(OHWORK) BILL SUBJECT TO SMARTPA CLINICAL RULES. INJURED WORKER DOES NOT HAVE REQUIRED DIAGNOSIS ON FILE SUPPORTING THE USE OF THE DRUG.
B
|
B
|
B
|
B
|
|
|
|
76
|
Plan Limitations Exceeded
|
4674
|
FL
|
Claim subject to SmartPA Clinical Rules. Dose not optimized.
(OHWORK) PA EFFECTIVE SPAN = 180DAYS
|
B
|
B
|
B
|
B
|
|
|
|
76
|
Plan Limitations Exceeded
|
4673
|
FL
|
Claim subject to SmartPA Clinical Rules. Claim exceeds SmartPA quantity limits/maximum daily dosage.
(OHWORK) PA EFFECTIVE SPAN = 180DAYS
|
B
|
B
|
B
|
B
|
|
|
|
76
|
Plan Limitations Exceeded
|
4823
|
B
|
Plan Limitations Exceeded - Prior Authorization Required From Health Care Excel 800-457-4518
(oxycontin limits)
|
B
|
B
|
B
|
B
|
|
|
|
76
|
Plan Limitations Exceeded
|
4970
|
C
|
Client Specific (IN) Step Care - Greater than 90 days in 180 days of Ranitidine or Nizatidine > 150 mg/day; Famotidine > 20mg/day; Cimetidine > 400mg/day PA required from Health Care Excel 800-457-4518
|
B
|
B
|
B
|
B
|
|
|
|
76
|
Plan Limitations Exceeded
|
4968
|
B
|
Non-PDL Drug - Supply Limited (TCP Program)
|
B
|
B
|
B
|
B
|
|
|
|
76
|
Plan Limitations Exceeded
|
4552
|
B
|
Base edit for condition: greater than 34 days supply for non-maintenance drug
|
B
|
B
|
B
|
B
|
|
|
|
76
|
Plan Limitations Exceeded
|
4913
|
C
|
Client Specific (IN) CSR 43 - greater than 34 days supply for non-maint. Drug Prior Authorization required from Health Care Excel 800-457-4518
|
B
|
B
|
B
|
B
|
|
|
|
76
|
Plan Limitations Exceeded
|
4831
|
B
|
Plan Limits Exceeded - see below reason codes:
B =Custom Rec; All Doses - Max $ Limit Exceeded for Spec Dur
|
D
|
D
|
D
|
D
|
|
|
|
76
|
Plan Limitations Exceeded
|
4832
|
B
|
C =Custom Rec; Acute Dose - Max $ Limit Exceeded for Spec Duration
|
D
|
D
|
D
|
D
|
|
|
|
76
|
Plan Limitations Exceeded
|
4165
|
B
|
D =Custom Rec; All Doses - Submitted Units > Max Units for Spec Claim
Submitted Quantity Exceeds Custom Plan Limits
The Custom Plan Max Units Accum equals “A” (All Doses)
AND
The Claim Submitted Quantity is greater than Custom Plan Max Units
AND
The Custom Plan Max Units Status equals “D” (Deny)
AND
Prior authorization indicator is not equal to (“Prior Authorized” or “Covered”).
|
D
|
D
|
D
|
D
|
|
|
|
76
|
Plan Limitations Exceeded
|
4867
|
B
|
E =Custom Rec; Acute Dose - Submitted Units > Max Units for Spec Claim
|
D
|
D
|
D
|
D
|
|
|
|
76
|
Plan Limitations Exceeded
|
4168
|
B
|
F =Custom Rec; All Doses - Submitted days > Max Days Supp for Spec Claim
DUR Days Supplied Limits Exceeded
An entry exists on the Custom Record
AND DUR Days Supply Accumulator Code on the Custom Record is not equal to “N”
AND DUR Days Supply Amount on the Custom Record is greater than +0 and less than +999
AND ((DUR Days Supply Accumulator Code on the Custom Record equals “C” (Acute))
AND (IP Daily Dose is greater than the Maintenance Claim Dose on the Custom Record)
AND (DUR Days Supply Total is greater than the DUR Days Supply Amount on the Custom Record)
AND (DUR Days Supply Status on the Custom Record equals “D”)
AND (Prior authorization indicator is not equal to “C” (Covered) and not equal to “A” (Prior Authorization)))
OR ((DUR Days Supply Accumulator Code on the Custom Record equals “A” (All))
AND (DUR Days Supply Total is greater than the DUR Days Supply Amount on the Custom Record)
AND (DUR Says Supply Status on the Custom Record equals “D”)
AND (Prior authorization indicator is not equal to “C” (Covered) and not equal to “A” (Prior Authorization)))
|
D
|
D
|
D
|
D
|
|
|
|
76
|
Plan Limitations Exceeded
|
4163
|
B
|
G =Custom Rec; Acute Dose - Submitted days > Max Days Sup for Spec claim
Exceeds Custom Plan Days Supplied Limits
The Custom Plan Days Supplied Accum equals “A” (All Doses)
AND
The Claim Submitted Days greater than Custom Plan Days Supplied
AND
The Custom Plan Days Supplied Status equals “D” (Deny)
AND
The Prior authorization indicator is not equal to (“Prior Authorized” or “Covered”).
|
D
|
D
|
D
|
D
|
|
|
|
76
|
Plan Limitations Exceeded
|
4160
|
B
|
H =Custom Rec; Daily Dose > Maintenance Claim Dose
Not Covered By Custom Plan
The Daily Dose equals the Custom Plan Maintenance Claim Dose
AND
The Custom Plan Maintenance Indicator is not equal to “Pay”
AND
The Custom Plan Maintenance Claim Dose Indicator equals “Deny, no PA”
AND
The Prior authorization indicator is not equal to (“Prior Authorized” or “Covered”).
