Medicare Part D

In order to improve the process for increasing the match rate of Medicare Beneficiaries in the Eligibility Responses, we would like to provide you with some tips when submitting your eligibility transactions.

The best way to ensure a match is to use the Medicare A/B ID Card Number. This number should be entered into the Cardholder ID field exactly as it is shown on the beneficiaries Medicare ID Card. If the Medicare A/B ID Card Number is not available, the next best method is to enter the person’s full Social Security Number (SSN) into the Cardholder ID field. Please do not include any dashes when entering this information, simply enter the 9 digit SSN from left to right.

If the Medicare A/B ID Card Number or SSN is not available, the next recommendation is to enter the zip code (5 digit), gender code, first name, last name, and birth date. It is important include as much of this information as possible, the more that can be entered when submitting the request, the more likely the system will be able to establish a match.

The system will attempt to match on limited information. However, this limited amount of information does not always result in a match. For example, the system will try to match on last name, zip code, birth date, and gender code. If this information results in more than one person, the system will respond that there is not a match as we can not ensure that we are providing eligibility for the correct person.

The fields that are most important to enter (in order of priority) are:

Cardholder ID, which can be the Medicare A/B ID Card Number, or the full Social Security Number Last four digits of the Social Security Number, plus other identifying data (listed below)

  • ZIP Code
  • Gender Code
  • Last Name
  • First Name
  • Birth Date

Once again please note when using Zip Code, Gender Code, Last Name, First Name and Birth Date information, the more information that can be entered, the greater the likelihood of a match.

Also, please ensure that the first name is entered accurately and is the beneficiary’s birth name. For example, if the person indicates their name is “Jim”, question them regarding whether their birth name would be “James”.

11/21/2006

CMS has just announced a change to their current Medicare Pharmacy Eligibility Service as well as a new enhanced eligibility record to include more helpful information.

The current E1 will incorporate a change to reduce the number of false positives currently experienced by some pharmacies. This change will require that, when only the 9-digit SSN, Medicare A/B ID, or Railroad Retirement Board #, is used in the E1 query, the E1 must also include the first four characters of the patient's Last Name.

Beginning 12/1, Last Name MUST be included in the E1 query. If only the 9-digit SSN or Medicare A/B ID is included in the current E1 query, the TrOOP Facilitator will reject the query.

The TrOOP Facilitator is also releasing new functionality that should greatly enhance the ability of the pharmacy to provide service for their Part D patients. The new E1:

  1. Enhances the type of data returned in the response (see attached documentation)
  2. Increases the Date of Service time range from 1 day to 90 days past and future. That is, pharmacists can now request patient information as it existed up to 90 days ago or as far out as 90 in the future.
  3. Provides improved definitions for the reason a query was rejected.
  4. Pharmacies should contact their software partners to determine when this new version of E1 will be supported. CMS will continue supporting the existing E1 and has no plans for discontinuing that service.