The POS Facilitated Enrollment process was designed to ensure that individuals with both Medicare and Medicaid, known as "dual eligibles," who are not yet enrolled in a Part D prescription drug plan are still able to obtain immediate prescription drug coverage when evidence of Medicare and Medicaid eligibility is presented at the pharmacy. Other individuals who qualify for the Part D low-income subsidy (LIS), also called "extra help," are also now able to use the POS FE process.

The following four steps provide a quick reference guide for using the POS FE process:

1. Request Patient's Part D Plan ID Card
   
   If a patient has a Part D Plan ID card or other confirmation of Part D Plan Enrollment (see below), please submit claims to that payer.
   
   Note: If an individual does not have an ID card, he/she may have a plan enrollment "acknowledgement letter" or "confirmation letter" containing the 4Rx data-Bank Identification Number (BIN), Processor Control Number (PCN), Group ID for the patient's specific plan (GROUP), and Member ID information.
   
     If neither an ID Card nor an acknowledgement or confirmation letter is available, go to Step 2.
   
   
2. Submit an E1 Transaction to the TrOOP Facilitator
   
   If the individual has no proof of enrollment, plan billing information may be available through the Part D eligibility and enrollment online system, the TrOOP Facilitator. The TrOOP Facilitator can be accessed with an E1 query which provides 4Rx data. For those pharmacy software systems that support an "Enhanced E1" query, enrollment information within 90 days of the date the request is submitted can be obtained. If you are uncertain about how to submit an E1 or enhanced E1 query, please contact your software vendor.
   
   If the E1 query returns a BIN/PCN indicating the patient has current drug plan coverage, do NOT submit a claim to the POS FE process. If the E1 query returns a help desk telephone number, this indicates the individual has been enrolled in a plan, but the 4Rx data is not yet available. Please contact that plan for the proper 4Rx data.
   
     If the E1 query does not return a BIN/PCN indicating the individual has current drug plan coverage, go to Step 3.
   
   
3. Identify a "Dual Eligible" Individual (Medicare and Medicaid), or Those Eligible for the Low-Income Subsidy (LIS)
   
   Verify the individual's Medicare, Medicaid or LIS eligibility using one of the items listed below. If the individual cannot provide evidence of current eligibility for Medicare and Medicaid or the LIS, the claim should NOT be submitted to the POS FE process. The following options are available to verify an individual's dual eligibility/LIS eligibility:
   
   Medicaid
   
   • Medicaid ID card
   • Copy of current Medicaid award letter with effective dates
   • State eligibility verification system (EVS) queries (interactive voice response, online)
     
   Medicare
   
   • Submit an E1 query to determine Medicare Part A eligibility and/or Part B enrollment
     
   • Medicare ID card
     
   • Medicare Summary Notice (MSN)
     
   • Medicare pharmacy eligibility line-1-866-835-7595
     
   • LIS notice from Medicare or SSA
     
     If you are able to verify the patient's Medicare and Medicaid or LIS eligibility, go to Step 4.
   
   
4. Bill the POS FE Process
   
   To utilize POS FE, enter the claim through your claims system in accordance with the WellPoint Next Rx Payer Sheet.
   
   Note: The BIN/PCN for POS FE will remain the same in 2008.
   
   

As in 2007, all claims submitted to POS FE will be edited for eligibility to minimize the incidence of claims paid in error. User-friendly claims rejection messages will be returned to a pharmacy provider when a patient is determined to not be eligible. This editing is provided by RelayHealth, Inc.


Important Notes:

• It is critical that you submit both the Medicare HICN and the Medicaid ID number (for Medicaid eligibles) to validate the individual's dual eligibility status.
  
  
• No Medicaid ID number is required for those who are not Medicaid eligible but are LIS eligible.
  
  
• WellPoint may still need to reverse other ineligible claims (e.g., duplicate claims) that have been paid erroneously to pharmacies through the POS FE process, but these are expected to be minimal.
  
  
• If you need further information and resources regarding the POS FE process, please go to the NextRx Provider Portal.
  
  
• WellPoint will track the number of ineligible claims per pharmacy NCPDP number and carefully review claims from those pharmacies with high utilization of POS FE for ineligible patients.
  
  

For more information, read CMS' Point-of-Sale Facilitated Enrollment (POS FE) Process Four Steps for Pharmacists Memo (updated April 2008)