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 RxAmerica enrollees, scripts must be submitted to RxAmerica regardless of this review to realize the maximum beneficial impact. All prescriptions filled for an enrollee must be available. The submission of claims for RxAmerica must be done through the RxAmerica on-line 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 National Data Corporation (NDC) or ENVOY.
4. RxAmerica can accept any version of NCPDP Version 3.
5. BIN number is 610473.
6. Cardholder identification number is a nine (9) digit social security number 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:

Your vendor may call RxAmerica at (800) 770-8014 for information related to electronic set-up.

Compounded Prescriptions - Compounded prescriptions can be submitted to RxAmerica. The compound must contain one (1) 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 on the Universal Claim Form within 90 days from the date of remittance to the pharmacy by RxAmerica.

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

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

Signature of an authorized pharmacy representative.

RxAmerica claim number. This number is assigned by RxAmerica and is available from the Remittance Advice. Claims submitted for adjustment without a claim number cannot be processed.

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 RxAmerica system, by an RxAmerica service representative or by submitting an adjustment as detailed above.

Down-Time Submission Procedures

• During periods when on-line claim submission is not possible, RxAmerica’s Prescription Drug Program pharmacy enrollees should be serviced in the following manner:

• If the enrollee is a new customer and presents a valid Employee Benefit 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 a new customer and does not present a valid Employee Benefit Card, call the RxAmerica Help Desk at (800) 770-8014 to verify eligibility and to receive further instructions from an RxAmerica Member Service Representative. Please obtain the identification number of the cardholder and the date of birth of the enrollee for whom the prescription is to be filled before calling.

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

Dispensing Fees - RxAmerica’s 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 RxAmerica on-line 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 the RxAmerica 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