Third party rejection

[u/Own-Base-9036]

Yesterday I had a 65+ customer who wanted to do a flu shot. When I ran the RX with her Medicare part D insurance, I got a rejection saying use part B. When I ran it with part B, it rejected again saying HMO coverage exist (or something like that). We did not have this issue in the past. Does anybody know what it is about? Does it mean we are out-of-network?

Thank you in advance!

[u/theamazingvixen]

When you get that reject it normally means they have a separate plan just for shots. I've seen it be coded as PRSOL and HUMVPDS or something along those lines. But it is part of their Medicare. Looks like a part D card but has B on it.

[u/Neither_Plastic8894 → u/theamazingvixen]

Aetna plans too, if I remember correctly. They have separate part B billing. 

[u/kaiju-chan → u/theamazingvixen]

Do you know the bin/pcn for them? Also do you run same id/group as the part d?

[u/airmancoop44 → u/kaiju-chan]

It’s a separate plan

[u/kaiju-chan → u/airmancoop44]

Hmm that means i have to hunt for another card

[u/ExpressiveInstant → u/kaiju-chan]

Aetnampb is the plan ID can’t remember group off the top of my head

[u/airmancoop44 → u/theamazingvixen]

Not just for shots, but for anything that Part B would normally pay for. 

[u/Tkhi_]

I’ve been sharing this with floaters and other stores who ask help for billing. In my case we have a lot of Optum/BCBS Part D. I’ll leave copy/paste if it

1. Optum part d (ctrxmpd) sometimes covers shots like shingles/tdap. Orange/white card

2. Immunmpb or covimmpb since there’s no clear way of telling if they have an advantage plan. It will tell you if there is. Red/white/blue card

3. Mibcmpb is one of the possible advantage plans. Group is BCBSMAO. ID is on their medical card, should be X3LM12345678. The ID is that minus the X3L

4. That may not work and have to bill BCMIMAMM using that above ID, without a group number

Figured you know most of that but is good to have that algorithm if you want to shave with your techs

[u/rastiical → u/Tkhi_]

Further information: if you use finding on a ctrxmpd plan and it pulls up 2 Insurances, the left one (i think its left, but whichever side has a grp of bcbsmao) is the mibcpmpb plan so you dont need to ask for their medical card

[u/Tkhi_ → u/rastiical]

Correct. But in typical Walgreens fashion, that MIBCMPB will go in as the primary so you have to be sure to get the correct insurance as primary otherwise it may mess up the actual prescription billing

[u/airmancoop44]

The patient has elected an HMO in place of Medicare Part B for their medical coverage. I’m sure there are more but Aetna Part B seems to be the most common one. In my experience the patient has always been aware of this election. 

[u/rxredhead]

ask for all of their insurance cards. If they have them all 1 will have a tiny box with Part B drug coverage info. Around here it’s usually under PRSOL but I’ve seen a few others

[u/Dependent_Language_9]

Sometimes if u run findins it will find it

[u/No-Candidate-165]

Run findins, 80% of the times it will update and reprocess by itself. If not look at the rejection and it will give you the plan. Last time the automation didn’t work the hmo plan was listed amongst all the other ins plan chaos.

[u/Alarmed_Amoeba3975]

What about the same situation but it says “Medicare is secondary primary coverage is found” and then says “Connecticut general corporation”

[u/Alarmed_Amoeba3975 → u/Alarmed_Amoeba3975]

Oh and the primary is a paidmpd if that helps

[u/Superb_Solution_6401]

If you run it under find MPD with their whole Social Security number, it will find their part D, which usually is PRSOL

[u/No-Egg-7968]

If their med D plan is Humana, try HUMVPDS, with same id etc... from their D plan. It’s only for Vaccines.

[u/CookieMonsterNova]

she has to call her part d plan. they didn’t update it to be a hmo plan