Emdeon-Kmart Medicare Part B Billing Procedures
Overview
December 2014
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PATIENT SET-UP
Medicare Part B drugs, supplies, and durable medical equipment
PDX Carrier Code:
MCE
PDX Plan Code:
(blank)
Cardholder ID:
Medicare Recipient Number (HICN) i.e. 123456789A
Group:
-Supplemental & Medicaid (see exceptions below) = COBA ID (Coordination of Benefits
Agreement ID Number assigned by Medicare found on COBA ID List)
-Medicaid (CT, IN, ME, MI, NH, RI, VA & VT) = State abbreviation followed by Medicaid
Recipient Number i.e. CT-123456789 (must include the – (dash))
-SC and MA Medicaid = Do not crossover from Medicare – LEAVE GROUP BLANK
Address:
Must match what Medicare has on file for the patient (no punctuation permitted)
Medicare Part B immunizations
PDX Carrier Code:
IMU
PDX Plan Code:
MCE
Cardholder ID:
Medicare Recipient Number (HICN)
i.e. 123456789A
Group:
-Supplemental & Medicaid (see exceptions below) = COBA ID (Coordination of Benefits
Agreement ID Number assigned by Medicare found on COBA ID List)
-Medicaid (CT, IN, ME, MI, NH, RI, VA & VT) = State abbreviation followed by Medicaid
Recipient Number i.e. CT-123456789 (must include the – (dash))
-SC and MA Medicaid = Do not crossover from Medicare – LEAVE GROUP BLANK
Address:
Must match what Medicare has on file for the patient (no punctuation permitted)
PATIENT DOCUMENTATION/FORMS REQUIREMENTS
New Medicare Part B patients are required to fill out the following forms (must be kept on file at Kmart pharmacy
location):
 Patient Authorization & Intake Form
o Page 1 & Page 2 filled out/signed by patient and kept on file in pharmacy
o Page 3 & Page 4 handed to patient
 (Available on the Pharmacy Portal Pages under Third Party tab  Medicare Part B).
 Current Medicare Part B patients who have already filled out these forms, and they are on file with Kmart do
not have to fill these forms out again
 Forms must be filled out and kept on file for each pharmacy location patient gets Medicare Part B
prescriptions
 In the event it is known that Medicare Part B may not pay for an item that is being billed, an ABN form
(Advanced Beneficiary Notice) should be completed by the pharmacist and patient and kept on file at the
pharmacy location.
 These forms can be found on the Pharmacy Portal Pages (https://kmartpharmacy.searshc.com/Login)
PATIENT ELIGIBILITY
Emdeon provides an on-line, real-time Eligibility Verification System that accesses the Medicare Common Working File
 Includes effective and termination dates, Patient First and Last Name, DOB, Sex, HMO Coverage, Primary
Payer Information, and other information to ensure claims are paid
 Includes real-time patient deductible information
 If Medicare has not yet received a patient claim (from Dr or pharmacy), the working file will not show
the patient deductible has been met
 Patient is responsible for paying their deductible until Medicare shows they have paid it in full
o In the event a patient would overpay their deductible, Medicare will issue a refund to them
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Patient co-pays are determined on their eligibility with Medicare
 Patient who has Medicare Part B ONLY
 On claims Kmart accepts assignment on, patient pays 20%
 Patient who has Medicare Part B and Medicaid
 Patient pays $0 (zero)
 Patient who has Medicare Part B and Supplemental Insurance that DOES auto cross-over (MUST have COBA
ID assigned by Medicare found on COBA ID List)
 Patient pays $0 unless deductible has not yet been met
 Patient who has Medicare Part B and Supplemental Insurance that does NOT auto cross-over (does not have
COBA ID assigned by Medicare)
 Patient pays 20%, unless deductible has not yet been met, then submits reimbursement to supplemental
insurance
 Patient has primary insurance and Medicare Part B as a secondary payer
 Patient co-pay varies depending on patient primary coverage and remaining deductible amount
o For first fill Medicare Secondary Payer (MSP) claims please call the Emdeon Support Desk and
provide the patient’s primary insurance details
o The word SECONDARY should be placed in the Group Field
o The other coverage code should be a 2 or 3
 Kmart accepts assignment on all Medicare covered drugs and select diabetic testing supplies (see Kmart
Medicare Diabetic Supplies Formulary)
 On claims Kmart does not accept assignment on, patient pays 100% (Medicare will reimburse 80%)
MEDICARE PART B PRESCRIPTION REQUIREMENTS
All prescriptions billed to Medicare Part B must be written, faxed, or sent electronically by the prescriber (VERBAL
ORDERS NOT PERMITTED) and Medicare does not allow hand stamped physician scripts. MUST include the following:
