), or 1-800-MEDICARE at any other time to confirm enrollment.  Pharmacists will need to obtain certain identifying information from the beneficiary or the beneficiary's record to confirm eligibility over the phone.

If eligibility cannot be confirmed, the person must use other coverage, if available, or pay out-of-pocket for all or some of the prescription and be referred to 1-800-MEDICARE to resolve Medicare coverage status.  If the person was enrolled on the date of service of the claim, the person may submit the receipt to the Plan for reimbursement.
3. General
The person is enrolled in a plan and the pharmacy cannot confirm enrollment

If eligibility cannot be confirmed, the person must use other coverage, if available, or pay out-of-pocket for all or some of the prescription and be referred to 1-800-MEDICARE to resolve Medicare coverage status.  If the person was enrolled on the date of service of the claim, the person may submit the receipt to the Plan for reimbursement.
4. General
The person is enrolled in a plan and has secondary coverage. What happens if the pharmacy can't confirm enrollment in a Medicare drug plan?
If eligibility cannot be confirmed, the person must use other coverage, if available, or pay out-of-pocket for all or some of the prescription and be referred to 1-800-MEDICARE to resolve Medicare coverage status.  If a Part D Plan is actually the primary payer on the date of service, the Plan will make arrangements to reimburse the secondary payer and/or the beneficiary.  These arrangements may entail requesting the pharmacy to reverse the primary claim to the secondary payer and to rebill the Part D plan as primary, with any balance billed to the secondary payer.
5. General
The person is enrolled in a plan with a deductible. How will the deductible be accounted for?
Some, but not all, Part D plans charge deductibles.
6. General
The person is enrolled in a plan without a deductible. How will this work?
Some, but not all, Part D plans charge deductibles.

7. General
A person filled out a paper application for drug coverage, when will the enrollment be effective?
Since enrollments can be effective as soon as the day after the enrollment transaction has been received by the plan or the On-Line Enrollment Center, pharmacists may have to contact plans based on copies of an enrollment form to verify billing instructions.  If eligibility cannot be confirmed, the person must use other coverage, if available, or pay out-of-pocket for all or some of the prescription and be referred to 1-800-MEDICARE to resolve Medicare coverage status.  If the person was enrolled on the date of service of the claim, the person may submit the receipt to the Plan for reimbursement.
8. General
A person enrolled in more than one plan prior to 01/01/06 and they think they are in a different plan than the one that is in the Medicare record.


The pharmacist can only bill the plan in which the person is enrolled on the date of service.  If an E1 query indicates that the person is enrolled in one plan, but the beneficiary also has a letter indicating acknowledgement of enrollment in another plan, pharmacies should be able to default to the first payer who pays the claim, or the best available information in their opinion at their discretion.  

9. General
A person goes to a pharmacy that is listed in a PDP's network, and the pharmacy has not contracted with the PDP
The pharmacist should refer the person to their Plan member services line or 1-800-MEDICARE to locate a network pharmacy.  The pharmacy should also contact the plan to determine whose records are in error.
10. General
A person wants to enroll in a new plan, how can they do it?
Non-dual eligible beneficiaries have a limited number of opportunities to change Part D plans.  Consequently, some beneficiary coverage will change more often than once a year.


LTC NBFDE

Audience
What If…
1. LTC NBFDE
A person enters a LTC and is waiting for confirmation of their enrollment in a Medicare drug plan
Enrollment in Part D plans can be verified in the LTC setting in the same manner as in all other pharmacies.

All residents must receive drugs in accordance with their plan of care while a long-term care pharmacy and Part D plan of record are negotiating contractual terms.  All Plans are required to provide first fill transitional coverage in the LTC setting for non-formulary drugs.  Plans can be contacted for their detailed transition policies.  Beyond the transitional period, LTC pharmacies must ensure compliance with formulary drugs and utilization management rules in advance of dispensing drugs, even if billing is on a post-consumption basis.

