Programs: Maryland Medical Assistance Program (MA)

section.

section.

section.

E8 M/I Other Payer Date 443

E9 M/I Provider ID 444

FO M/I Plan ID 524

GE M/I Percentage Sales Tax Amount Submitted 482

HA M/I Flat Sales Tax Amount Submitted 481

HB M/I Other Payer Amount Paid Count 341

HC M/I Other Payer Amount Paid Qualifier 342

HD M/I Dispensing Status 343

HE M/I Percentage Sales Tax Rate Submitted 483

HF M/I Quantity Intended To Be Dispensed 344

HG M/I Days Supply Intended To Be Dispensed 345

H1 M/I Measurement Time 495

H2 M/I Measurement Dimension 496

H3 M/I Measurement Unit 497

H4 M/I Measurement Value 499

H5 M/I Primary Care Provider Location Code 469

H6 M/I DUR Co-Agent ID 476

H7 M/I Other Amount Claimed Submitted Count 478

H8 M/I Other Amount Claimed Submitted Qualifier 479

H9 M/I Other Amount Claimed Submitted 48Ø

JE M/I Percentage Sales Tax Basis Submitted 484

J9 M/I DUR Co-Agent ID Qualifier 475

KE M/I Coupon Type 485

M1 Patient Not Covered In This Aid Category

M2 Recipient Locked In

M3 Host PA/MC Error

EDITS

VERSION 5.Ø REJECT CODES FOR TELECOMMUNICATION STANDARD

Reject

Code

Field #

M4 Prescription/Service Reference Number/Time Limit

Exceeded

M5 Requires Manual Claim

M6 Host Eligibility Error

M7 Host Drug File Error

M8 Host Provider File Error

ME M/I Coupon Number 486

MZ Error Overflow

NE M/I Coupon Value Amount 487

NN Transaction Rejected At Switch Or Intermediary

PA PA Exhausted/Not Renewable

PB Invalid Transaction Count For This Transaction Code 1Ø3, 1Ø9

PC M/I Claim Segment 111

PD M/I Clinical Segment 111

PE M/I COB/Other Payments Segment 111

PF M/I Compound Segment 111

PG M/I Coupon Segment 111

PH M/I DUR/PPS Segment 111

PJ M/I Insurance Segment 111

PK M/I Patient Segment 111

PM M/I Pharmacy Provider Segment 111

PN M/I Prescriber Segment 111

PP M/I Pricing Segment 111

PR M/I Prior Authorization Segment 111

PS M/I Transaction Header Segment 111

PT M/I Workers’ Compensation Segment 111

PV Non-Matched Associated Prescription/Service Date 457

PW Non-Matched Employer ID 333

PX Non-Matched Other Payer ID 34Ø

PY Non-Matched Unit Form/Route of Administration 451, 452, 6ØØ

PZ Non-Matched Unit Of Measure To Product/Service ID 4Ø7, 6ØØ

P1 Associated Prescription/Service Reference Number Not

Found

P2 Clinical Information Counter Out Of Sequence 493

P3 Compound Ingredient Component Count Does Not Match

Number Of Repetitions

447

P4 Coordination Of Benefits/Other Payments Count Does

337

P6 Date Of Service Prior To Date Of Birth 3Ø4, 4Ø1

EDITS

6/20/03 47

Reject

Explanation Check NCPDP

Field #

Possible Solutions

Repetitions

491

P8 DUR/PPS Code Counter Out Of Sequence 473

RA PA Reversal Out Of Order

RB Multiple Partials Not Allowed

RC Different Drug Entity Between Partial & Completion

RD Mismatched Cardholder/Group ID-Partial To

Completion

3Ø1, 3Ø2

RE M/I Compound Product ID Qualifier 488

RF Improper Order Of ‘Dispensing Status’ Code On Partial

Fill Transaction

RG M/I Associated Prescription/service Reference Number

On Completion Transaction

456

RH M/I Associated Prescription/Service Date On Completion

457

RK Partial Fill Transaction Not Supported

RM Completion Transaction Not Permitted With Same ‘Date

Of Service’ As Partial Transaction

4Ø1

RN Plan Limits Exceeded On Intended Partial Fill Values 344, 345

