AND
The primary care provider id is missing.
B
|
B
|
B
|
B
|
|
|
|
38
|
M/I Basis of Cost
|
4759
|
B
|
Basis of Cost is missing or invalid
|
B
|
B
|
B
|
B
|
|
|
|
39
|
M/I Diagnosis Code
|
4760
|
B
|
Diagnosis Code is missing or invalid
|
B
|
B
|
B
|
B
|
|
|
|
4C
|
M/I Coordination Of Benefits/Other Payments Count
|
4074
|
B
|
Missing/Invalid Coordination Of Benefits/Other Payments Count – 5.1 Only
A COB segment is present and the Coordination Of Benefits/Other Payments Count is missing (zeros).
|
D
|
D
|
D
|
D
|
|
|
|
4E
|
M/I Primary Care Provider Last Name
|
4925
|
B
|
M/I Primary Care Provider Last Name
|
B
|
B
|
B
|
B
|
|
|
|
40
|
Pharmacy not contracted with plan on date of service
|
4862
|
C
|
Pharmacy not contracted with plan on date of service - Checks if the pharmacy is on file and if the date range for the plan includes the date of service on the claim; if not - then post the error
Edit will post for non-590 providers submitting 590 claims
Note: This is a generic edit that posts for non-INCAID or non-590 providers; accordingly
|
D
|
D
|
D
|
D
|
|
|
|
40
|
Pharmacy not contracted with plan on date of service
|
4756
|
B
|
prov. inelig. to bill for DOS
|
D
|
D
|
D
|
D
|
|
|
|
40
|
Pharmacy not contracted with plan on date of service
|
4075
|
B
|
The Date Of Service does not fall within the date range on the provider network table that the provider was eligible to provide services.
OR
The Date Of Service does fall within the date range on the provider network table that the provider was eligible to provide services for the plan but the network was not valid for the Customer and Group on the Date Of Service
|
D
|
D
|
D
|
D
|
|
|
|
40
|
Pharmacy not contracted with plan on date of service
|
4806
|
X
|
Pharmacy not contracted with plan on date of service
|
D
|
D
|
D
|
D
|
|
|
|
41
|
Submit bill to other processor or primary payer
|
4077
|
B
|
Edit will post if the participant has TPL And TPL amount less is than 5% of submitted ingredient cost And Other insurance indicator = 2 - 3 or 4
|
B
|
B
|
B
|
B
|
|
|
|
41
|
Submit bill to other processor or primary payer
|
4863
|
C
|
member covered by private ins
|
D
|
D
|
D
|
D
|
|
|
|
41
|
Submit bill to other processor or primary payer
|
4427
|
NE
|
Nebraska Client Specific edit:
Patient has other coverage and the only policy is a cancer policy (policy coverage code 43) and the claim is for a cancer drug (one of the following 16 specific therapeutic classes): L5J, Q5N, V1A, V1B, V1C, V1D, V1E, V1F, V1J, V1K, V1N, V1O, V1Q, V1R, Z2E, Z2G.
BugTracker #4427
|
B
|
B
|
B
|
B
|
|
|
|
41
|
Submit bill to other processor or primary payer
|
4433
|
MA
|
Client Specific (MA): The coverage type is not “17” and the other insurance indicator is “0 -1 -3 -4” and the other amount paid is zero.
|
B
|
B
|
B
|
B
|
|
|
|
41
|
Submit bill to other processor or primary payer
|
4962
|
B
|
If claim indicates no other coverage but datebase indicates COB coverage, then post edit (1-30-04 Revised description:)
|
D
|
D
|
D
|
D
|
|
|
|
41
|
Submit bill to other processor
|
4460
|
MD
|
Primary paid amount is less than 20% of allowable charge".
