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Summary of New Plan Sponsors and Important Information - page 5 / 5





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Medco Health Solutions, Inc. 100 Parsons Pond Drive Franklin Lakes, NJ 07417 www.medco.com/rph

Important Information Effective January 1, 2010

This document is intended to be a reference document to help with successful claims processing through the TelePAID® System. Please review all of the information carefully. We have included a list of some of our new plan sponsors effective

January 1, 2010. Eligibility Information:

Eligibility Reject Codes:

Always ask to see member’s ID card and submit the following information:

  • Member’s ID number

  • Rx Group number

  • Rx BIN number

  • Patient’s first name

  • Full date of birth (CCYYMMDD)

  • Gender

  • Patient’s 2-digit person code

  • Patient’s 1-digit relationship code

Incorrect eligibility information may reject with:

Rx Origin Code:

  • NCPDP Reject 51 – “Non-matched group number”. Check ID card

  • NCPDP Reject 52 – “Non-matched cardholder ID”. Check ID card and verify submitted information.

  • NCPDP Reject 65 – “Patient not covered” - Check the fields listed above for accuracy.

  • NCPDP Reject 69 – “Filled after coverage terminated” – Ask member for new ID and confirm current processor information.

Eligibility can be verified by calling Pharmacy Services Help Desk at 1 800 922-1557 and pressing number 1 and following the IVR prompts. Effective the second quarter of 2010, Medco will edit for accepted values for the Prescription Origin Code field on all incoming claims (primary and secondary). Valid values for new prescriptions are:

  • 1 – Written

  • 2 – Telephone

  • 3 – Electronic

  • 4 – Facsimile

Valid values for refilled prescriptions are

  • 0 – Not Known

  • 1 – Written

  • 2 – Telephone

  • 3 – Electronic

  • 4 – Facsimile

Valid values for transferred prescriptions are:

  • 0 – Not Known (Only valid if transferred prescriptions is transmitted as a refill prescription, if the transferred prescription is transmitted as a new prescriptions then

    • 0

      is not valid).

  • 1 – Written

  • 2 – Telephone

  • 3 – Electronic

  • 4 – Facsimile

General Information:

The value 0 will be an acceptable value for refills only if the pharmacy cannot determine how the prescriber initially submitted the prescription. Claims with missing or invalid prescription origin code will reject with:

    • NCPDP Reject 33: “Missing/Invalid Prescription Origin Code”

  • The most current payer sheets are available at www.medco.com/rph.

  • The claim adjudication window for claim submission and reversals is 90 days from the date of service.

  • Billing for vaccine administration fee when administration of covered vaccine products should be submitted as follows:

    • Populate “MA” in Field 440-E5, Professional Service Code, when submitting for vaccine administration.

    • Vaccine administration fee should be submitted in Field 438-E3, Incentive Fee Submitted.


For claim adjudication or general questions:

For Medicare Part D Sponsors, please see “2010 Medco Medicare Part D Reference Document” available at www.medco.com/rph. Contact the Pharmacy Services Help Desk toll-free at 1 800 922-1557, or visit the Pharmacist Resource Center at www.medco.com/rph.

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