RS M/I Associated Prescription/Service Date On Partial

Transaction

457

On Partial Transaction

456

RU Mandatory Data Elements Must Occur Before Optional

R1 Other Amount Claimed Submitted Count Does Not Match

Number Of Repetitions

478, 48Ø

Repetitions

471, 472

R3 Procedure Modifier Code Count Does Not Match Number

Of Repetitions

458, 459

R5 Product/Service ID Must Be Zero When Product/Service

ID Qualifier Equals Ø6

4Ø7, 436

R7 Repeating Segment Not Allowed In Same Transaction

R8 Syntax Error

R9 Value In Gross Amount Due Does Not Follow Pricing

Formulae

43Ø

TE M/I Compound Product ID 489

EDITS

6/20/03 48

Reject

Explanation Check NCPDP

Field #

Possible Solutions

VE M/I Diagnosis Code Count 491

WE M/I Diagnosis Code Qualifier 492

XE M/I Clinical Information Counter 493

ZE M/I Measurement Date 494

EDITS

Host System Problems:

Occasionally providers may receive a message that indicates their network is having technical problems

communicating with FIRST HEALTH SERVICES.

NCPDP Message

90 Host Hung Up

Host disconnected before session completed.

NCPDP Message

92 System Unavailable/Host Unavailable

Processing host did not accept transaction or did not respond within time out period.

NCPDP Message

93 Planned Unavailable

Transmission occurred during scheduled downtime. AFFILIATED COMPUTER SERVICES, INC.will provide system

availability from:

4:00 AM – 3:00 AM, EST Monday through Saturday;

4:00 AM – 10:00 PM, EST Sunday.

NCPDP Message

99 Host Processing Error

Do not retransmit claims.

EDITS

DUR Fields:

When denials for ProDUR edits are received, providers may override these denials using the appropriate

DUR Reason of Service (Conflict), Professional Results (Intervention), and Result of Service (Outcome

Codes), with the exception of Early Refill (ER). Following are the ProDUR edits that will deny for

Maryland Medicaid:

Early Refill (ER) – providers must contact the First Health Technical Call Center to request

overrides (provider overrides not allowed).

Therapeutic Duplication (TD) - selected therapeutic classes deny, others return warning message

only.

NCPDP Message

88 DUR Reject Error

MA, MPAP & MPDP Therapeutic Duplication Denial NCPDP 88, ‘DUR Reject Error TD’.

Alpha-Adrenergic Blocking Agents

Anticholinergics/Antispasmodics

Antihistamines

Barbiturates

Bile Salt Sequestrants

Bile Salts

Calcium Channel Blocking Agents

Cerivastin, Lovastatin, Simvastatin, Pravastatin, Fluvastatin, Atrovastatin

Diabetic Therapy

Digitalis Glycosides

Gastric Acid Secretion Reducers

Hypotensives, ACE Inhibitors

Hypotensives, Sympatholytic

Hypotensives, Vasolidators

Loop Diuretics

NSAIDS

Psychostimulants-Antidepressants

Quinolones

Thiazide and Related Diuretics

EDITS

6/20/03 51

dose exceeds 68 days) NCPDP 88, ‘DUR Reject Error PP’. The diagnosis must be written on the

prescription and the diagnosis must be included on the list of acceptable diagnoses.

Acceptable Diagnoses for Continued Use of H2 Blockers and PPIs at acute doses beyond 68

days:

Barrett’s Disease, Barrett Esophagitis, Barrett’s Esophagatus or Esophagus, Barrett’s Epithelium,

GERD (Gastroesophageal Reflux Disease, Reflux, Reflux Disease, or Reflux Esophagitis, or

Peptic Esophagitis), Esophagitis, Gastroesophagitis, Erosive or Ulcerative Esophagitis)

Hiatal Hernias, Symptomatic Hiatal Hernias, etc.

