Attention: Pharmacy Providers Upcoming Changes in NCPDP D.0 Claims for QMB Cost Sharing

As described in the CMS Informational Bulletin, Payment of Medicare Cost Sharing for Qualified Medicare Beneficiaries (QMBs) dated June 7, 2013, Medicaid is legally obligated to reimburse providers for cost sharing that is due for a QMB according to the state's CMS-approved Medicare cost-sharing payment methodology. In addition, the NCTracks system must adjudicate and reimburse providers for QMB cost sharing "without regard to whether the costs incurred were for items and services for which medical assistance is otherwise available under the plan, i.e., not covered by NC Medicaid."

Beginning March 1, 2015, NCTracks will accept values in three fields (353-NR, 351-NP, and 352-NQ) on NCPDP D.0 claims to identify the Coordination of Benefits/Other Payer for Medicare Q-class dual eligible claims. These fields will be used to identify patients’ Medicare Coinsurance, Medicare Deductible, and Medicare Copayment amounts.

Providers can access the latest version of the NCPDP D.0/Pharmaceutical Drug Claims Companion Guide located on the NCTracks Trading Partners page for additional information on how to properly submit claims. The NCPDP D.0/ Pharmaceutical Drug Claims Companion Guide can be found at the link below.

Additional information is forthcoming regardng QMB cost sharing and non-pharmacy claims.