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1134 Chapter 7:Worker guides • Section 6: MSP worker guides (07/2026) Part D covered drugs. Claims that have been paid primary by an MA plan are paid in a different manner than other DMAP claims. There is not a “cross-over claims” process as with Original Medicare. (Crossover claims require only one action from the provider, who receives both the primary and secondary payments from that single action.) Providers should be referred to DMAP Provider Services Unit to receive assistance with filing these claims. When choice counseling MSP eligible individuals, please review the following educational QMB-MMA flyer with the individual. (Important Information For People in the QMB Program). Medicare and other third-party insurance If a person has good private health insurance that covers prescription drugs, they may not need to enroll in a PDP or MA-PD. Health insurance companies will notify their customers when they first become eligible for Medicare. The notice will say if the insurance is as good as or better than Medicare’s prescription drug coverage available to the general Medicare beneficiary. This is called creditable coverage. Most plans that are considered creditable will NOT have prescriptions copayments at the LIS level. Creditable coverage can be in the form of Retiree or Employer plans, such as PERS or Railroad Retiree Board plans, or government benefits like Veteran’s or Tricare benefits. If you cannot determine whether the individual’s coverage is creditable, or whether the plan should provide the LIS level of copayments for a individual, please submit a referral to the MMA Hotline Team for investigation. (See MMA Problem Solving Referral Form - SDS 0728). MMA problem solving Many individuals have trouble accessing their medications through the Medicare Part D program when there are changes in their status or changes in their plan selections. Some of the common problems that individuals will run into are: pharmacy does not know which plan to bill, copayments are not correct, plan denies specific drugs, individuals have no plan in place, the pharmacy is not able to determine whether the medication is covered by Part B, Part D, or Medicaid. Some problems are easy to fix, such as letting the pharmacy know that an individual is dual eligible, or telling the pharmacy what plan an individual is in. Other problems are much more extensive. These may require as much as several hours of time to resolve one individual’s issue. To help improve the speed in which individuals are able to access their medications, MMA problem solving referrals should be sent to Central Office for any individual that is having a problem that you cannot resolve in 20 minutes or less. Urgent problems Individuals that are currently out of medications, or will be within 3 days should be sent as “Urgent” cases to the Central Office. It is critical that the MMA Hotline Team receive the cases as early as possible to provide enough time to resolve the problem. If a case was previously sent as non-urgent, but has since become urgent, please call 1-877-585-0007 to upgrade the status to an “Urgent” case. MMA Problem Solving Referral Form In order to best assist the individual, each field in the Referral Form should be filled in to the best of your ability. All of the information is important, but mandatory information includes: Individual Name, Prime, Contact Information, Case Worker, Branch, Phone #, Pharmacy Name, Pharmacy #, Drugs that individual needs, Date that the individual