Pathological Hypersecretory Conditions (including ZE Syndrome)

Unhealed Ulcers

Wermer (Endocrine Adenoma-Peptic Ulcer Complex; Multiple Endocrine Neoplasias;

Pluriglandular Adenomatosis etc.)

ZE (Zollinger-Ellison Syndrome, Strom-Zollinger-Ellison, Gastrinoma, Multiple Partial

Endocrine Adenomatosis, Multiple Partial Adenomatosis; Pancreatic Ulcerogenic or

Polyglandular Adenomatosis, Systemic Mastocytosis)

Drug Acute Dose

Cimetidine (Tagamet) >/= 800mg/day

Esomeprazole (Nexium) >/= 40mg/day

Famotidine (Pepcid) >/= 40mg/day

Lansoprazole (Prevacid) >/= 30mg/day

Nizatidine (Axid) >/= 300mg/day

Omeprazole (Prilosec) >/= 40mg/day

Pantoprazole (Protonix) >/= 80mg/day

Rabeprazole (Aciphex) >/= 40mg/day

Ranitidine (Zantac) >/= 300mg/day

EDITS

KDP ProDUR Therapeutic Duplication Denial NCPDP 88, ‘DUR Reject Error TD’.

Alpha-Adrenergic Blocking Agents

Antihistamines

Barbiturates

Calcium Channel Blocking Agents

Diabetic Therapy

Digitalis Glycosides

Gastric Acid Secretion Reducers

Hypotensives, ACE Inhibitors

Hypotensives, Sympatholytic

Hypotensives, Vasolidators

Loop Diuretics

NSAIDS

Psychostimulants-Antidepressants

Quinolones

Thiazide and Related Diuretics

Note: Provider overrides are on a per claim (date of service only) basis. For quality of care

purposes, pharmacists are required to retain documentation relative to these overrides.

EDITS

6/20/03 53

The DUR Reason for Service is used to define the type of utilization conflict that was detected

(NCPDP field 439).

Valid DUR Reason for Service for the MA, MPAP & MPDP and KDP are:

ER = EARLY REFILL

TD = THERAPEUTIC DUPLICATION

PP = PLAN PROTOCOL (ACUTE TO MAINTENANCE

ANTI-ULCER)

NCPDP Message

E4 M/I DUR conflict/reason for service code

DUR Professional Service/ Intervention Code:

The DUR Professional Service is used to define the type of interaction or intervention that was

performed by the pharmacist (NCPDP field 440).

Override Codes: Designated Professional Service must accompany the designated Result of Service

to allow the override.

NCPDP Message

E5 M/I DUR intervention/professional service code

DUR Result of Service/ Outcome Code:

The DUR Result of Service is used to define the action taken by the pharmacist in response to a

ProDUR Reason for Service or the Result of Service (NCPDP field 441).

Override Codes: Note that designated Professional Service must accompany the designated Result of

Service to allow the override.

NCPDP Message

E6 M/I DUR outcome/ result of service code

Override Codes for both Maryland Medicaid and KDP: the following codes will be used to allow for provider level

overrides for Therapeutic Duplication (TD), and Plan Protocol (PP) denials.

Professional Service/ Description (NCPCP

field #440-E5)

Result of Service/ Description (NCPDP field #441-E6)

