19
|
M/I Days Supply
|
4386
|
B
|
The Claim’s Submitted Days Supply Amount (Days Supply) > Plan Header Days Supply Limit (or Maintenance Days Supply Limit for Maintenance Drugs)
AND
A Custom Plan Benefit Limit record exists for this Customer - Plan - and Benefit Limit Type
AND
The Custom Plan Accumulation Code = ‘Edit Acute Only’
AND
The Custom Plan’s Maintenance Dose < Default Daily Dose (9999.999)
AND
The Claim’s calculated Daily Dose > Custom Plan’s Maintenance Dose
AND
The Claim’s Submitted Days Supply Amount (Days Supply) > Custom Plan’s Days Submitted Number
|
D
|
D
|
D
|
D
|
|
|
|
19
|
M/I Days Supply
|
4387
|
B
|
The Claim’s Submitted Days Supply Amount (Days Supply) > Plan Header Days Supply Limit (or Maintenance Days Supply Limit for Maintenance Drugs)
AND
A Custom Plan Benefit Limit record exists for this Customer - Plan - and Benefit Limit Type
AND
The Custom Plan Accumulation Code = ‘Edit All Drugs’
AND
The Claim’s Submitted Days Supply Amount (Days Supply) > Custom Plan’s Days Submitted Number
|
D
|
D
|
D
|
D
|
|
|
|
19
|
M/I Days Supply
|
4388
|
B
|
The Plan’s Max Units Limit < “Unlimited Units (9999.999)”
AND
The Claim’s Drug Submitted Quantity > Plan’s Max Units Limit
AND
No Custom Plan Benefit Limit record exists for this Customer - Plan - and Benefit Limit Type
|
D
|
D
|
D
|
D
|
|
|
|
19
|
M/I Days Supply
|
4389
|
B
|
The Plan’s Max Units Limit < “Unlimited Units (9999.999)”
AND
The Claim’s Drug Submitted Quantity > Plan’s Max Units Limit
AND
A Custom Plan Benefit Limit record exists for this Customer - Plan - and Benefit Limit Type
AND
The Custom Plan Max Units Accumulation Code = ‘No Edit’
AND
The Custom Plan’s Units Limit Number < Default Max Units (9999.999)
|
D
|
D
|
D
|
D
|
|
|
|
19
|
M/I Days Supply
|
4390
|
B
|
The Custom Plan Max Units Accumulation Code = ‘Edit Acute Only’
AND
The Custom Plan’s Maintenance Dose < Default Daily Dose (9999.999)
AND
The Claim’s calculated Daily Dose > Custom Plan’s Maintenance Dose
AND
The Claim’s Drug Submitted Quantity > Plan’s Max Units Limit
|
D
|
D
|
D
|
D
|
|
|
|
19
|
M/I Days Supply
|
4391
|
B
|
The Custom Plan Max Units Accumulation Code = ‘Edit All Drugs’
AND
The Claim’s Drug Submitted Quantity > Custom Plan’s Max Units Limit
|
D
|
D
|
D
|
D
|
|
|
|
19
|
M/I Days Supply
|
4392
|
C
|
The Claim’s Drug DEA Code = ‘2’ (Schedule 2 - Most Abused)
AND
(The Drug’s Category Code = ‘Z’ (Attention Deficit Disorder)
AND
The Claim’s Submitted Days Supply Amount (Days Supply) > 60 Days)
OR
(The Drug’s Category Code not = ‘Z’ (Attention Deficit Disorder)
AND
The Claim’s Submitted Days Supply Amount (Days Supply) > 30 Days)
|
D
|
D
|
D
|
D
|
|
|
|
19
|
M/I Days Supply
|
4400
|
B
|
A Custom Plan Benefit Limit record exists for this Customer, Plan, and Benefit Limit Type
AND
The Claim’s Submitted Days Supply Amount (Days Supply) > Plan Header Days Supply Limit (or Maintenance Days Supply Limit for Maintenance Drugs)
AND
The Custom Plan’s Days Submitted Number = Default Days Supply Number (999)
|
D
|
D
|
D
|
D
|
|
|
|
19
|
M/I Days Supply
|
4401
|
B
|
A Custom Plan Benefit Limit record exists for this Customer, Plan, and Benefit Limit Type
AND
The Claim’s Submitted Days Supply Amount (Days Supply) > Plan Header Days Supply Limit (or Maintenance Days Supply Limit for Maintenance Drugs)
AND
The Custom Plan’s Days Submitted Number not = Default Days Supply Number (999)
AND
The Claim’s Submitted Days Supply Amount (Days Supply) > The Custom Plan’s Days Submitted Number
AND
The Drug’s Therapeutic Class is not in an “Exempt” hard-coded table
AND
The Drug’s Category Code is not = ‘C’ (Oral Contraceptives)
AND
The Claim’s Drug DEA Code = ‘0’ or ‘1’ (Schedule 0 – No DEA Control, Schedule 1 - Research)
|
D
|
D
|
D
|
D
|
|
|
|
19
|
M/I Days Supply
|
4403
|
B
|
A Custom Plan Benefit Limit record does not exist for this Customer - Plan - and Benefit Limit Type
AND
The Claim’s Submitted Days Supply Amount (Days Supply) > Plan Header Days Supply Limit (or Maintenance Days Supply Limit for Maintenance Drugs)
|
D
|
D
|
D
|
D
|
|
|
|
2C
|
M/I Pregnancy Indicator
|
4031
|
B
|
Missing/Invalid Pregnancy Indicator 5.1 only
The pregnancy indicator is missing (spaces) or it does not match one of the valid values specified for the field.