|
B
|
D
|
D
|
B
|
|
|
|
42
|
Future Use
|
4880
|
|
|
|
|
|
|
|
|
|
43
|
Future Use
|
4881
|
|
|
|
|
|
|
|
|
|
44
|
Future Use
|
4882
|
|
|
|
|
|
|
|
|
|
45
|
Future Use
|
4883
|
|
|
|
|
|
|
|
|
|
46
|
Future Use
|
4884
|
|
|
|
|
|
|
|
|
|
47
|
Future Use
|
4885
|
|
|
|
|
|
|
|
|
|
48
|
Future Use
|
4886
|
|
|
|
|
|
|
|
|
|
49
|
Future Use
|
4887
|
|
|
|
|
|
|
|
|
|
5C
|
M/I Other Payer Coverage Type
|
4078
|
B
|
The Other Payer Coverage Type (COB Heirarchy) is missing (spaces) or it does not match one of the valid values specified for the field.
|
D
|
D
|
D
|
D
|
|
|
|
5E
|
M/I Other Payer Reject Count
|
4079
|
B
|
A COB segment is present and the Other Payer Reject Count is missing.
|
D
|
D
|
D
|
D
|
|
|
|
50
|
Non-Matched Pharmacy Number
|
4440
|
B
|
An adjustment request record has a Servicing Pharmacy (ALT ID) equal to spaces.
|
B
|
B
|
B
|
B
|
|
|
|
50
|
Non-Matched Pharmacy Number
|
4442
|
B
|
An adjustment request record has targeted a history record for adjustment - but the billing provider number on the adjustment request record does not match the billing provider number on the history record
|
B
|
B
|
B
|
B
|
|
|
|
51
|
Non-Matched Group Id
|
4689
|
B
|
IF DURING THE 1ST OR 2ND PASS OF THE ADJUDICATION PROCESS, THE GROUP-ID WAS CHANGED IN THE CLAIM TYPE ASSIGNMENT PROGRAM AS A RESULT OF THE PRIORITY RANKING SYSTEM, THEREFORE, THE GROUP-ID BEING USED NO LONGER EQUALS THE GROUP-ID SUBMITTED IN THE ORIGINAL CLAIM.
|
B
|
B
|
B
|
B
|
|
|
|
51
|
Non-Matched Group Id
|
4083
|
B
|
ACS Required A - 1st Date of Svc not in range of the plan on the group file
|
D
|
D
|
D
|
D
|
|
|
|
51
|
Non-Matched Group Id
|
4082
|
B
|
B - Group Record not on file
|
D
|
D
|
D
|
D
|
|
|
|
51
|
Non-Matched Group Id
|
4085
|
B
|
C - Mail Order claim: Mail order pricing id not on the group file.
|
B
|
B
|
B
|
B
|
|
|
|
52
|
Non-Matched Cardholder Id
|
4086
|
B
|
Non-matched member id. member not found on eligibility file.
|
D
|
D
|
D
|
D
|
|
|
|
52
|
Non-Matched Cardholder Id
|
4369
|
B
|
The Participant ID on the replacement or credit request does not match the Participant ID on the claim that is being replaced or credited.
|
D
|
D
|
D
|
D
|
|
|
|
53
|
Non-Matched Person Code
|
4088
|
B
|
The member number was not found on the participant member table.
|
B
|
B
|
B
|
B
|
|
|
|
54
|
Non-Matched Product/Service ID Number
|
4685
|
B
|
Date of Service is prior to the NDDF Added Date.
|
B
|
B
|
B
|
B
|
|
|
|
54
|
Non-Matched Product/Service ID Number
|
4089
|
B
|
Non-matched NDC (not on drug file)
|
D
|
D
|
D
|
D
|
|
|
|
55
|
Non-Matched Product Package Size
|
4761
|
B
|
Non-Matched Product Package Size
|
B
|
B
|
B
|
B
|
|
|
|
55
|
UNBREAKABLE PACKAGE
|
4451
|
B
|
CLAIM UNITS MUST BE MULTIPLE OF PACKAGE SIZE.
