Give us the state you work in, region of state, and which company you work for. You will get more specific answer. If you want to be anonymous, make a new account and post that information.
I can only share about California, Los Angeles County, so hopefully this will help some friends out there....
For example:
For ID,
In California,
Medicaid: Main Plan (Straight Medicaid): Use all of ID: 14 digits total.
Medicaid: Sub plan: Use most of ID: 9 digits total: start with number, up to and
include the
letter.
Issue date is important in some cases, so, always type in.
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If Medicaid: If Green Card for Family Planning Program:
Use all ID, 10 digits total, start with number, include letter, and the last digit.
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If Medicaid: Temporary Paper Card for Pregnant Women:
For ID: Ignore the dash.
Must set expiration date in your computer so you don't give out free medication after card expires and get audit later.
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Within the company software, how to input the insurance is different. Just putting the BIN will show you over 20 different plans that will confuse you.
Picking randomly 1 of that 20 plans and try while patient waiting is not acceptable.
That's why I ask to please tell us the company you work for and the region and we will guide you specifically which common plan to pick.
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For commercial insurance:
Example: you see ID on card, what do you do?
ABC123456789-01
For ID:
Case 1: 95% of cases: Ignore the first 3 letters and ignore the dash and the number after dash.
ID is:
number after first 3 letters.
ID is: 123456789
Case 2: 5% of cases: Use all of ID, still ignoring the dash and number after dash.
ID is: ABC123456789
Ending of ID:
Case 1: 95% of cases: Ignore the relationship code at the end of ID.
ID is: 123456789
Case 2: 5% of cases: Use the relationship code at the end of ID
ID is: 12345678901
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BIN: Must have.
PCN: NOT Must have.
GROUP: NOT Must have (ignore all dash in any field.)
ID: Must have (ignore all dash in any field.)
Person Code: often, pick: Card Holder
Relationship code: (I use blank space in many cases.)
Often,
Card Holder: 01 (But have seen 00 zero zero).
Spouse: 02 (have seen 01).
Child: 03 (have seen 02).
Nowadays,
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Wrong Birth Date: common problem. If insurance hiccup, always double check this. You must match birth date with whatever birth date the plan has, then, payment will go through. Patient will argue that my birth date is wrong. Your answer: Please fix with your plan. If I fix in my computer to the way you like, payment will not go through and you have to pay your own money.
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Wrong Gender: common problem. If insurance hiccup, always double check this.
Name of card holder: have seen cases where wrong name of card holder does not matter.
Relationship Code: have seen cases where Relationship Code does not matter (I use blank space in many cases.)
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Rejection:
Day supply:
As pharmacist, you may see rejection in billing with the message indicating because of Day Supply Problem while tech can not see that message.
Example: 9 pills of Imitrex, instruction is: 1 or 2 a day as needed.
Tried day supply as 4 days, not going through.
Tried day supply as 15 days, not going through.
Tried day supply as 20days, not going through.
Tried day supply as 25 days, not going through.
Tried day supply as 30 days, YES: going through.
Tried day supply as 29 days, not going through.
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Rejection:
Too soon:
As pharmacist, you may see rejection in billing with the message indicating because of Too Soon Problem while tech can not see that message.
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Too soon can be fixed by:
If previous fill was at your pharmacy and if previous setting of day supply was wrong, you can edit old script, mark as sold, fill new script.
For example:
Itch Cream (Hydrocortisone 2.5%) was filled, previous script was set to be 30 days.
Patient used all cream and showed up at pharmacy on day 20, you try to fill. Rejection: Too Soon to fill.
Fix: edit last script, set date to be 20 days (seems reasonable for 1 tube of 28 grams), finalize script, mark as sold, fill new script. Will go through.
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If Too Soon because of different pharmacy, you may or may not know where, depending on insurance. I have seen message from insurance telling me the name of pharmacy and the phone of pharmacy. I have seen message from insurance simply telling me it was filled at Other Pharmacy.
Case: Script was sent to different pharmacy last week, somewhere out there. Now, script is sent to you. You try to bill. Rejection: Too Soon.
Fix: Call insurance. Ask phone of Other Pharmacy. Call that Pharmacy.
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Duplicate Claim? Even after you are sure you reversed the claim at your own pharmacy?
Try:
PA field: 01
PA code field: 9991
Helped me in 50 percent of cases. Learned from a tech support specialist at my company.
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.............
Los Angeles County Medicaid:
At this time, you have at least 5 sub plans:
Anthem.
Blue Cross.
L.A. Care.
Kaiser (You can not bill if you are not inside Kaiser.)
Health Net.
Care1st.
Medimpact Medcare Network.
Molina (sometimes.)
Orange County Medicaid:
CalOptima.
If both Medicare and Medicaid: for Medicaid, you then have to pick:
CalWrap.
You see...certain county has certain trick of trade. If you really want to master the insurance of your area in a short time, somehow relay the message here about the area you work at. Someone will help.
