Pharmacists offered E1 eligibility tips

March 20, 2006

The number of electronic queries about Medicare Part D beneficiary eligibility has dropped since the 6.5 million peak during the first week of implementation. But pharmacists were reminded of how the system works in a recent conference call set up by the Centers for Medicare & Medicaid Services.

The number of electronic queries about Medicare Part D beneficiary eligibility has dropped since the 6.5 million peak during the first week of implementation. But pharmacists were reminded of how the system works in a recent conference call set up by the Centers for Medicare & Medicaid Services.

When a pharmacy uses the E1 system, the query is delivered through the normal real-time process used for billing claims. It is routed by the pharmacy's software vendor or switch to the Per Se database. If the pharmacy doesn't send real-time transactions, it can submit batch transactions electronically as long as they follow the National Council for Prescription Drug Programs (NCPDP) format.

When submitting an E1 query, the information and the amount of information determine the chances of successfully matching a patient, Eidex told listeners on the call. The best way to up the odds of a match is to submit either the patient's Medicare A/B Card number or nine-digit Social Security number as the Cardholder ID in the E1 transaction.

If the Medicare card number or Social Security number isn't available, the next best thing is to submit the last four digits of the patient's Social Security number, the zip code, gender, last name, first name, and birth date.

"We'll use a combination of those fields to locate patients," said Eidex. "The more information you provide in those fields, the more likely you are to get a match."

The information that is supposed to be returned from the E1 query are the BIN, PCN, group, Cardholder ID, person code, and phone number of the plan's technical helpdesk. If the information is returned, it's used to bill the patient's Rx claims. Eidex added that each E1 query that results in a match costs 1.5 cents. The pharmacy's usual routing fee is also charged for the transaction.

Some R.Ph.s have contacted their software vendors to complain that the E1 system isn't working, conference call participant William Lockwood Jr. later told Drug Topics. He is the chairman and publisher of Computer Talk magazine and the executive director of the American Society for Automation in Pharmacy, which has been helping CMS with E1 educational outreach through software vendors.

"Vendors are taking the heat," said Lockwood. "Someone phones his or her vendor [about E1] and says, 'It doesn't work; all I'm getting is a phone number.' Well, it is working. That's all that was given to the facilitator. What's happened and continues to happen is that the Part D plans send CMS files that lack information so that the only data element is the phone number of the plan. And in many cases, the phone number is not valid or it's for the wrong department. It's just created a lot of problems at the pharmacy level."

Pharmacies can also send a B1 eligibility query with a special PCN-BIN combination that signals Per Se to map it to the E1 system, Lockwood said. There is an extra charge for the B1 transactions of "maybe a penny," he added.

More information about the E1 system is on the Web at http:// http://medifacd.ndchealth.com/. The Per Se helpdesk at 1-(800) 388-2316 takes calls about the data contained in the transaction and helps with getting signed up for the E1 service. The reps handle only calls from pharmacy, not patients, and they don't answer questions about patient enrollment or eligibility, or about plan coverage amounts or which drugs are covered.