00/ no intervention

M0/ prescriber consulted

PE/ patient education

P0/ patient consulted

R0/ pharmacist consulted other source

1A/ filled as is, false positive

1B/ filled prescription as is

1C/ filled with different dose

1D/ filled with different directions

1F/ filled with different quantity

1G/ filled with prescriber approval

APPENDIX A

PAYER

4/16/03 A

APPENDIX B

OTHER CARRIER

CODE LIST

4/16/03 B.1

OTHER_PAYER_ID OTHER_PAYER_NAME

I0288 ADVANCE PARADIGM

I1413 ADVANCED PCS

I1606 AETNA PHARMACY

I0340 AETNA PHARMACY MANAGEMENT

I1414 AETNA SERVICES INC

I1647 AETNA US HEALTHCARE

AT531 ALLIANCE PPO MAPST

I0255 AMERICAN COMMUNITY MUTUAL INS

I0411 ASSOCIATE PRESCRIPTION SERVICE

BB24D BC BS OF MD FED EMPLOYEES

AO655 BC/BS

I1758 BLUE CROSS BLUE SHIELD

I1174 CAREFIRST

BB24A CAREFIRST B/C B/S OF MD

AU146 CAREMARK

AY314 CAREMARK

I0530 CAREMARK

I0668 CAREMARK

I0691 CAREMARK

I1535 CAREMARK

AP622 CIGNA HEALTH CARE

I0534 CIGNA HEALTH CARE

AR983 CIGNA HEALTH PLAN

I1782 CIGNA PHARMACY

I1338 CIGNA RX

I1317 CLAIMS PRO

I0680 DIVERSIFIED PHARMACEUTICAL

I1329 ECKERD PHARMACY SERV

I1206 EXPRESS SCRIPT

I1061 EXPRESS SCRIPT VALUE RX

I0559 EXPRESS SCRIPTS

I0929 EXPRESS SCRIPTS

I1296 EXPRESS SCRIPTS

I1511 EXPRESS SCRIPTS

I1628 EXPRESS SCRIPTS

I1379 EXPRESS SCRIPTS/GOODYEAR

I0592 MEDCO

I0504 MEDCO BEHAVIORAL CARE

QD174 MEDCO MNG CARE-AIM COMP ASSOC

I0766 MERCK MEDCO

APPENDIX B

OTHER CARRIER

CODE LIST

4/16/03 B.2

OTHER_PAYER_ID OTHER_PAYER_NAME

I1550 MERCK MEDCO

I0276 MERCK/MEDCO

I1783 MERCK/MEDCO

I1443 MERCK-MEDCO

I0907 MEREK MEDCO

AW076 MET LIFE

I1213 MMRX OF FLA

AT142 NATIONAL PRESCRIPTION ADM

I1214 NEIGHBOR CARE PHARMACY

I0262 NPA

I1158 NPA

I1778 PA BLUE SHIELD

AY653 PAID PRESCRIPTIONS

I0483 PAID PRESCRIPTIONS

I1074 PAID PRESCRIPTIONS

I1196 PAID PRESCRIPTIONS

I1259 PAID PRESCRIPTIONS

I1295 PAID PRESCRIPTIONS

I1579 PAID PRESCRIPTIONS

I1032 PAID PRESCRIPTIONS INC

I1180 PAID PRESCRIPTIONS INC

I0954 PCS

I1364 PCS

I0899 PCS HEALTH SYSTEM

QD185 PCS HEALTH SYSTEMS INC

I1106 PD PRESCRIPTIONS INS

I1250 PHARMACARE

I0856 PREFORM

I0498 PRO VANTAGE

AR076 PRUDENTIAL

I0323 RETAIL PHARMACY PROGRAM

I0244 RX PRIME

I1272 RX PRIME CUSSTOMER SERVICE

I1789 RX WEST

I0820 SCRIPT RX

I1621 SERVICE BENEFIT PLAN

AP070 TRIGON BC AND BS

I1330 UNITED CONCORDIA

I1439 UNITED HEALTH CARE

AT020 UNITED HEALTHCARE

APPENDIX B

OTHER CARRIER

CODE LIST

4/16/03 B.3

OTHER_PAYER_ID OTHER_PAYER_NAME

I0491 VALUE RX

I0624 VALUE RX

I0824 VALUE RX

I0028 VALUE RX SERV

AY793 VALUE RX SERVICES

I1336 VSP

I1627 WELL POINT PHARMACY MANAGEMENT

88888 MEDICARE

99999 MEDICAID

APPENDIX C

MARYLAND FORMS