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What to do when faced with a consumer that has not enrolled or has not been auto-enrolled.
Point of Sale Facilitated Enrollment
This process applies only to full-benefit dual eligible individuals
This does not include:
- The deemed population (QMB-only, SLMB-only, Q1-1)
- Medicare-only beneficiaries
The 12 step process entails:
1) Full benefit dual eligible individual presents at the pharmacy with either a Medicaid card, previous history of Medicaid billing in the pharmacy’s patient profile, or a copy of a current Medicaid award letter.
2) The pharmacist requests photo identification, or other supporting documentation, and checks for Part D enrollment or eligibility for Medicare Parts A & B by submitting and E1 query to the TrOOP facilitator.
Other (offline) ways to check for A/B Medicare eligibility:
• Request to se a Medicare card
• Request to see a Medicare Summary Notice (MSN); or
• Call the dedicated Medicare pharmacy line (1-866-835-7595) available Monday-Friday 8AM-8PM EST; or
• Call 1-800-MEDICARE (available 24/7)
3) If the E1 query returns Part D plan enrollment information, the pharmacist bills the appropriate plan. If the pharmacist can not identify the appropriate plan to bill, but is able to verify Medicaid eligibility (step 1) and Medicare eligibility (step 3), the process continues.
4) The pharmacist enters the claim into the automated pharmacy system, including available beneficiary data, such as name, Medicare ID number, Medicaid ID number, or SSN, date of birth, address, and phone number.
5) The pharmacist submits the claim to the unique BIN/PCN account indicated on the POS Contractor’s payer sheet.
• Claim submitted to Anthem Prescription, LLC
• BIN-610575
• PCN-CMSDUAL01
If compliance with the paid claim response, the pharmacist provides prescription drug to the beneficiary and collects co pay of either $1 generic or preferred multi-source brand or $3 for any other brand.
6) The POS Contractor processes the claim as paid. Most pharmacies will process as paid whether they are in or out of a Wellpoint network- but on some occasions if the pharmacy is out-of-network, special instructions will need to be sent to the pharmacy to establish the mechanism for payment.
7) The POS Contractor sends a daily file to the Enrollment Contractor with submitted beneficiary data.
8) The Enrollment Contractor uses this information to validate dual eligibility and returns a validation of eligibility or ineligibility to the POS Contractor.
9) If the individual is dually eligible, and not enrolled in a Part D plan, the POS Contractor enrolls him/her in a POS Contractor plan.
• All facilitated enrollees have the option to choose another plan.
10) If the beneficiary is a full-benefit dual eligible individual, but already enrolled in a Part D plan, the POS Contractor will contact the pharmacy to reverse the claim, and the pharmacy will bill the appropriate Part D plan. Wellpoint will generally provide information on the other Part D plan to the pharmacy at the time contact is made to reverse the claim.
11) If the beneficiary is Medicaid-eligible only, the POS Contractor will contact the pharmacy to reverse the claim, and the pharmacy will bill the appropriate state agency.
12) If the person is Mediare-eligible only, The Enrollment Contractor notifies the beneficiary that she/he is ineligible for facilitated enrollment, but may enroll in a Part D plan under normal enrollment rules. The POS Contractor will contact the pharmacy to reverse the claim, and the pharmacy will pursue collections.