B
Invalid Other Insurance 2 – 5.1 Only
If the Other Coverage Code is “2” (other coverage exists - Payment collected)
AND
The Other Payer Amount Paid equals zeros
OR
The Other Payerid Date = 0001-01-01
|
D
|
D
|
D
|
D
|
|
|
|
E8
|
M/I Other Payer Date
|
4261
|
B
|
Invalid Other Insurance 2 – 5.1 Only
If the Other Coverage Code is “2” (other coverage exists - Payment collected)
AND
The Other Payer Amount Paid equals zeros
OR
The Other Payerid Date = 0001-01-01
|
D
|
D
|
D
|
D
|
|
|
|
E9
|
Provider Id
|
4263
|
B
|
The pharmacy provider id is missing and the pharmacy provider id qualifier is present.
|
B
|
B
|
B
|
B
|
|
|
|
FO
|
M/I Plan ID
|
4264
|
B
|
The Plan ID is missing (spaces).
|
B
|
B
|
B
|
B
|
|
|
|
GE
|
M/I Percentage Sales Tax Amount Submitted
|
4682
|
B
|
Percentage Sales Tax Amount Submitted is equal to or greater than U&C, silk ticket 988
|
B
|
B
|
B
|
B
|
|
|
|
GE
|
M/I Percentage Sales Tax Amount Submitted
|
4265
|
B
|
The Percentage Sales Tax Amount Submitted is missing (zeros)
AND
The flat tax amount is missing or zeroes.
|
B
|
B
|
B
|
B
|
|
|
|
HA
|
M/I Flat Sales Tax Amount Submitted
|
4681
|
B
|
submitted sales tax is equal to or greater than U&C, silk ticket 988
|
B
|
B
|
B
|
B
|
|
|
|
HA
|
M/I Flat Sales Tax Amount Submitted
|
4266
|
B
|
The Flat Sales Tax Amount Submitted is missing (zeros)
AND
The percentage sales tax amount is missing or zeroes.
|
B
|
B
|
B
|
B
|
|
|
|
HB
|
M/I Other Payer Amount Paid Count
|
4267
|
B
|
A COB segment is present and the Other Payer Amount Paid Count is missing (zeros).
|
D
|
D
|
D
|
D
|
|
|
|
HB
|
M/I Other Payer Amount Paid Count
|
4268
|
B
|
The Other Payer Amount Paid Count does not match the number of Other Payer Amount Paid fields received on a COB/Other Payments segment.
|
D
|
D
|
D
|
D
|
|
|
|
HC
|
M/I Other Payer Amount Paid Qualifier
|
4269
|
B
|
The Other Payer Amount Paid Qualifier is missing (spaces) and the Other Payer Amount Paid is greater than zeros.
|
D
|
D
|
D
|
D
|
|
|
|
HC
|
M/I Other Payer Amount Paid Qualifier
|
4270
|
B
|
The Other Payer Amount Paid Qualifier does not match one of the valid values specified for the field
|
D
|
D
|
D
|
D
|
|
|
|
HD
|
M/I Dispensing Status
|
4271
|
B
|
If the Dispensing Status is missing (spaces)
AND
The Quantity Intended To Be Dispensed is greater than zeros
OR
The Days Supply Intended To Be Dispensed is greater than zeros.
|
D
|
D
|
D
|
D
|
|
|
|
HD
|
M/I Dispensing Status
|
4272
|
B
|
The Dispensing Status does not match one of the valid values specified for the field.
|
D
|
D
|
D
|
D
|
|
|
|
HD
|
M/I Dispensing Status
|
4416
|
B
|
Compound Code is equal to ‘2’ and the Dispensing Status is greater than spaces.
|
D
|
D
|
D
|
D
|
|
|
|
HE
|
M/I Percentage Sales Tax Rate Submitted
|
4273
|
B
|
The Percentage Sales Tax Rate Submitted is missing (zeros).
|
B
|
B
|
B
|
B
|
|
|
|
HF
|
M/I Quantity Intended To Be Dispensed
|
4274
|
B
|
The Quantity Intended To Be Dispensed is missing (zeros) and the Dispensing Status indicates a partial fill (‘P’) or ‘C’.
