In the most recent round of OptumRx/SCIO desk audits, PAAS is seeing audits for test strips, insulin used in a pump, nebulizer solutions, immunosuppressants, chemotherapy medications, and vaccines. If the patient is Medicare-eligible and meets Medicare requirements, these claims should be billed to Medicare Part B. If the pharmacy is processing under a Medicare Advantage plan (Part C), they are required to cover everything that is covered by Part A, B and sometimes D. Some plans require that all drugs and supplies be billed to the prescription benefit and they will process them under either B or D as appropriate. Other plans may require that you bill Part B drugs and supplies to the medical benefit and only Part D to the prescription benefit.
Why do these potential Medicare B claims go through the Part D plan at the point of sale?
- Pharmacies should be aware of drug classes typically billed to Medicare B
- Determine if patient is Medicare eligible
- Contact the equipment supplier to verify if they are billing Part B for supplies, if so, then the drugs should be billed to Part B
- If billing a Part C plan, confirm with the plan on how to bill
- Pay close attention to any soft reject messages and do not override just to get a claim paid
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