|
B
|
B
|
B
|
B
|
|
|
|
2E
|
M/I Primary Care Provider ID Qualifier
|
4032
|
B
|
Missing/Invalid Primary Care Provider ID Qualifier 5.1 only
The Primary Care Provider ID is submitted on the Prescriber Segment
AND The Primary Care Provider ID Qualifier is missing or it does not match one of the valid values specified for the field.
|
B
|
B
|
B
|
B
|
|
|
|
20
|
M/I Compound Code
|
4033
|
B
|
Edit posted if not 0 - 1 - 2
Client Specific (IN): Note: if value 2 (compound) - will be rejected by edit M5 (requires manual claim)
|
D
|
D
|
D
|
D
|
|
|
|
21
|
M/I Product/Service ID
|
4645
|
B
|
Post edit when a line item on a 5.1 claim is a dummy drug. A dummy drug will have "CONSULTEC" as the manufactors name.
|
D
|
D
|
D
|
D
|
|
|
|
21
|
M/I Product/Service ID
|
4034
|
B
|
The National Drug Code (NDC) is missing - non-numeric - or all zeros.
|
D
|
D
|
D
|
D
|
|
|
|
21
|
M/I Product/Service ID
|
4803
|
B
|
NDC invalid format
|
D
|
D
|
D
|
D
|
|
|
|
21
|
M/I Product/Service ID
|
4450
|
B
|
The Product/Service ID Qualifier indicates the Product/Service ID is an NDC
AND
The NDC is missing or non-numeric.
|
D
|
D
|
D
|
D
|
|
|
|
22
|
M/I Dispensed As Written Code
|
4622
|
B
|
Edit to deny claims that request a DAW code that is not valid for the plan, ie: a claim was paid with a DAW of '2', but '2' is not a valid DAW code per the given plan.
|
D
|
D
|
D
|
D
|
|
|
|
22
|
M/I Dispensed As Written Code
|
4037
|
B
|
The Dispense As Written DAW/Product Selection Code does not match one of the valid values specified for the field.
|
D
|
D
|
D
|
D
|
|
|
|
23
|
M/I Ingredient Cost Submitted
|
4038
|
B
|
The submitted ingredient amount/Ingredient Cost Submitted is missing (zero).
|
D
|
D
|
D
|
D
|
|
|
|
25
|
M/I Prescriber Identification
|
4973
|
B
|
Prescriber on Review (Suspend)
|
B
|
B
|
B
|
B
|
|
|
|
25
|
M/I Prescriber Identification
|
4979
|
B
|
Prescriber writing prescription for schedule II drug must have a valid DEA# on file
|
B
|
B
|
B
|
B
|
|
|
|
25
|
M/I Prescriber Identification
|
4975
|
B
|
Prescriber on Review (Deny)
|
B
|
B
|
B
|
B
|
|
|
|
25
|
M/I Prescriber Identification
|
4042
|
B
|
The Prescriber ID Qualifier is equal to DEA and the first two positions of the Prescriber Provider Id are not alphanumeric
OR
The Prescriber ID Qualifier is equal to DEA and the last seven positions of the Prescriber Provider Id do not pass the check sum validation routine.
|
D
|
D
|
D
|
D
|
|
|
|
26
|
M/I Unit Of Measure
|
4876
|
B
|
The Unit of Measure code is not equal to the valid values
|
D
|
D
|
D
|
D
|
|
|
|
27
|
Future Use
|
4877
|
B
|
|
B
|
B
|
B
|
B
|
|
|
|
28
|
M/I Date RX Written
|
4043
|
B
|
The Date Prescription Written is missing or invalid
|
D
|
D
|
D
|
D
|
|
|
|
28
|
M/I Date RX Written
|
4044
|
B
|
Client Specific (IN): The claim Date Prescribed is less than the date the participant eligibility on the participant member table began minus 30 days
OR
The claim Date Prescribed is greater than the date the participant eligibility on the participant member table ended.
|
D
|
D
|
D
|
D
|
|
|
|
28
|
M/I Date RX Written
|
4045
|
B / C
|
The drug is a Schedule II drug and the number of days since the date prescribed is more than 30 days prior to the first date of service
|
D
|
D
|
D
|
D
|
|
|
|
|