|
B
|
B
|
B
|
B
|
|
|
|
56
|
Non-Matched Prescriber Identification
|
4090
|
B
|
Physician # does not match physician # on Lockin Note: updated 12/12/06 to read "RECIPIENT LOCKED INTO DIFFERENT PHYSICIAN "
|
D
|
D
|
D
|
D
|
|
|
|
56
|
Non-Matched Prescriber Identification
|
4977
|
C
|
Physician Lic# not on file
|
B
|
B
|
B
|
B
|
|
|
|
56
|
Non-Matched Prescriber Identification
|
4421
|
B
|
Prescriber ID not found on provider enrollment eligibility table. Prescriber ID not valid for this client
|
B
|
B
|
B
|
B
|
|
|
|
58
|
Non-Matched Primary Prescriber
|
4763
|
B
|
Non Matched Primary Prescriber
|
B
|
B
|
B
|
B
|
|
|
|
59
|
Non-Matched Clinic Identification
|
4764
|
B
|
Non-matched Clinic id
|
B
|
B
|
B
|
B
|
|
|
|
6C
|
M/I Other Payer ID Qualifier
|
4926
|
B
|
**No description for exception code
|
D
|
D
|
D
|
D
|
|
|
|
6E
|
M/I Other Payer Reject Code
|
4091
|
B
|
The other payer reject count is greater than zero and the other payer reject code is missing (spaces).
|
D
|
D
|
D
|
D
|
|
|
|
60
|
Drug Not Covered For Patient Age
|
4092
|
B
|
Post if minimum age on custom record and patient is below that age and no pa exists.
11/26 EOB edit moved from edit 88
|
D
|
D
|
D
|
D
|
|
|
|
60
|
Drug Not Covered For Patient Age
|
4093
|
C
|
The IP participant age is less than the Minimum Age or greater than the maximum age on the Custom Plan Table
AND
Prior authorization indicator does NOT equal “Covered”
AND
The Age Edit Status on the Custom Plan table does NOT equal “Prior Authorization”
|
D
|
D
|
D
|
D
|
|
|
|
61
|
Drug Not Covered For Patient Gender
|
4094
|
B
|
Drug not covered for patient gender. If the drug is specified for a particular gender on the custom record and the patient is not that gender and no prior authorization on the medical profile; then post the error.
|
D
|
D
|
D
|
D
|
|
|
|
62
|
Patient/Card Holder ID name Mismatch
|
4765
|
B
|
member name & Number Disagree
|
B
|
B
|
B
|
B
|
|
|
|
64
|
Claim Submitted Does Not Match Prior Authorization
|
4096
|
B
|
(The Claim PA Number missing
OR
The Claim PA Number does not match the PA number)
AND
The PA Requires a matching PA number on the Claim
|
B
|
B
|
B
|
B
|
|
|
|
65
|
Patient is Not Covered
|
4985
|
B
|
EDIT WILL POST IF MEMBER IS NOT COVERED BY MEDICAID EVEN IF ELIGIBLE UNDER A SPECIFIC PLAN
|
B
|
B
|
B
|
B
|
|
|
|
65
|
Patient is Not Covered
|
4097
|
B
|
Patient not covered – Checks the coverage data on the eligibility file to see if the claim FDOS is in range. Also checks the relationship to determine if the member is covered and checks to see if it is a covered member id. If not covered for any of these reasons; then post the error.
|
D
|
D
|
D
|
D
|
|
|
|
65
|
Patient is Not Covered
|
4958
|
B
|
Patient no longer covered because deceased
|
B
|
B
|
B
|
B
|
|
|
|
65
|
Patient is Not Covered
|
4810
|
B
|
Client Specific (IN): member enrolled w/MCO on DOS
|
B
|
B
|
B
|
B
|
|
|
|
65
|
Patient is Not Covered
|
4813
|
C
|
member has other insurance but no other payor amt or other payor date submitted on the claim
|
B
|
B
|
B
|
B
|
|
|
|
65
|
Patient is Not Covered
|
4911
|
C
|
Filled before coverage effective – If the claim’s FDOS falls before the oldest coverage beginning date in the coverage table (Eligibility file); then the error is posted.
