AND
DUR Units Amount on the Custom Record is greater than +0.000 and less than +99999.999
AND
((DUR Units 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 Units Total is greater than the DUR Units Amount on the Custom Record)
AND
(DUR Units Status on the Custom Record equals “D”)
AND
(Medical Profile Override Indicator is not equal 1 and not equal 3)
AND
(Prior authorization indicator is not equal “C” (Covered) and not equal “A” (Prior Authorization))
OR
((DUR Units Accumulator Code on the Custom Record equals “A” (All))
AND
(DUR Units Total is greater than the DUR Units Amount on the Custom Record)
AND
(DUR Units 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
|
4170
|
C
|
History Accumulator Greater Than 60 Days
IP Generic Code Number one of the following: 01697, 01698, 04348, 12867, 12868, 13025, 40120, 64269, 92989, 92999, 94639
AND
IP first date of service is greater than the current date minus 181 days
AND
Massachusetts History Accumulator is greater than +60
AND
The Prior authorization indicatory is not equal to “Covered” and not equal to “Prior Authorization”
|
B
|
B
|
B
|
B
|
|
|
|
76
|
Plan Limitations Exceeded
|
4126
|
B
|
StepCare
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 “76”
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
|
|
|
|
77
|
Discontinued Product/Service ID Number
|
4173
|
B
|
Discontinued NDC number - HCFA
The Claim Date Of Service is greater than the HCFA Drug Termination Date on the Drug Table.
|
D
|
D
|
D
|
D
|
|
|
|
78
|
Cost Exceeds Maximum
|
4174
|
B
|
The allowed ingredient charge on a non-compound claim is greater than $99,999.99
|
D
|
D
|
D
|
D
|
|
|
|
78
|
Cost Exceeds Maximum
|
4175
|
B
|
The Claim total Reimbursement Amount is Greater than the Group Maximum Compound Drug Amount.
|
D
|
D
|
D
|
D
|
|
|
|
78
|
Cost Exceeds Maximum
|
4176
|
B
|
This edit is posted if the submitted sales tax for providers located in New Mexico, Louisiana, or Illinois exceeds 20%.
If the submitted sales tax and the total claim charge is equal, the edit will not be posted.
This edit will also zero out the submitted sales tax if the provider is from any state other than the three listed above. These states do not charge sales tax on prescriptions.
|
D
|
D
|
D
|
D
|
|
|
|
79
|
Refill Too Soon
|
4063
|
B
|
FILLED AFTER-EXCEEDS 15 DAYS EARLY OVER 180 PERIOD-PA REQUIRED. CALL ACS AT 866-556-9320-VALID REFILL TOO SOON CRITERIA:DOSAGE CHANGE OR LOST RX 1 TIME PER YEAR
|
B
|
B
|
B
|
B
|
|
|
|
79
|
Refill Too Soon
|
4177
|
B
|
In Process Member Number equals History Member Number
AND
The history claim’s participant ID equals In Process claim’s Participant ID
AND
The history claim’s status code equals “to be paid” or “paid”
AND
The history claim’s transaction type code equals “Original” or “Debit of Adjustment”
AND
The history claim’s document type code equals “Adjustment” or “Fee for Service (FFS)”
AND
The history claim’s TCN is not equal to In Process claim’s replaced TCN
AND NOT
((In Process Prescription Denial Override equals (“Vacation Supply” or “Lost Prescription” or “Therapy Change” or “Starter Dose” or “Medically Necessary”))
OR
(In Process Prior Authorization Type Indicator equals “Medical Certify”)
OR
(Medical Profile Override Indicator equals (2 or 3)))
AND
Total Days Supplied greater than Days Elapsed
AND
The Custom Record’s Refill Exempt Indicator is not equal to “Y”.
|
B
|
B
|
B
|
B
|
|
|
|
8C
|
M/I Facility ID
|
4927
|
B
|
M/I Facility ID
|
B
|
B
|
B
|
B
|
|
|
|
8E
|
M/I DUR/PPS Level Of Effort
|
4928
|
B
|
M/I DUR/PPS Level Of Effort
|
B
|
B
|
B
|
B
|
|
|
|
8E
|
M/I DUR/PPS Level Of Effort
|
4178
|
B
|
A DUR/PPS segment is present and the DUR/PPS Level Of Effort does not match one of the valid values specified for the field
|
B
|
B
|
B
|
B
|
|
|
|
81
|
Claim Too Old
|
4735
|
OH
|
AGED SUSPENDED BILL
|
B
|
B
|
B
|
B
|
|
|
|
81
|
Claim Too Old
|
4577
|
MS
|
Client Specific Edit (MS): Timely Filing Date is less than the First Date of Service
|
B
|
B
|
B
|
B
|
|
|
|
81
|
Claim Too Old
|
4184
|
B
|
If claim is older than the filing limit established on the group file; then the error is posted.
|
D
|
D
|
D
|
D
|
|
|
|
81
|
Claim Too Old
|
4180
|
C
|
The Claim is not an Adjustment via POS
AND
The claim Other Insurance Indicator is Secondary Insurance Claim (2 -3 -4)
AND
The claim COB PayerId Date is numeric and greater than zeros
AND
The claim Date Of Adjudication (Current Date) is greater than the claim COB Payerid Date plus 90 days and less than the claim COB Payerid Date plus 549 days.