 Signature of prescriber
 Narrative Diagnosis and/or ICD-9 Code Describing the Patient’s Condition
 Insulin-dependent indication
 Date Written
 Patient Name
 Quantity & Drug(s)/Item(s) to be dispensed
 Specific Dosing and Frequency
 “As Directed” SIG Not Acceptable
Medicare Part B prescriptions for diabetic testing supplies require:
 A modifier must be sent in the Procedure Modifier field to indicate patient insulin usage
 If patient is insulin dependent, send KX
 If patient is not insulin dependent, send KS
o The Procedure Modifier Field is located in the Extra Info Screen, bottom left
 This modifier determines the Medicare set Utilization Guidelines for diabetic testing
 Non-insulin dependent patients are allowed one time a day testing
 Insulin dependent patients are allowed up to three times a day testing
 Valid Diagnosis Code
 Diabetes Melitis Type I – 250.01 (Odd digit in 100th position)
 Diabetes Melitis Type II – 250.00 (Even digit in 100th position)
 ICD-9 codes must fall between 250.00 and 250.93
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Medicare Part B prescriptions for Nebulizers require:
 Beneficiary Owned Equipment Date
 HCPCS code of base equipment or UPC/NDC (or make & model information)
 Notation that this equipment is beneficiary-owned
 Date the patient obtained the equipment
o If a claim submitted to Emdeon requires the above information for Medicare, the claim will
reject and the pharmacy will be prompted to call Emdeon with the correct information
o Or the Store may enter the Date of Purchase in the Prior Auth Field as YYYYMM or YYYYMMDD
 Each RPh is responsible for the validity of the information billed to Medicare Part B
 It is important that we communicate with our patients the significance of accurate/current information
being provided to Medicare
 If a patient does not know the information that is required to process a claim to Medicare, the claim should
not be billed until the information is obtained
 For example: If a patient provides you with a date they think is correct but they aren’t certain, they should
sign an ABN form (Advanced Beneficiary Notice) that informs the patient why their item may not be covered
by Medicare (if the date is not correct), and the financial responsibility for the patient in the event the item
is not covered.
 Valid Diagnosis Code
 COPD – 496
 Asthma – 493.XX *Must send 5 digit code for Asthma
 Chronic Bronchitis – 491.0
 Emphysema – 492.8
Medicare Part B prescriptions for immunosuppressive/transplant medications require:
 Medicare Eligibility at time of transplant is required for Medicare to approve the claim
 Transplant Discharge Date
 Enter Discharge Date in the Date of Injury Field
o Located on the T/P Worker's Comp Setup Screen
o PLEASE NOTE: You MUST enter a Y in the Worker's Comp field located on the Patient T/P
Information Screen in order for the Injury/Discharge Date to send
 Valid Diagnosis Code
 Heart Transplant – V42.1
 Liver Transplant – V42.7
 Kidney Transplant – V42.0
 Lung Transplant – V42.6
 Please Note: Kmart does NOT Cover Brand Cellcept, Prograf and/or Gengraf
Medicare Part B prescriptions for oral Anti-Emetic drugs require:
 Verify Criteria in the Oral Anti-Emetic Coverage and Billing Procedure (Oral Anti-Emetic Store Guide) are met
then you may call the Emdeon Pharmacy Services Helpdesk to override
 All 3 drugs (Dexamethasone, Emend and Anzemet, Zofran or Kytril) must be transmitted on the same day
with the same date of service
 Valid Diagnosis Code
 ICD-9 codes must fall between 140.0 – 208.91, 230.0 – 239.9, 259.2, 273.3 and V58.0 – V58.12
 Please Note: You are no longer required to enter the route indicator in the Cardholder ID
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Medicare Part B prescriptions for Anti-Cancer/Chemotherapy drugs require:
 Valid Prescription Order
 Valid Diagnosis Code
 ICD-9 codes must fall between 140.0 – 208.91, 230.0 – 239.9, 259.2, 273.3 and V58.11
Additional prescription requirements for Medicare covered durable medical equipment (canes, walkers, etc.) can be found on the
Pharmacy Portal Page https://kmartpharmacy.searshc.com/Login
Kmart Pharmacy is DMEPOS accredited with HQAA to bill the following DME items:
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Blood Glucose monitors and/or Supplies
Canes and/or Crutches
Commodes/Urinals/Bedpans
Heat & Cold Applications
Nebulizer Equipment and/or Supplies
Ostomy Supplies
Surgical Dressings
Urological Supplies
Walkers
Wheelchair Seating/Cushions
SUPPLEMENTAL INSURANCE BILLING
CMS (Centers for Medicare & Medicaid Services) assigns a COBA (Coordination of Benefits Agreement) ID to
supplemental payers and insurers that have agreed to auto cross-over.