|
D
|
D
|
D
|
D
|
|
|
|
65
|
Patient is Not Covered
|
4865
|
|
Filled after coverage expired
|
D
|
D
|
D
|
D
|
|
|
|
65
|
Patient is Not Covered
|
4866
|
B
|
Filled after coverage terminated
|
D
|
D
|
D
|
D
|
|
|
|
65
|
Patient is Not Covered
|
4099
|
C
|
The date of service on the claim matches a segment on the participant plan table
AND
The Plan ID is not 001 or 002
AND
The aid category on the COE table does not match the first two bytes of the COE on the COE table.
|
B
|
B
|
B
|
B
|
|
|
|
65
|
Patient is Not Covered
|
4101
|
B
|
The claim drug coverage code is Family but the Participant Relationship Code is not Self - Spouse - Child - or Other
OR
(The claim drug coverage code is Individual
AND
The Participant Relationship Code is not Self)
OR
(The claim drug coverage code is Subscriber Spouse
AND
The Participant Relationship Code is not Self or Spouse)
OR
(The claim drug coverage code is Subscriber Child
AND
The Participant Relationship Code is not Self or Child)
OR
(The claim drug coverage code is Other
AND
The Participant Relationship Code is not Self or spouse or Child or Other)
|
B
|
B
|
B
|
B
|
|
|
|
65
|
Patient is Not Covered
|
4102
|
B
|
The claim member id is not equal to the member id on the participant’s member table
OR
The claim First Date Of Service is less than the participant member table eligibility began date
OR
The claim First Date Of Service is greater than the participant member table eligibility end date.
|
D
|
D
|
D
|
D
|
|
|
|
65
|
Patient is Not Covered
|
4429
|
|
If the participant is production and the claim was marked as a test claim because it contained a test provider
|
D
|
D
|
D
|
D
|
|
|
|
66
|
Patient Age Exceeds Maximum Age
|
4103
|
B
|
Post if drug has a maximum age specified on a customer record and the age of the member exceeds this maximum
|
D
|
D
|
D
|
D
|
|
|
|
66
|
Patient Age Exceeds Maximum Age
|
4105
|
C
|
Drug Maximum Age Exceeded
The IP Participant Age is equal to or greater than the custom plan table drug maximum age
AND
The prior authorization Indicator does not equal “Covered”
AND
The Age Edit Status on the Custom Record not = “Prior Authorization”.
|
D
|
D
|
D
|
D
|
|
|
|
67
|
Filled Before Coverage Effective
|
4728
|
OH/MD
|
MD (1/17/07) - THIS FIELD IS USED TO SUBMIT THE COPAY WHEN OTHER COVERAGE CODE = 8.
|
B
|
D
|
B
|
D
|
|
|
|
67
|
Filled Before Coverage Effective
|
4727
|
OH/MD
|
MD (1/17/07) - This field is required when submitting a copay amount with other coverage code = 8. The qualifier should be 99 (other)
|
B
|
D
|
B
|
D
|
|
|
|
67
|
Filled Before Coverage Effective
|
4726
|
OH/MD
|
MD (1/17/07) - This field is required when submitting a copay amount with other coverage code = 8. The count is typically 1.
|
B
|
D
|
B
|
D
|
|
|
|
67
|
Filled Before Coverage Effective
|
4722
|
OH
|
PENDING INJURY; ALLEGED CLAIM
|
B
|
D
|
B
|
B
|
|
|
|
67
|
Filled Before Coverage Effective
|
4106
|
B
|
Note: edit deleted by Nashville
The claim Date Of Service is less than the oldest plan coverage beginning date.
