Pharmacy claims and billing

About pharmacy claims

The PAN Foundation contracts with SS&C Health on a global network to process pharmacy claims. You can submit claims for patients with active grants that cover deductibles, copayments, and coinsurance costs related to eligible medications or supplies.

PAN is the payer of last resort, so all patients must be insured, the patient’s insurance must cover their medication, and the patient’s medication or product must be listed as a covered medication for their disease fund.

What services are covered

PAN covers products that are FDA-approved or listed in official compendia or evidence-based guidelines for the specific disease fund. PAN reimburses:

All prescription medications in the disease fund formulary, including:

• Brand medications
• Generic medications
• Bioequivalent or biosimilar drugs
• Specialty drugs
• Radiopharmaceuticals

Certain disease funds cover medical supplies for administering treatments, preventative vaccines and health insurance premium assistance.

For pharmacy claims, the diagnosis code submitted must be covered under the respective disease fund. To verify diagnosis code coverage and review the list of disease funds and covered medications, go to the Find a Disease Fund page, and select the relevant disease.

PAN will not reimburse:

• Medications or over-the-counter products not covered by the patient’s insurance
• Medications paid by the insurance payer at 100%
• Medications billed only to drug discount cards and not insurance
• Medical services, such as lab work, diagnostic testing, genetic testing, ER visits, and office visits
• Medications not covered under PAN’s formulary for the relevant disease fund

To request new medication coverage for a medication not covered by the patient’s grant, you can submit an online request or call us. Note that we cannot guarantee new medication coverage.

When to submit claims

If the grant is active, you may submit claims throughout the eligibility period. Grant eligibility periods are for 12 months with a look back period of 90 days for any initial grant. At the end of the grant eligibility period, you have 60 days to submit any outstanding claims with dates of services within the eligibility period.

PAN’s grant use policy requires patients, or their representative, to request and receive payment for a claim from PAN every 120 days to keep the grant active. If a claim is not submitted and paid during that timeframe, the grant will be canceled.

Before submitting a claim

Check your patient’s grant balance

Before submitting claims, verify the patient’s grant balance using your PAN portal account. You can also use our 24/7 self-service option by calling 1-866-316-7263 and pressing 1 when prompted. You’ll need to provide the patient’s PAN member ID and date of birth.

Check if the patient is linked to your account

The patient must be linked to your PAN portal account before you can review claim submission status or review payment details.

How to submit claims

Submit an electronic claim

Electronic claims may be submitted directly via your billing software and are the preferred and fastest way to submit a claim. Electronic claims are processed in real-time for pharmacies. Please include the following information:

Billing ID:	Rx BIN:	Rx Group:	Rx PCN:
10-digit numeric ID unique to each patient	610728	Listed on our claims help resources page	PANF

Submit a manual claim

1. Collect your:

• Complete Universal Claim Form or CMS-1500 form
• Corresponding Remittance Advice (RA) or Explanation of Benefit (EOB) statement

2. Make sure the claim form and the EOB/RA are legible. Illegible claims will be returned and require resubmission, which can cause delays.

3. Fax or mail claim(s) to:

• Fax: 1-844-871-9753
• Mail: SS&C Health, Dept. 0756, PO Box 419019, Kansas City, MO 64141

Submitting multiple claims by fax or mail

Each manual claim needs its own claim form and EOB/RA. Separate claims with a blank page or fax cover sheet to make sure each claim is processed correctly. Please don’t fax any extra documentation such as welcome letters, clinical notes, fax confirmations or income verification documents with a claim.

Rx Group numbers

Find the Rx Group number you need on our claims help resources page.

After submitting a claim

Checking the status of submitted claims

You can verify receipt of claims submitted though the portal and payment details through the PAN portal. You can also call PAN to verify receipt of the point of sale (POS) and to check claims status and payment details for the POS and manual claims.

Note that to review a claim in your portal account, the tax ID and NPI on the claim must match the tax ID and NPI used to create the portal account.

Returned claims

A claim may be returned if the submitted claim is illegible, or the claim is missing the NDC number or required documentation for processing.

For reconsideration, update the reimbursement form with the correct information and resubmit a legible claim for reprocessing. Make sure you write “corrected claim” on the resubmission.

Processed and denied claims

If a POS claim was processed and denied, check the claim denial reason.

If a manual claim was processed and denied, check the pharmacy remittance for the claim denial reason.

If more information is required or you want the claim to be reconsidered, please update, and resubmit the claim with the original documents along with the required information and write “corrected claim” for reprocessing. Make sure all documents are uploaded as a single document file.

The most common reasons PAN may deny a pharmacy claim include:

• The member is not eligible. The grant was not effective on the date of service billed. If the date of service falls after the eligibility period, you can check the disease fund status to renew the grant, or contact us.
• Service code or diagnosis code is not covered. Please refer to our list of covered services above, and verify if the medication is covered under the disease fund.
• Date filled or date received interval is greater than the plan allows. The claim is too old.

The full list of denied claim messages and remediation steps is available on our claims help resources page. If you have questions about a denied claim, please securely message us in the PAN portal, contact us online, or call us at 1-866-316-7263, Monday through Friday, 9:00 a.m. to 5:30 p.m. ET.

Extensions and grant reinstatement

We also have an appeal process for extenuating circumstances. Contact us via secure message on the PAN portal or call us at 1-866-316-7263, Monday through Friday, 9:00 a.m. to 5:30 p.m. ET.

Getting pharmacy payments

Pharmacy payments are sent by SS&C Health. Payments are issued twice a month on the 16th and the last day of the month. SS&C Health payments are issued via electronic funds transfer and paper checks. For more information, contact the SS&C Health reconciliation team at 1-866-211-9459 Monday through Friday, 8 a.m. to 3:30 p.m. CDT.

Payment methods

You have two payment options:

• Electronic funds transfer
• Paper checks

Remittance advice can be found on argushealth.com/login.

Claim adjustments

If the patient was overpaid or underpaid, here’s how you adjust the claims:

If the claim is 60 days or less old, reverse it electronically.

If over 60 days old:

• For single claim adjustments, contact the SS&C Health Help Desk at 1-844-616-9448.
• For multiple claim adjustments (5 or more claims), complete the Multiple Adjustments Request Form.

Please submit the Multiple Claims Adjustment Form using one of the following methods:

• Fax: 1-816-843-6415
• Encrypt and email: multiple.adjustments@argushealth.com
• Mail: SS&C Health, Attn: Multiple Adjustments, 1300 Washington Street, Kansas City, MO 64105-1433

Refunds

SS&C doesn’t accept refunds. Refer to the instructions above on how to submit an adjustment to PAN. For claims older than November 2017, please contact us.

Forms

• CMS-1500 health insurance claim form
• CMS-1500 form example
• CMS 1450 UB-04 claim form
• PAN medical claims fax cover sheet
• Multiple Claims Adjustment Form

Claims and billing help

If you need help with claims and billing, you can securely message us through your PAN portal, or call us at 1-866-316-7263, Monday through Friday, 9:00 a.m. to 5:30 p.m. ET.