|
D
|
D
|
D
|
D
|
|
|
|
HF
|
M/I Quantity Intended To Be Dispensed
|
4275
|
B
|
The Quantity Intended To Be Dispensed is greater than zeros but the Dispensing Status does not indicate a partial fill (‘P’).
|
D
|
D
|
D
|
D
|
|
|
|
HG
|
M/I Days Supply Intended To Be Dispensed
|
4276
|
B
|
The Days Supply Intended To Be Dispensed is missing (zeros) and the Dispensing Status indicates a partial fill (‘P’).
|
D
|
D
|
D
|
D
|
|
|
|
HG
|
M/I Days Supply Intended To Be Dispensed
|
4277
|
B
|
The Days Supply Intended To Be Dispensed is greater than zeros but the Dispensing Status does not indicate a partial fill (‘P’).
|
D
|
D
|
D
|
D
|
|
|
|
H1
|
M/I Measurement Time
|
4278
|
B
|
The Measurement Time is missing (zeros).
|
B
|
B
|
B
|
B
|
|
|
|
H2
|
M/I Measurement Dimension
|
4279
|
B
|
The Measurement Dimension is missing (spaces) or it does not match one of the valid values specified for the field.
|
B
|
B
|
B
|
B
|
|
|
|
H3
|
M/I Measurement Unit
|
4280
|
B
|
The Measurement Unit is missing (spaces) or it does not match one of the valid values specified for the field.
|
B
|
B
|
B
|
B
|
|
|
|
H4
|
M/I Measurement Value
|
4281
|
B
|
The Measurement Value is missing (spaces).
|
B
|
B
|
B
|
B
|
|
|
|
H5
|
M/I Primary Care Provider Location Code
|
4282
|
B
|
The Primary Care Provider Location Code is missing (spaces) or it does not match one of the valid values specified for the field.
|
B
|
B
|
B
|
B
|
|
|
|
H6
|
M/I DUR Co-Agent ID
|
4283
|
B
|
The DUR Co-Agent ID is missing (spaces).
|
B
|
B
|
B
|
B
|
|
|
|
H7
|
M/I Other Amount Claimed Submitted Count
|
4284
|
B & IN
|
The Other Amount Claimed Submitted Count is missing (zeros) and the other amount claimed submitted qualifier or amount is present.
Indiana Only: If Other Coverage Code = 8 (billing for copay), then field H7 must = 1
|
B
|
B
|
B
|
B
|
|
|
|
H8
|
M/I Other Amount Claimed Submitted Qualifier
|
4285
|
B & IN
|
The Other Amount Claimed Submitted Qualifier is missing (spaces) or it does not match one of the valid values specified for the field and the other amount claimed submitted amount is greater than zero.
Indiana Only: If Other Coverage Code = 8 (billing for copay), then field H8 must = 99
|
B
|
B
|
B
|
B
|
|
|
|
H9
|
M/I Other Amount Claimed Submitted
|
4286
|
B & IN
|
The Other Amount Claimed Submitted is missing (zeros) and the other amount claimed submitted qualifier is present
Indiana Only: If Other Coverage Code = 8 (billing for copay), then field H9 must = Gross Amt (field id: DU)
|
B
|
B
|
B
|
B
|
|
|
|
JE
|
M/I Percentage Sales Tax Basis Submitted
|
4287
|
B
|
The Percentage Sales Tax Basis Submitted is missing (spaces) or it does not match one of the valid values specified for the field.
|
B
|
B
|
B
|
B
|
|
|
|
J9
|
M/I DUR Co-Agent ID Qualifier
|
4288
|
B
|
The DUR Co-Agent ID Qualifier is missing (spaces) or it does not match one of the valid values specified for the field.
|
B
|
B
|
B
|
B
|
|
|
|
KE
|
M/I Coupon Type
|
4942
|
B
|
M/I Coupon Type
|
B
|
B
|
B
|
B
|
|
|
|
M1
|
Patient Not Covered in this Aid Category
|
4856
|
B
|
Patient Not Covered in this Aid Category
|
B
|
B
|
B
|
B
|
|
|
|
|
