Medicare AdvantageAdministrativeHigh impact
Senior Services News Vol. 9, No. 03
New Jersey Medicaid·NJ · Pharmacy·Pharmacy
Effective date
Jan 1, 2006
We identified it
Jun 20, 2026
Summary
Effective January 1, 2006, pharmacies must coordinate PAAD and Senior Gold prescription drug benefits with new Medicare Part D coverage. Pharmacists must submit eligible prescriptions to Medicare PDPs for primary payment before billing the state, use new processor control numbers based on program type, and follow revised copayment and coverage rules for Part D-enrolled beneficiaries.
Action Required
REQUIREMENTS:
By January 1, 2006: Pharmacy billing team must:
1. Implement new electronic claims submission protocols - update billing software to use new Processor Control Number values: "PAAD" for PAAD beneficiaries, "SUPPNJ" for Senior Gold and other programs, "ADDP" for AIDS Drug Distribution Program, and blank spaces for non-Part D claims or Part D primary payer denials (see Attachment B specifications).
2. Establish workflow to submit all eligible Medicare Part D prescriptions to PDPs for primary payment BEFORE submitting to Unisys (state fiscal agent). Claims submitted to Unisys showing Part D coverage will be denied with edit code 2017.
3. Update system to collect Medicare PDP plan information from beneficiary ID cards or by calling PDP/MAPD directly at numbers provided - state POS responses will only identify plan sponsor, not specific subscriber/group numbers.
4. Modify copayment collection procedures: collect $5.00 PAAD copay unless PDP/MAPD requires lower amount; for Senior Gold enrollees in Part D, collect $15 plus half of remaining coinsurance from PDP.
5. Configure system to identify Part D-exempt drugs (benzodiazepines, barbiturates, certain vitamins) and continue submitting these directly to Unisys for PAAD/SG payment without Part D routing.
6. Establish process for Part B-covered drugs (diabetic testing supplies, nebulizer solutions, immunosuppressants, oral chemotherapy): obtain PDP denial of benefit coverage first before submitting secondary claim to Unisys; request prior authorization by calling 1-866-854-1596 for Part B-eligible drugs.
7. Update system to handle non-formulary denials: when PDP denies as non-formulary, contact prescriber for formulary alternatives or initiate PDP appeal process; contact 1-866-854-1596 for PAAD/SG consideration of non-formulary coverage based on medical necessity.
8. Update BIN number field (101-A1) to continue using 610515; update Software Vendor/Certification ID field to begin with "NJP" followed by seven-digit EMC Submitter ID.
9. Verify your pharmacy participates in each PDP network where PAAD/SG clients are enrolled - PAAD/SG will not reimburse secondary payments for out-of-network pharmacy services.
10. Ensure all pharmacy staff understand that PAAD and Senior Gold are always payers of last resort and must process claims with any other private insurance identified by PDP responses.
Consequences of inaction: Claims submitted improperly will be denied with edit code 2017, delayed payments, and beneficiary access issues to medications.