DUR Reject Error
4194
|
B
|
Accompanied by DUR conflict code: TD
The claim dates of service overlap: (NOT (History LDOS is less than IP FDOS and History FDOS is greater than IP LDOS)
AND((History Route Code equals IP Route Code
OR (IP Route Code equals (A or B or C or H or L or S or T or 1 or 2 or 3 or 7)
AND History Route Code equals (A or B or C or H or L or S or T or 1 or 2 or 3 or 7))
AND History Therapeutic Class Code Specific equals IP Therapeutic Class Code Specific
AND NOT (History Generic Code equals IP Generic Code
OR History NDC equals IP NDC
OR IP Generic Code equals “01697” AND History Generic Code equals “02521”
OR History NDC equals IP NDC
OR IP Generic Code equals “01698” AND History Generic Code equals “02529”)
OR History NDC equals IP NDC
OR IP Generic Code equals “92989” AND History Generic Code equals “08453”
OR IP Generic Code equals “04348” AND History Generic Code equals “08450”
OR IP Generic Code equals “92999” AND History Generic Code equals “08452”)
If the previous “NOT” condition occurs, then post the edit if one of the following conditions occurs:
IP FDOS is greater than History FDOS
AND IP Days Supplied is greater than DUR Grace Period
AND IP FDOS is greater than (History FDOS plus History Days Supplied minus DUR Grace Period)
OR NOT (IP FDOS is greater than History FDOS
AND IP Days Supplied is greater than DUR Grace Period)
AND History Days Supplied is greater than DUR Grace Period AND History FDOS is less than (IP FDOS plus IP Days Supplied minus DUR Grace Period)
|
P
|
P
|
P
|
P
|
|
|
|
88
|
DUR Reject Error
|
4197
|
B
|
Client Specific (IN) Accompanied by DUR conflict code: DD Drug/Drug Interactions with a Severity Level of 1; require Prior Authorization from Health Care Excel 800-457-4518
The claim dates of service overlap
AND The History NDC found on Drug Record
AND NOT ((History Generic Code equals IP Generic Code
OR History NDC equals IP NDC
OR IP Generic Code equals “01697” AND History Generic Code equals “02521”)
OR IP Generic Code equals “01698” AND History Generic Code equals “02529”
OR IP Generic Code equals “92989” AND History Generic Code equals “08453”
OR IP Generic Code equals “04348” AND History Generic Code equals “08450”
OR IP Generic Code equals “92999” AND History Generic Code equals “08452”)
AND The number of drug interactions on each drug record must be greater than zero
AND The sum of any two interaction codes (1 from the current record and 1 from the history record) must be 32000
AND The History Generic Sequence Number is equal to any Override Add Generic Sequence Number listed on the Drug Interaction Override Record.
Note: the edit is overridden and not posted if any Drug Interaction Code on the History Drug Record is equal to any Drug Interaction Code on the Drug Interaction Override Record
AND The severity level equals 1
AND The history pharmacy provider is not equal to the IP pharmacy provider, then post reject 75.
|
P
|
P
|
P
|
P
|
|
|
|
88
|
DUR Reject Error
|
4839
|
B
|
Accompanied by DUR conflict code for DC (Disease precaution) sent in DUR segment
|
B
|
B
|
B
|
B
|
|
|
|
88
|
DUR Reject Error
|
4199
|
B
|
Age Exception
(History FDOS is greater than IP FDOS
OR
After processing through all of history claims)
AND
The IP participant is older than the maximum age on the drug record.
AND
The IP participant is younger than the minimum age on the Drug Record
AND
Default values of all zeros or all nines on the Drug Record will prevent an age exception from posting
|
P
|
P
|
P
|
P
|
|
|
|
88
|
DUR Reject Error
|
4195
|
B
|
Prenatal Exception
(History FDOS is greater than IP FDOS
OR
After processing through all of history claims)
AND
IP Participant Sex Code equals “Female”
AND
IP Therapeutic Class Code Specific equals “Pre-Natal Vitamins”
AND
IP Participant Age is greater than 11 and IP Participant Age is less than 60
|
P
|
P
|
P
|
P
|
|
|
|
88
|
DUR Reject Error
|
4196
|
B
|
Excessive Duration Exception
This edit is posted after accumulating the Total Number of Days Supplied for all History claims and adding the IP Days Supply to the total when:
The IP Participant is younger than 13
AND
The pediatric duration of therapy maximum number of days on the Drug Record using the IP NDC is less than the Total Number of Days Supplied
OR
The IP Participant is older than 60
OR
The Geriatric Duration of Therapy Maximum Number of Days on the Drug Record using the IP NDC is less than the Total Number of Days Supplied
AND
The IP Participant is any other age
AND
The Adult Duration of Therapy Maximum Number of Days on the Drug Record Using the IP NDC is less than the Total Number of Days Supplied
|
P
|
P
|
P
|
P
|
|
|
|
88
|
DUR Reject Error
|
4198
|
B
|
Ingredient Duplication
First date of service on the current claim must be after the first date of service on the history claim.
