The following claim submission procedures are for SeniorCare participants who are in the spenddown or $850 deductible level of participation, regardless of whether or not SeniorCare makes a payment. These procedures apply only to SeniorCare participants with incomes over 200 percent of the Federal Poverty Level (FPL).

Claim Submission

Claims submitted to Wisconsin SeniorCare for participants who are enrolled in Wisconsin SeniorCare and a Medicare Part D Prescription Drug Plan (PDP) require a bank identification number (BIN) and a processor control number (PCN). Providers should use the BIN/PCN information received in the claim response from the PDP to submit the claim to Wisconsin SeniorCare for participants with incomes over 200 percent of the FPL. For SeniorCare participants with incomes over 200 percent of the FPL, the BIN is 610499 and the PCN is WIPARTD. Providers should refer to the PDP’s payer sheet for guidance about how to interpret the information contained in the claim response.

After a claim has been submitted to Wisconsin SeniorCare with the BIN/PCN, the pharmacy provider and the true out-of-pocket (TrOOP) facilitator will receive a response that identifies whether the claim was reimbursed or denied. Effective for dates of process on and after January 1, 2007, Wisconsin SeniorCare will implement the following Explanation of Benefits (EOB) message when a real-time pharmacy Point-of-Sale (POS) claim is submitted to SeniorCare without a BIN/PCN: “Denied. Missing Processor Control Number (PCN) for SeniorCare participant over 200% FPL. Invalid PCN for Medicaid recipient or SeniorCare participant at or below 200% FPL.”

Providers will receive this EOB in the following situations:

• When a BIN/PCN is not received on a claim for a SeniorCare participant with income over 200 percent of the FPL.
• When a pharmacy claim is received for a Medicaid recipient or SeniorCare participant under 200 percent of the FPL with BIN number 610499 and PCN WIPARTD.

Payments issued by Wisconsin SeniorCare or the participant are applied to the participant’s TrOOP amount. Providers may contact the appropriate PDP for information about a participant’s TrOOP expenditures or balance. If a claim is submitted in a batch and not through the real-time pharmacy POS claims processing system, the participant’s TrOOP cost-sharing amount will still be submitted to the TrOOP facilitator by Wisconsin SeniorCare.

Payer of Last Resort

Wisconsin SeniorCare is the payer of last resort. Providers are required to submit claims to a participant’s PDP and other health insurance sources before submitting claims to SeniorCare.

SeniorCare Coordination of Benefits

Wisconsin SeniorCare does not currently require coordination of benefits with Medicare Part D PDPs for participants with incomes above 200 percent of the FPL. With the implementation of the TrOOP process described in this Wisconsin Medicaid and BadgerCare Update, Wisconsin SeniorCare will require coordination of benefits between SeniorCare and Medicare Part D.

As a result, pharmacy providers may experience an increase in the number of SeniorCare claims that may be impacted by the coordination of benefits process. If a claim is submitted to Wisconsin SeniorCare before it is submitted to Medicare Part D for a participant with income over 200 percent of the FPL who is enrolled in a PDP and SeniorCare, the pharmacy provider will receive EOB message 268, which states the following: “Participant is enrolled in Medicare Part D for DOS. Submit claim to participant’s PDP prior to SeniorCare. PDP payment/denial information required on claim to SeniorCare.”

Providers may refer to the July 2006 Update (2006-65), titled “SeniorCare Coordination of Benefits with Medicare Part D,” for additional coordination of benefits information.

Enrollment

Wisconsin SeniorCare participants may be enrolled in both SeniorCare and in a Medicare Part D PDP. SeniorCare participants with incomes greater than 200 percent of the FPL who are enrolled in both programs must satisfy their annual TrOOP cost sharing before Medicare Part D catastrophic coverage becomes effective. (Medicare catastrophic coverage reimburses 95 percent of a drug claim’s cost.) The TrOOP amount in 2007 is $3,850.

For More Information

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

• The TrOOP Web site at medifacd.ndchealth.com/home/MediFacd_home.htm.
• The Medicare Web site at www.medicare.gov/.
• The revised Wisconsin Medicaid Companion Document to HIPAA Implementation Guide — NCPDP 5.1
• The SeniorCare Customer Service Hotline at (800) 657-2038.
• Provider Services at (800) 947-9627 or (608) 221-9883.