Any changes of Part D plan enrollment are generally prospective, that is, effective the first day of the following month.  Consequently, in the event that a resident changes Part D plans for any reason, each Part D plan is required to provide in-network access for the period during which the resident is a member of their plan.

 Medicare Part D testing (11/16/2005)
DayTech is committed to the success of the Medicare Part D program. We intend to participate in every testing opportunity made available to us between now and the scheduled rollout date of  01/01/2006.
We are pleased to announce that our products passed Medicare Part D Vendor Certification testing with both Caremark/PCS and Merck Medco. All test transactions available from the TrOOP Facilitator have been successfully completed as well. We hope to be actively involved in additional testing initiatives if the inductry provides them, and will post the results to this site as they become available.    
  CMS Posts Security Education Documents (08/22/2005)
The following web links may be used to review educational documents posted on the CMS web site that relate to implementation of the final HIPAA Security Rule. These documents are designed to assist Providers and Payers in understanding the basics of how to comply with the Rule which took effect earlier this year. You must have Adobe Reader in order to view these files:
Basics of Risk Analysis and Risk Management  (PDF, 228KB)
Security Standards - Administrative Safeguards  (PDF, 350KB)
Security Standards - Organizational Policies & Procedures  (PDF, 165KB)
Security Standards - Physical Safeguards  (PDF, 105KB)
Security Standards - Technical Safeguards  (PDF, 238KB)
Security 101 for Covered Entities  (PDF, 91KB)

Other educational material regarding Security as well as Transactions and Code Sets may be found at:

http://www.cms.hhs.gov/hipaa/hipaa2/education/default.asp#SecurityEd

 Medicare Part D is on the way!  (8/22/2005)
Starting in January of 2006 the Medicare Part D prescription drug benefit will take effect. Under this benefit, prescription drug claims for over 28 million Medicare recipients will be required to be created using the NCPDP Version 5.1 format and transmitted using the NCPDP Version 5.1 Telecommunications Standard. The current versions of both ECSS and CE2000 are already able to support the new Medicare Part D requirements including Eligibility requests, Coordination of Benefits and TrOOP facilitation. We belong to a number of NCPDP Task Groups working on Medicare Part D planning in order to assure that we remain current on this issue. DayTech is committed to supporting the Medicare Modernization Act / Medicare Part D prescription drug claims processing to the fullest extent possible.

 DayTech's NCPDP V5.1 Certifications (as of 10/20/03)
DayTech holds official Switch Certifications from both RelayHealth (NDC) and Change Healthcare (Envoy) for the transmission of prescription drug claims using the new HIPAA-required NCPDP Version 5.1 format. We were the first company in the nation to receive this level of certification. We are also certified with NHIN. Our ECSS and Claims Engine products have the ability to create and transmit all 14 transaction types defined in NCPDP Version 5.1 including patient eligibility, claim billing, reversal and rebill as well as prior authorization, information and controlled substance reporting. We support such functions as coordination of benefits, multi-ingredient compounding, partial fill, DUR/PPS reporting and clinical measurement reporting.
DayTech products are formally certified for NCPDP Version 5.1 with:
ACS Consultec
BS of MI
CA Medicaid
CT Medicaid
DE Medicaid
Express Scripts
First Health
NDC Health
MA Medicaid
NHIN
OmniSys
Paid (Medco)
PA Medicaid
PCS (both)
RI Medicaid
TX Medicaid
VA Medicaid
Envoy/WebMD
Wellpoint
3rd Party Sol.

The list above reflects only the Payers who required or requested a separate Vendor certification for NCPDP Version 5.1.
We have also tested with many Payers who either accept our Certification with RelayHealth, NHIN or Change Healthcare, or with whom we certified under a separate test conducted by their PBM.
DayTech products are able to transmit prescription drug claims to all State Medicaid plans and Commercial Payers that use the NCPDP Version 5.1 format.
See the Products area of this site for more information