Overview

Medicare Eligibility Verification Transaction

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.

What is an E1 Transaction?

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:

  •  Cardholder ID
  •  Full Last Name
  •  Full First Name (optional)
  •  First Initial of First Name
  •  Date of Birth
  •  ZIP/Postal Code 

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.

When should the pharmacy submit an E1?

There are number of situations when a pharmacy may need to submit an E1:

  • A prescription is called into a pharmacy, the pharmacy has not filled a prescription for the patient before, and the patient would qualify for Medicare.
  • The pharmacy has filled prescriptions for the patient before and they have been covered by a commercial plan or by Medicare Part A, B, or D. However those claims are not rejecting for the member as “not covered.” If the patient is eligible for Medicare, the pharmacy should submit an E1 to see if there is other coverage.
  • The pharmacy is told by a patient that has Medicare Part D that they have other coverage, but the patient does not have the coverage information. By submitting an E1, if the other coverage is on file with CMS, the E1 will return the 4Rx (BIN, PCN, Group ID, Cardholder ID), for the other health insurance so that the pharmacy can submit a Coordination of Benefits (COB) supplemental claim.
  • If the patient comes to pick up a prescription and cannot provide evidence of Medicare enrollment, the pharmacy can submit an E1 to get plan information and other health insurance coverage.  

How does the Pharmacy 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.

What are the results when I submit an E1?

  1. Pharmacy submits the E1 request transaction from the pharmacy system.
  2. The switch (routes transactions to the Transaction Facilitator) that the pharmacy has contracted to handle transactions (i.e., claim billing) will forward the E1 request to the Transaction Facilitator.
  3. The Transaction Facilitator uses the E1 request to match the data contained within the request to the CMS Eligibility file.
  4. The Transaction Facilitator returns the E1 Response to the switch.
  5. The switch returns the E1 Response to the pharmacy System.
  6. The Pharmacy uses the information contained in the E1 Response to create the billing claim for the patient.  If a beneficiary cannot be found or there is no coverage for the beneficiary, the pharmacy will need to contact the beneficiary directly for proof of coverage.

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Do not include PHI (Protected Health Information) in this form