Claim Submission

Topics

Claim SubmissionDown Time Procedures
Compounded PrescriptionsIngredient Costs
Rejected Claims Dispensing Fees
Claims AdjustmentsRemittance Advice
Claim ReversalsMedicare Part D Payer Sheets



Claim Submission

All prescriptions filled for RxAmerica enrollees must be submitted to RxAmerica regardless of adjudication status. This includes prescriptions for enrollees for which no reimbursement from the plan is due to the pharmacy. RxAmerica performs drug utilization reviews for all of its enrollees. In order for all prescriptions to be filled for enrollees, prescriptions must be submitted to RxAmerica regardless of this review in attempt to maximize the beneficial impact. All prescriptions filled for an enrollee must be available. The submission of claims to RxAmerica must be done through the RxAmerica online claims adjudication system.

To submit claims to RxAmerica:

  1. Contact your software vendor.
  2. Inform your vendor that you want to submit claims to RxAmerica.
  3. All claims must be submitted to RxAmerica through the National Data Corporation (NDC) or ENVOY.
  4. RxAmerica can accept any version of NCPDP Version 3.
  5. BIN number is 610473.
  6. Cardholder ID number is listed on the RxAmerica card.
  7. Member numbers are as follows:
    001 - Cardholder
    002 - Spouse
    003, etc. - Children (in birth date order - oldest to youngest)
  8. Group numbers are not necessary when submitting claims to RxAmerica.
  9. Physician DEA number is required.
  10. Submit “test” claims to RxAmerica using the following information:

Test Information
BIN: 610473
NABP: 9909989
Cardholder ID: 123456789
Member Code: 001
Help Desk: 1-800-770-8014

Your vendor can call RxAmerica toll-free at 1-800-770-8014 for information related to electronic set up.

Compounded Prescriptions

Compounded prescriptions can be submitted to CVS Caremark. The compound must contain one ingredient that is a Federal Legend Drug. When submitting compounds, use the NDC number of the most expensive ingredient when transmitting the claim.

Rejected Claims

Rejected claims may be resubmitted, following correction, in the same manner as original claims. Rejected claims submitted on-line as an adjustment cannot be processed.

Claim Adjustments

Adjustments to claims must be submitted using the Universal Claim Form within 90 days from the date of remittance to the pharmacy by CVS Caremark.

Adjustments for overpayment or underpayment must be submitted using the Universal Claim Form. Adjustments should not reflect the amounts already paid by CVS Caremark. (The ingredient cost submitted should be for the claim as if nothing had been previously paid by CVS Caremark.)

In addition to the required standard claim information, the following must also be included:

  1. Signature of an authorized pharmacy representative.
  2. CVS Caremark claim number. This number is assigned by CVS Caremark and is available from the Remittance Advice. Claims submitted for adjustment without a claim number cannot be processed.
  3. A brief explanation for the adjustment request.

Electronically submitted adjustments will be rejected. Processed adjustments appear on the pharmacy’s Remittance Advice.

Claim Reversals

Claim reversals can be accomplished through the CVS Caremark system, by a CVS Caremark service representative or by submitting an adjustment as detailed above.

Down-Time Submission Procedures

During periods when online claim submission is not possible, CVS Caremark Prescription Drug Program pharmacy enrollees should be serviced in the following manner:

  • If the enrollee is new to CVS Caremark and presents a valid benefit ID card, fill the prescription for a one- or two-day supply of medication and ask the enrollee to return the next day for the remainder of the prescription.
  • If the enrollee is new to CVS Caremark and does not present a valid benefit ID card, call CVS Caremark Customer Care toll-free at 1-800-770-8014 to verify eligibility and receive further instructions. Please obtain the ID number of the cardholder and the date of birth of the person for whom the prescription is written before calling.

When online submission is interrupted and it is not possible to submit claims at a later time through the CVS Caremark system, claims may be submitted on magnetic tape or on the Universal Claim Forms.

Ingredient Cost

The basis for calculating the ingredient cost of a claim is defined in the pharmacy’s Affiliation Agreement. Average Wholesale Price (AWP) shall mean the list ingredient price for a pharmaceutical as established by MediSpan.

Dispensing Fees

CVS Caremark dispensing fees are indicated in the pharmacy’s Provider Agreement.

Remittance Advice

All approved claims submitted are reported in complete detail to the pharmacy.

NOTE: Claims denied through the CVS Caremark online claims adjudication system do not appear on the Remittance Advice.

In addition to various data elements submitted by the pharmacy, the Remittance Advice includes the amount of CVS Caremark ingredient cost, dispensing fees, sales tax (if applicable), enrollee copayments, claim disposition code (reject or payment), data transmission charge, claims status and net amount paid.

Medicare Part D Payer Sheets

RxAmerica Payer Sheet - Medicare Part D B1/B2

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