Tertiary Billing
This is the correct billing order for a participant with CRDP coverage, Part D and PACE.
What is bill Medicare Part D first, CRDP second, and PACE third?
This is what COB stands for.
What is coordination of benefits?
This is the first step in identifying an OCC-3 edit claim rejection.
What are the rejection codes?
This is what ADAP stands for.
What is AIDS Drug Assistance Program?
This is a type of code that maybe entered to bypass a claim rejection.
What is an override code?
This is to ensure each payer is billed appropriately based on their coverage responsibility.
What is correct billing order?
This is why it is called coordination of benefits.
What is to show all coverages being billed?
This is the second step in gathering information on an OCC3 claim.
What is make sure that both the primary in the COB and Other Payer Coverage is the same?
$0
What is ADAP copay for all covered medications?
This is faxed to the doctor when a medication needs to be proven medically necessary.
What is a medical exception (prior authorization) form
The pharmacy skipped billing a coverage. This is why it rejected.
What is improper billing order?
This is what happens when all fields on the second row of the COB are empty except for the first field.
What is a primary rejection?
This is the third step to verify before calling the UR department.
What is check to see if a one-time medical exception has been performed?
Other
What is a cost-exceed override for ADAP?
When a CSR sees a rejected claim, this is the first step.
What is click the response?
This must be corrected when the primary is paying, the secondary is rejecting, and the third coverage will pay-but the claim is denied due to M/I OCC/COB.
What is change the secondary OCC to match the Primary OCC?
This field must match the COB or the claim will reject.
What is the "other coverage code" field?
This is the information given to the reviewer for an OCC3 edit rejection.
What is the CHID, CH name, medication name, DOS, Medical exceptions performed?
Before performing a Cost Exceeds Override, CSRs must check this this resource. If the medication is not listed, CSRs then must contact this person.
What is the Non-PACE Cost Exceeds Max list and who is Nicole the pharmacist?
This is used to determine what medical exception is needed.
What is trial adjudication?
This is the recommended solution when a pharmacy cannot change the OCC to properly bill all three coverages.
What is advise the participant to go to a pharmacy that can bill all their coverages in the correct order?
This field shows the full billed amount of the medication.
What is the Benefit Stage amount?
These are the medications that are on the OCC3 edit amongst any other medication that is over the U&C amount of $1000 that the primary rejects.
What are
Eliquis
Farxiga
Repatha
Trulicity
Victoza/ Saxenda
Ozempic/Wegovy
*And their generics?
For every early refill request-regardless of the reason-CSRs must complete this and send it to one of the two individuals.
What is an Early Refill Form, and who are Shamona and Amy B?
This needs to be checked before any and all medical exceptions are placed.
What is the UR Chart?