|
B
|
B
|
B
|
B
|
|
|
|
68
|
Filled After Coverage Expired
|
4108
|
B
|
The Date Of Service is before the market entry date on the drug table.
|
B
|
B
|
B
|
B
|
|
|
|
69
|
Filled After Coverage Terminated
|
4888
|
B
|
Filled After Coverage Terminated
|
B
|
B
|
B
|
B
|
|
|
|
7C
|
M/I Other Payer ID
|
4957
|
B
|
Non-Matched Other Payer Id
|
D
|
D
|
D
|
B
|
|
|
|
7E
|
M/I DUR/PPS Code Counter
|
4110
|
B
|
The DUR/PPS Code Counter is missing (zeros).
|
D
|
D
|
D
|
D
|
|
|
|
70
|
NDC Not Covered
|
4684
|
B
|
NDC NOT COVERED - REASON CODES: A =DESI DRUG B =NO REBATE C = NOT COVERED ON PLAN FILE D =NO VALID PRICING CATEGORY ON GROUP FILE FOR DOS E =NO PRICING ON DRUG FILE FOR DATE OF CLAIM F =NO MAIL-ORDER SERVICE FOR CLIENT G =MAIL-ORDER FOR MAINTENANCE DRUGS ONLY I= DEFAULT CODE - NOT COVERED ON PLAN
**3.2 edit only - see 4683 for equivalent 5.1 edit**
|
D
|
D
|
D
|
D
|
|
|
|
70
|
NDC Not Covered
|
4619
|
NE
|
Deny the claim if the date filled is 366 days past the drug obsolete date (not term date)
|
D
|
D
|
D
|
D
|
|
|
|
70
|
Product/Service Not Covered
|
4980
|
BE / IA
|
Reason code P - The Labeler portion of the NDC indicates it is not covered
|
D
|
D
|
D
|
D
|
|
|
|
70
|
Product/Service Not Covered
|
4116
|
B
|
NDC not covered – Reason Codes:
A =DESI Drug
B =No Rebate
C = Not Covered on Plan File
D =No Valid Pricing Category on Group File for DOS
E =No Pricing on Drug File for Date of Claim
F =No Mail-Order Service for Client
G =Mail-Order for Maintenance Drugs Only
I= Default Code – Not Covered on Plan
Nashville description:
The Product/Service ID Qualifier indicates that the Product/Service ID field contains a NDC and the Plan indicates a Non-Covered Drug
|
D
|
D
|
D
|
D
|
|
|
|
70
|
Product/Service Not Covered
|
4853
|
C
|
Less than effective Drug
|
B
|
B
|
B
|
B
|
|
|
|
70
|
Product/Service Not Covered
|
4123
|
B
|
Reason Code E: No price on drug file
The Product/Service ID Qualifier indicates that the Product/Service ID field contains a NDC and no drug pricing data for the drug was in effect for the claim Date of Service.
|
D
|
D
|
D
|
D
|
|
|
|
70
|
Product/Service Not Covered
|
4113
|
B
|
A =DESI Drug
(Less than effective Drug) - non-reimbursable
Nashville description:
If the Product/Service ID Qualifier indicates a NDC in the Product/Service ID field
AND
The Plan’s Designer Drug Allowed indicator equals ‘N’
AND
The DESI Drug Override is not equal to ‘Y’
AND
The Drug's DESI Code = '1', '4', or '5'.
|
D
|
D
|
D
|
D
|
|
|
|
70
|
Product/Service Not Covered
|
4117
|
B
|
No signed rebate agreement (reason code B).
