Changes to the Medicare Part D drug benefit program go into effect on Jan. 1, 2011, including a mandate that most Part D claims transactions be done electronically.

Under a final rule published on April 15, Part D sponsors must contractually mandate "that their network pharmacies submit claims electronically to the Part D sponsor or its intermediary on behalf of the beneficiary whenever feasible unless the enrollee expressly requests that a particular claim not be submitted to the Part D sponsor or its intermediary."

The Centers for Medicare and Medicaid Services added the provision to facilitate more accurate accounting of enrollees' true out-of-pocket and total drug costs. CMS also was made aware that pharmacies increasingly are not submitting Part D claims to sponsors on behalf of enrollees. "Generally, we believe it is in the best interest of Part D enrollees to have their claims consistently processed through the Part D sponsor (or its intermediary)," the agency noted in the rule.

Among other changes, CMS also required sponsors and their intermediaries to adopt unique "RxID" routing identifiers, effective Jan. 1, 2012, to identify Medicare Part D member claims. These claims currently cannot be distinguished from other types of prescription drug coverage.

Exclusive use of the new identifiers in 2012 "requires that claims will only be paid if these specific numbers are submitted in the claims transaction," according to the rule, available here.

--Joseph Goedert


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