Provider Bulletin 09-01 October 2009
Provider BulletinNew York State EPIC - Prescription Protection for Seniors
P.O. BOX 15018
ALBANY, NY 12212-5018
Bulletin No. 09-01
Subjects: Coordination of Benefits - New Claim Edits: Other Coverage Code and Follow Part D Plan Limits
Most EPIC members are also enrolled in a Medicare Part D or other drug plan, which is their primary drug plan. EPIC provides wraparound coverage for seniors with other drug coverage, helping them pay the out-of-pocket costs required by their primary plan.
It is important that the primary coverage is being fully utilized so that EPIC is not paying for costs that are the responsibility of the primary payer, and seniors pay the lowest possible cost. To ensure that EPIC is not billed as primary when the senior has Part D coverage, the following edit on Other Coverage Code (OCC) will be added to the EPIC online claim system for prescriptions dispensed on or after November 18, 2009.
New Edit: Claims with OCC of 1 or 7 will be denied if EPIC records show active Part D coverage
- If your records show the senior has no other coverage or if the senior insists they do not have Part D coverage, before billing EPIC as primary with OCC 1 or 7, submit a Medicare eligibility transaction (E1) to obtain up-to-date information pertaining to the senior's enrollment in a Part D plan. This information can also be obtained by calling Medicare at 1-866-835-7595. Contact your software vendor or corporate office for technical assistance with the E1 transaction.
- If the E1 transaction or Medicare helpline confirms there is currently no other coverage for the senior, call the EPIC Provider Helpline at 1-800-634-1340 for an override of the EPIC denial.
Chart of Other Coverage Codes
|Not specified||0||This code is used when the participant has no other coverage.|
|No other coverage identified||1||This code is used after an E1 transaction was completed and indicates that the participant does not currently have primary coverage other than NY EPIC.|
|Other coverage exists, payment collected||2||DO NOT USE. Claim will deny. (Use OCC 8)|
|Other coverage exists, this claim not covered||3||This code is used when a claim is denied by the primary plan (other than for reasons indicated in OCC 6 and OCC 7). The other payer denial information must be included on the claim submitted to NY EPIC.|
|Other coverage exists, payment not collected||4||DO NOT USE. Claim will deny. (Use OCC 8)|
|Managed Care Plan Denial||5||DO NOT USE. Claim will deny. (Use OCC 3)|
|Other coverage denied, not a participating provider||6||This code is used when the primary payer denies a claim because the provider is non-participating.|
|Other coverage exists, not in effect on date of service||7||This code is used when the primary payer denies a claim because the participant is not enrolled on the date of service submitted. This differs from OCC 1 in that there is or was coverage, but not in effect on that date.|
|Copay only billing||8||This code is used for any claim that is approved by the primary payer, including claims with no payment, e.g. deductible or coverage gap claims.|
When billing EPIC as secondary, use BIN 012345 and PCN P024012345.
Reminder: Follow primary plan limits
Claims denied by the Part D or other primary plan with reject code 76 (plan limitations exceeded) should be corrected to adhere to the limits of the primary payer before being submitted to EPIC as secondary payer.