|
B
|
B
|
B
|
B
|
|
|
|
81
|
Claim Too Old
|
4181
|
C
|
The Claim is not an Adjustment via POS
AND
The claim Other Coverage Code is Secondary Insurance Claim (2 -3 -4)
AND
The claim COB Payerid Date is numeric and greater than zeros
AND
The claim Date Of Adjudication (Current Date) is greater than the claim COB Payerid Date plus 548 days.
|
B
|
B
|
B
|
B
|
|
|
|
81
|
Claim Too Old
|
4182
|
C
|
The Claim is not an Adjustment via POS
AND
The claim Other Insurance Indicator is not Secondary Insurance Claim (2 -3 -4)
AND
The claim Date Of Adjudication (Current Date) is greater than the claim First Date Of Service plus 90 days and less than the claim First Date Of Service plus 366 days.
|
B
|
B
|
B
|
B
|
|
|
|
81
|
Claim Too Old
|
4183
|
C
|
The Claim is not an Adjustment via POS
AND
The claim Other Insurance Indicator is not Secondary Insurance Claim (2 -3 -4)
AND
The claim Date Of Adjudication (Current Date) is greater than the claim First Date Of Service plus 365 days.
|
B
|
B
|
B
|
B
|
|
|
|
82
|
Claim is Post Dated
|
4871
|
B
|
Claim post dated
|
D
|
D
|
D
|
D
|
|
|
|
82
|
Claim is Post Dated
|
4802
|
B
|
Date billed after adjudication date
|
D
|
D
|
D
|
D
|
|
|
|
82
|
Claim is Post Dated
|
4420
|
B
|
Batch date less than first date of service
|
D
|
D
|
D
|
D
|
|
|
|
83
|
Duplicate Paid/Captured Claim
|
4854
|
B
|
Dup Check: Searches history. If a claim with the same FDOS and 1st 5 characters of the GCN’s are equal; then dup check continues. If prior authorization is required; or the prescribing physician DEA numbers are equal; or the prior auth med cert code indicates medical certification; or the denial override is set to medically necessary; then dup check is ended; otherwise; it checks to see if a custom record exists with the dup check indicator set to “Y”; if not; if the provider numbers are equal; error “Exact Duplicate (83)” is posted; else “Possible Duplicate (83)” is posted. I f all 5 characters of the GCN are equal - checks to see if it is 94200; if so; if the therapeutic classes are different; or the drug category code = reusable/disposable syringes; or {the generic product indicator = non-drug item; and the drug class = over-the-counter and the 1st 9 chars. of the NDC are equal}; then dup check is terminated. If these conditions are not met; then the same process as for a 4-character GCN match continues at the point of determining if a custom record exists.
|
D
|
D
|
D
|
D
|
|
|
|
83
|
Duplicate Paid/Captured Claim
|
4186
|
B
|
Duplicate across providers
The history claim’s participant ID equals In Process claim’s Participant ID
AND
The history claim’s first date of service (FDOS) equals In Process claim’s FDOS
AND
The history claim’s member number equals In Process claim’s member number
AND
The history claim’s Generic Code equals In Process claim’s Generic Code
AND
The history claim’s status code equals “to be paid” or “paid”
AND
The history claim’s transaction type code equals “Original” or “Debit of Adjustment”
AND
The history claim’s document type code equals “Adjustment” or “Fee for Service (FFS)”
AND
The history claim’s TCN is not equal to In Process claim’s replaced TCN
AND
The custom plan record’s “DUP-CHECK-EXEMPT-IND” is not equal to “Y.”
AND NOT
(If in process claim is a medical supply claim (Generic Code equals 94200)
AND
((The history claim’s therapeutic class code spec is not equal to In Process claim’s therapeutic class code spec)
OR
(The Drug Record’s drug category code is equals “Reuse Syringe Insulin” (Q) or “Dispose Syringe Insulin” (R))
OR
(In Process claim’s Generic Product Indicator equals Non-Drug Item
AND
History Claim’s Generic Product Indicator equals Non-Drug Item
AND
The Drug Record’s Drug Class equals “Over the counter”
AND
The History claim’s NDC is not equal to In Process NDC )))
|
D
|
D
|
D
|
D
|
|
|
|
83
|
Duplicate Paid/Captured Claim
|
4185
|
B
|
Exact Duplicate
The history claim’s Pharmacy Provider equals In Process claim’s Pharmacy Provider
AND
The history claim’s participant ID equals In Process claim’s Participant ID
AND
The history claim’s first date of service (FDOS) equals In Process claim’s FDOS
AND
The history claim’s member number equals In Process claim’s member number
AND
The history claim’s Generic Code equals In Process claim’s Generic Code
AND
The history claim’s status code equals “to be paid” or “paid”
AND
The history claim’s transaction type code equals “Original” or “Debit of Adjustment”
AND
The history claim’s document type code equals “Adjustment” or “Fee for Service (FFS)”
|
