M3P claims submission training video

Welcome to this video brought to you by Optum Rx.

We're excited to inform you about the Medicare Prescription Payment Plan, a new payment option designed to help manage out-of-pocket drug costs for Medicare beneficiaries.

This video will provide you with all the essential information you need to know as a pharmacy.

About the Medicare Prescription Payment Plan (M3P):

M3P helps members manage high out-of-pocket costs by spreading them out over the year.

Pharmacies play a vital role in ensuring that members are informed about their options.

Encourage your patients to:

• Visit their plan's website
• Contact their plan directly to learn more about the Medicare Prescription Payment Plan and determine if it's the right choice for them

Starting January 1st, 2025:

All Medicare Part D drug plans and Medicare health plans with drug coverage must offer this payment option.

How It Works:

If a Part D enrollee selects this payment option, they will no longer be required to pay out-of-pocket costs for Part D prescription drugs at the time of receiving their prescription.

Instead, they will get a bill from their health or drug plan for their prescription drugs.

Claims Processing:

If a Part D enrollee is not elected to the Medicare Prescription Payment Plan and incurs out-of-pocket costs for a single prescription that equals or exceeds $600, you will receive an approved 056 message code with instructions to provide the Likely to Benefit Notification to the enrollee.

If a Part D enrollee has elected to the Medicare Prescription Payment Plan and you process a Part D claim, you will receive an approved 057 message code and the BIN/PCN for the plan to process the claim against the additional coverage.

If you receive a 058 message code or a 056/058, and the member feels this is incorrect due to a recent change, please have them contact their plan for further instructions.

Common Claim Submission Errors:

Claims submitted to Medicare Prescription Payment Plan first.

Claim submission to M3P when the member has not elected coverage.

Other coverage code errors where '8' is the only allowable value.

M3P claim with other payer responsibility data missing or in the patient responsibility field.

Important Processing Notes:

Claims must always be processed under Part D coverage first.

If the Part D claim returns a message code of 057, then and only then should the claim be processed under the additional Medicare Prescription Payment Plan BIN PCN Group (BPG).

When processing M3P claims, field 308-C8 should indicate the other coverage; the only acceptable value here is '8'.

For the Other Payer Responsibility (OPR) field, reference the payer sheet and ensure the field has an appropriate value.

If the Part D claim returns message code 057 and you do not get a successful M3P claim, call the Pharmacy Help Desk before letting the member leave with only a successful Part D claim.

Additional Guidance:

CMS has different requirements for non-retail pharmacies. Specific parameters for using the Medicare Prescription Payment Plan are outlined in the part two guidance.

Optum Rx is committed to supporting pharmacies and implementing the Medicare Prescription Payment Plan.

The Optum Rx Provider Manual has been updated to include claims processing messaging.

Ongoing tips and information will be issued through fax blast communications.

Please familiarize yourself with all communications from Optum Rx regarding the Medicare Prescription Payment Plan.

Thank you for watching this video on the Medicare Prescription Payment Plan.

At Optum Rx, we are committed to supporting you and providing the best care for your patients.