In the early stages of development of the Medicare Part D program, CMS realized that the pharmacies would need a mechanism to determine eligibility for its Part D enrollees on a real-time basis at point of sale.
As a result, CMS reached out to NCPDP, who in turn developed a transaction that would allow pharmacies to submit basic demographic information on a beneficiary. In return, pharmacies would receive information that would allow them to bill the beneficiary’s Part D Plan.
The transaction, called an E1 transaction, is currently the only method available to pharmacies for determining Part D enrollment other than information provided by the beneficiary.
As part of the E1 process, CMS contracted with the Transaction Facilitator (RelayHealth) to house the CMS Medicare Part A, B, and D eligibility information and respond to the real-time E1 transaction requests.
An E1 transaction is a Medicare Eligibility Verification transaction intended to provide the status of a beneficiary’s Medicare health plan covering the individual, along with details regarding primary and supplemental coverage if applicable.
The transaction comprises of a request and a response. The pharmacy submits a request transaction that contains beneficiary demographic information, (see bulleted list below), that is sent in the E1 Request to the Transaction Facilitator. In the request the pharmacy submits the following beneficiary demographic information:
If a Part D beneficiary match is found in the CMS Eligibility Database, the beneficiary’s Part D plan information is returned along with any other health insurance coverage in the response to the pharmacy.
If a Part A or Part B beneficiary match is found, a indicator value of "A" or "B" is returned in the response to the pharmacy.
If there is no match found in the CMS Eligibility Database, a reject response with a coinciding message is returned in the response.
There are number of situations when a pharmacy may need to submit an E1:
Pharmacies generally use information from their patient profiles/demographics to submit a real-time query (E1). If you are unsure of how to submit an E1 transaction, you should contact your corporate office and/or software vendor.
The Transaction Facilitator returns information about whether the patient is eligible for Part A, Part B, or Part D and accurate patient information needed to submit the claim.
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