Nashville description:
HCFA Rebate Criteria Not Met – 3.2 Only (Mass Specific)
The Product/Service ID Qualifier indicates that the Product/Service ID field contains a NDC
AND
((Drug Rebate data is found for the Claim’s NDC and Date of Service on the Drug Rebate Table
AND
The Drug Rebate Code for the NDC = “No Rebate” (‘0’)
AND
The NDC is not a “Rebate Exempt” NDC (hard-coded table – Massachusetts specific))
OR
(Drug Rebate data is not found for the Claim’s NDC and Date of Service on the Drug Rebate Table))
AND
The Drug’s Class Code not = “OTC” (‘O’)
AND
The Drug’s Therapeutic Class not = “Vaccine” (‘W7B’ thru ‘W7Q’)
AND
The Drug’s GCN not = “Non-Drug Item” (‘94200’)
AND
The Claim’s Drug Compound Code not = “Compound” (‘2’)
|
D
|
D
|
D
|
D
|
|
|
|
70
|
Product/Service Not Covered
|
4120
|
B
|
D =No Valid Pricing Category on Group File for DOS
Nashville description:
The Product/Service ID Qualifier indicates that the Product/Service ID field contains a NDC and a valid group pricing segment was not found on the group pricing table
|
D
|
D
|
D
|
D
|
|
|
|
70
|
Product/Service Not Covered
|
4118
|
B
|
F =No Mail-Order Service for Client
If the Product/Service ID Qualifier indicates that the Product/Service ID field contains a NDC
AND
The Claim’s Input Form Code indicates a Mail Order claim
AND
The Customer table Mail Order Program Indicator is not equal to Mail Order Program
|
B
|
B
|
B
|
B
|
|
|
|
70
|
Product/Service Not Covered
|
4119
|
B
|
G =Mail-Order for Maintenance Drugs Only
Nashville Description:
If the claim input form code is mail order
AND
The Product/Service ID Qualifier indicates that the Product/Service ID field contains a NDC
AND
The Customer Mail Order Code equals Maintenance Only Covered
AND
The Claim Maintenance Drug Indicator is not equal to Maintenance Drug.
|
B
|
B
|
B
|
B
|
|
|
|
70
|
Product/Service Not Covered
|
4115
|
B
|
I= Default Code – Not Covered on Plan
The Product/Service ID Qualifier indicates that the Product/Service ID field contains a NDC and the Plan benefit limit range table indicates a Non-Covered Drug.
|
D
|
D
|
D
|
D
|
|
|
|
70
|
Product/Service Not Covered
|
4111
|
B
|
The First Date Of Service on a Claim with a Workers Compensation Customer ID is less than the date of injury on the Prior Authorization Header Table.
|
B
|
B
|
B
|
B
|
|
|
|
70
|
Product/Service Not Covered
|
4114
|
B
|
If the Product/Service ID Qualifier indicates that the Product/Service ID field contains a NDC
AND
The NDC is a Plan Non-Covered Drug from the benefit limit range table
AND
No previous pricing edits have been set for this claim
AND
The Plan Benefit Limit Override PA is not equal to “I “ (Override Initial RX).
|
D
|
D
|
D
|
D
|
|
|
|
70
|
Product/Service Not Covered
|
4121
|
B
|
If the Product/Service ID Qualifier indicates that the Product/Service ID field contains a NDC
AND
The Claim Allowed Charge equals $0.00
AND
The Group Pricing DAW code on the group pricing table equals spaces.
|
B
|
B
|
B
|
B
|
|
|
|
70
|
Product/Service Not Covered
|
4122
|
C
|
If the Product/Service ID Qualifier indicates that the Product/Service ID field contains a NDC
AND
The drug is a Plan Non-Covered Drug
AND
No previous pricing edits have been set for this claim
AND
The Plan Benefit Limit Override PA is not equal to “I “ (Override Initial RX)
AND
The Plan ID is not equal to ‘101’ thru ‘123’ (Massachusetts Long Term Care Plan).
|
B
|
B
|
B
|
B
|
|
|
|
70
|
Product/Service Not Covered
|
4124
|
B
|
If the stepcare indicator on the customer and group tables is equal to ‘Y’
AND
The drug is not covered by the Plan or by a PA
AND
The reject code on the StepCare record is “70”
AND
The number of agents taken is less than the number of agents required
OR
The amount of time the drugs were taken was less than the therapy span required.