|
D
|
D
|
D
|
D
|
|
|
|
76
|
Plan Limitations Exceeded
|
4169
|
B
|
I =Custom Rec; All Doses - Max Num of Scripts exceeded for Spec Dur
An entry exists on the Custom Record
AND
DUR Max RX Accumulator Code on the Custom Record is not equal to “N”
AND
DUR Max RX Amount on the Custom Record is greater than +0 and less than +999
AND
((DUR Max RX Accumulator Code on the Custom Record equals “C” (Acute))
AND
(IP Daily Dose is greater than the Maintenance Claim Dose on the Custom Record)
AND
(DUR Max RX Total is greater than the DUR Max RX Amount on the Custom Record)
AND
(DUR Max RX Status on the Custom Record equals “D”)
AND
(Prior authorization indicator is not equal to “C” (Covered) and not equal to “A” (Prior Authorization)))
OR
((DUR Max RX Accumulator Code on the Custom Record equals “A” (All))
AND
(DUR Max RX Total is greater than the DUR Max RX Amount on the Custom Record)
AND
(DUR Max RX Status on the Custom Record equals “D”)
AND
(Prior authorization indicator is not equal to “C” (Covered) and not equal to “A” (Prior Authorization)))
|
D
|
D
|
D
|
D
|
|
|
|
76
|
Plan Limitations Exceeded
|
4868
|
B
|
J =Custom Rec; Acute Dose - Max num Scripts exceeded for Spec Dur
|
D
|
D
|
D
|
D
|
|
|
|
76
|
Plan Limitations Exceeded
|
4869
|
B
|
K =Custom Rec; All Doses - Submitted Days > Max Days Supp for Spec Duration
|
D
|
D
|
D
|
D
|
|
|
|
76
|
Plan Limitations Exceeded
|
4870
|
B
|
L =Custom Rec: Acute Dose - Submitted Days > Max Days Supp for Spec Duration
|
D
|
D
|
D
|
D
|
|
|
|
76
|
Plan Limitations Exceeded
|
4171
|
B
|
M =Custom Rec; All Doses - Submitted Units > Max Units for Spec Dur
The DUR amount limit accumulator equals ‘A’ (all)
AND
The DUR amount limit total 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 ‘D’
AND
There is no prior authorization
|
D
|
D
|
D
|
D
|
|
|
|
76
|
Plan Limitations Exceeded
|
4172
|
B
|
N =Custom Rec; Acute Dose - Submitted Units > Max Units for Spec Dur
DUR Daily Dosage Limit Exceeded
The DUR amount limit accumulator on the plan benefits limits database equals ‘C’ (acute)
AND
The daily dose is greater than the maintenance claim dose on the plan’s benefits limit table
AND
The DUR amount limit total 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 ‘D’
AND
There is no prior authorization
|
D
|
D
|
D
|
D
|
|
|
|
76
|
Plan Limitations Exceeded
|
4166
|
B
|
O =Plan file Max Scripts exceeded for a Specific Duration
The Number of Scripts on the Plan Record is greater than zero and less than 999.
AND
The Script Limit Total is greater than the Number of Scripts on the Plan Record.
AND
Prior authorization indicator is not equal to “1” or “3”
AND
The Prescription Limit Exempt Indicator on the Custom Record is not equal to “Y”.
|
D
|
D
|
D
|
D
|
|
|
|
76
|
Plan Limitations Exceeded
|
4833
|
B
|
P= Patient Exceeds Monthly Refill Limit
|
D
|
D
|
D
|
D
|
|
|
|
76
|
Plan Limitations Exceeded
|
4161
|
B
|
The Number of Scripts on the Plan Record is greater than zero and less than 999.
AND
The Script Limit Total is greater than the Number of Scripts on the Plan Record.
AND
Prior authorization indicator is not equal to“1” or “3”
AND
The Prescription Limit Exempt Indicator on the Custom Record is not equal to “Y”
|
D
|
D
|
D
|
D
|
|
|
|
76
|
Plan Limitations Exceeded
|
4162
|
B
|
(The Custom Plan Days Supplied Accum is not equal to “N” (None)
OR
The Custom Plan Days Supplied is not equal to Work Default Days (999))
AND
The Custom Plan Days Supplied Accum equals “C” (Acute Dose Only)
AND
The Custom Plan Maintenance Claim Dose less than Work Default Dose (9999.999)
AND
The Daily Dose is greater than Custom Plan Maintenance Claim Dose
AND
The Claim Submitted Days is greater than Custom Plan Days Supplied
AND
The Custom Plan Days Supplied Status equals “D” (Deny)
AND
The Prior authorization indicator is not equal to (“Prior Authorized” or “Covered”).
|
D
|
D
|
D
|
D
|
|
|
|
76
|
Plan Limitations Exceeded
|
4164
|
B
|
(The Custom Plan Max Units Accum is not equal to “N” (None)
AND
The Custom Plan Max Units is not equal to Work Default Max Units (99999.999))
AND
The Custom Plan Max Units Accum equals “C” (Acute Dose Only)
AND
The Custom Plan Maintenance Claim Dose less than Work Default Dose (9999.999)
AND
The Daily Dose is greater than Custom Plan Maintenance Claim Dose
AND
The Claim Submitted Quantity is greater than Custom Plan Max Units
AND
The Custom Plan Max Units Status equals “D” (Deny)
AND
The Prior authorization indicator is not equal to (“Prior Authorized” or “Covered”).
|
D
|
D
|
D
|
D
|
|
|
|
76
|
Plan Limitations Exceeded
|
4167
|
B
|
An entry exists on the Custom Record
AND
DUR Units Accumulator Code on the Custom Record is not equal to “N”
|