 This means that once the claim has been billed to Medicare and they have “paid” their 80% portion of the
claim, the claim will automatically be billed to the supplemental insurance and Kmart can then expect
payment for the remaining 20%
 Patient pays zero co-pay at the register
 Emdeon does not assign the COBA ID’s
 Emdeon can assist in locating a COBA ID, but they are simply using the same COBA ID List that CMS has
provided (located on the Pharmacy Portal Page  Third Party  Medicare Part B)
 Medicaid – Vary depending on State
 CT, IN, ME, MI, NH, RI, VA & VT = Use State abbreviation followed by Medicaid Recipient Number
o i.e. CT123456789
 MA & SC = Do not crossover from Medicare therefore the Group would be blank
o You may still split-bill the claim to Medicaid (MMA/MSC) in PDX to receive $0 copay
 ALL Other Medicaid States = USE COBA ID List
 PLEASE NOTE: AZ = ONLY crossover from Medicare for CERTAIN member types, Emdeon will indicate if
the COBA ID 70054 should remain in the Group or be removed – again, the claim may be split-billed in
PDX for the patient to receive a $0 copay
Patients who have a supplemental insurance that has elected to not get a COBA ID (which means they have not
agreed to auto cross-over) are responsible for both paying the 20% portion themselves and billing their carrier
themselves for reimbursement.
 Neither Kmart nor Emdeon has the ability to “get” a COBA ID for a supplemental insurance that does not
already have one
 It is imperative that all pharmacists, store staff, and patients understand Kmart is in no way trying to “push”
patients away by charging them a 20% co-pay
 Claims that do not auto cross-over to Kmart result in a loss to the pharmacy for the 20% co-pay if the patient
does not pay at the register
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If a patient states they have supplemental insurance, do the following:
 Ask for a copy of their supplemental insurance card
 Look for the name of the supplemental insurance plan on the COBA ID List
 If the supplemental insurance plan name does not appear anywhere on the COBA ID List, look on the card
for an insurance processor name
 If an insurance processor name appears on the card, look for the processor’s name on the COBA ID List
 If the patient does not have a supplemental insurance card with them, or the above steps have not assisted
in identifying the COBA ID, try these additional suggestions:
 Call the supplemental insurance and ask them if they have a COBA ID (match with COBA ID List)
 Call the supplemental insurance and ask them who processes prescription drug claims for them (match
with COBA ID List)
 If you have are still unable to obtain a COBA ID:
 Contact Emdeon at 866-379-6389
 Open a Help Ticket to the Pharmacy Support Desk
 The patient’s secondary (supplemental) insurance may NOT have a COBA ID, but it may be split-billed
 Check patient’s supplemental insurance card for a BIN and PCN to bill on-line
SUPPORT AND CLAIM ASSISTANCE
The Emdeon Help Desk
 866-379-6389
 Monday – Friday 8am-10pm Eastern
 Saturday 9am-6pm Eastern
 Closed Sundays
 Spanish speaking representatives are available
Training documentation available 24/7/364 from Kmart
 Pharmacy Portal : https://kmartpharmacy.searshc.com/Login
 Third Party tab  Medicare Part B
Further questions/clarification can be addressed by opening a Help Ticket to:
 Category: Pharmacy Support Desk
 Sub-category: Medicare Part B Claims (MCE)
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