OR
If the number of agents required is greater than the number of drugs that were each taken for the correct therapy span
|
B
|
D
|
B
|
B
|
|
|
|
71
|
Prescriber is Not Covered
|
4770
|
X
|
Prescriber is Not Covered
|
B
|
B
|
B
|
B
|
|
|
|
72
|
Primary Prescriber is Not Covered
|
4771
|
X
|
Primary Prescriber is Not Covered
|
B
|
B
|
B
|
B
|
|
|
|
73
|
Refills are Not Covered
|
4131
|
B
|
The Custom Plan Max Number of Refills is not equal to “Unlimited” (999)
AND
The Plan Benefit Limit Override PA is equal to “N” (No Override) or “ “ (not set)
AND
The Custom Plan Max Number of Refills is less than Claim Refill Indicator (Fill Number)
AND
The drug prescription override indicator is not equal to “Y”.
|
B
|
B
|
B
|
B
|
|
|
|
73
|
Refills are Not Covered
|
4128
|
B
|
The Custom Plan Max Number of Refills is not equal to “Unlimited” (999)
AND
The Plan Benefit Limit Override PA is equal to “N” (No Override) or “ “ (not set)
AND
The Custom Plan Max Number of Refills is less than Claim Refill Indicator (Fill Number)
AND
The drug prescription override indicator is not equal to “Y”.
|
D
|
D
|
D
|
D
|
|
|
|
73
|
Refills are Not Covered
|
4129
|
B
|
Number Of Mail Order Refills Exceeded
The provider payment code is mail order
AND
The Claim Refill Indicator (Fill Number) is greater than the plan number of refill limit
|
B
|
B
|
B
|
B
|
|
|
|
73
|
Refills are Not Covered
|
4130
|
B
|
Maximum Number Of Refills Exceeded
If the claim is not mail order
AND
The Claim Refill Indicator is greater than the plan Authorized Refills
|
B
|
B
|
B
|
B
|
|
|
|
74
|
Other Carrier Payment Meets or Exceeds Payable
|
4772
|
B
|
Client Specific (CO) Other carrier payment meets or exceeds payable – PDCS CO only
|
B
|
B
|
B
|
B
|
|
|
|
75
|
Prior Authorization Required
|
4711
|
OH
|
BILL SUBJECT TO SMARTPA CLINICAL RULES. SMARTPA RULES ENGINE DOWN.
|
D
|
B
|
B
|
D
|
|
|
|
75
|
Prior Authorization Required
|
4965
|
C
|
Client Specific (IN) 590 claims in excess of $500 require PA. If there is no PA; the claim should deny for NCPDP edit 75 and EOB 3002.
|
B
|
B
|
B
|
B
|
|
|
|
75
|
Prior Authorization Required
|
4133
|
B
|
If the DUR amount limit accumulator equals ‘all’
AND
The DUR amount limit total (a calculated field) is greater than the DUR amount limit from the plan benefits limit table
AND
The DUR amount limit status on the plan’s benefits limit table equals ‘P’
AND
There is no prior authorization indicated on the claim.
|
B
|
B
|
B
|
B
|
|
|
|
75
|
Prior Authorization Required
|
4146
|
B
|
If the Plan Benefit Limit Override PA equals “I “ (Override Initial RX)
AND
The Claim Refill Indicator equals 0
AND
The Prior authorization indicator is not equal to (“Prior Authorized” or “Covered”).
|
B
|
B
|
B
|
B
|
|
|
|
75
|
Prior Authorization Required
|
4134
|
B
|
The Prior Authorization used units plus the claim drug quantity is greater than the Prior Authorization approved units amount
|
D
|
D
|
D
|
D
|
|
|
|
75
|
Prior Authorization Required
|
4821
|
|
Client Specific (IN) out of state provider req. PA
|