AND
First date of service on the current claim must be before the date calculated to be the history claim’s first date of service plus days supplied less the grace period.
AND
The claim dates of service overlap
AND
(History Route Code equals IP Route Code
OR
(IP Route Code equals (A or B or C or H or L or S or T or 1 or 2 or 3 or 7)
AND
History Rout Code equals (A or B or C or H or L or S or T or 1 or 2 or 3 or 7))
AND
The History NDC found on Drug Record
AND NOT
(History Generic Code equals IP Generic Code
OR
History NDC equals IP NDC
OR
IP Generic Code equals “01697” AND History Generic Code equals “02521”
OR
History NDC equals IP NDC
OR
IP Generic Code equals “01698” AND History Generic Code equals “02529”
OR
History NDC equals IP NDC
OR
IP Generic Code equals “92989” AND History Generic Code equals “08453”
OR
IP Generic Code equals “04348” AND History Generic Code equals “08450”
OR
IP Generic Code equals “92999” AND History Generic Code equals “08452”)
AND
The route codes must be the same or they must both be systemic route
(History Route Code equals IP Route Code
OR
(IP Route Code equals (A or B or C or H or L or S or T or 1 or 2 or 3 or 7)
AND
History Rout Code equals (A or B or C or H or L or S or T or 1 or 2 or 3 or 7)))
AND
Specific therapeutic class must be the same. Any Therapeutic Class Code Specific on the Drug Record from the IP NDC is equal to any Therapeutic Class Code specific on the Drug Record from the History NDC.
|
P
|
P
|
P
|
P
|
|
|
|
88
|
DUR Reject Error
|
4200
|
B
|
Gender Exception
(History FDOS is greater than IP FDOS
OR
After processing through all of history claims)
AND
IP Participant’s sex code (‘M’ or ‘F’) must match the sex code on the Drug Record
|
P
|
P
|
P
|
P
|
|
|
|
88
|
DUR Reject Error
|
4201
|
B
|
Low Dose Exception
(History FDOS is greater than IP FDOS
OR
After processing through all of history claims)
AND
The Dose Form on the Drug Record from the IP NDC must equal ‘each’ or ‘milliliter’
AND
IP Participant must be at least 18 years old and not older than 60 years
AND
Calculated Daily Dose must be less than the Minimum Daily Dose on the Drug Record
|
P
|
P
|
P
|
P
|
|
|
|
88
|
DUR Reject Error
|
4203
|
B
|
Allergy Exception
(History FDOS is greater than IP FDOS
OR
After processing through all of history claims)
AND
The IP Participant must have a prior authorization
AND
The condition type on the prior authorization table must be set to ‘AC‘
AND
One of the Condition Range fields on the prior authorization table must match one of the three Allergy Codes on the Drug Record for the IP NDC.
|
B
|
B
|
B
|
B
|
|
|
|
88
|
DUR Reject Error
|
4204
|
B
|
– Pregnancy Exception
(History FDOS is greater than IP FDOS
OR
After processing through all of history claims)
AND
Pregnancy precaution codes must be present on the Drug Record for the IP NDC
AND
The IP Participant may have a prior authorization table with pregnancy flagged on it
AND
The pregnancy indicator on the prior authorization table must be set to ‘Y’
AND
The pregnancy end date must be greater than or equal to the first date of service on the current claim
AND
(The severity level of the pregnancy precaution master file for the pregnancy precaution code on the Drug Record for the IP NDC must be a ‘D’ - ‘X’ - or ‘1’)
|
P
|
P
|
P
|
P
|
|
|
|
88
|
DUR Reject Error
|
4431
|
B
|
DUR Reject Deny
Edit 88 from the DUR Program has been posted and the conflict code exists on the DUR Filter Record
AND
Generic code or Therapeutic Class Code Specific (From the history or IP claim - depending on the 88 exception that was posted) is on the DUR Filter Record
AND
The Adjudication Indicator on the DUR Filter Record is equal to “Deny”
AND
If the history claim is being processed for DUR
AND
(History Participant Age is less than the Minimum Age on the DUR Filter Record
OR
History Participant Age is greater than the Max Age on the DUR Filter Record
OR
History Day Supplied is greater than Days Supplied on the DUR Filter Record
OR
IP Submitted Quantity / IP Days Supplied is greater than Max Daily Dose Units on the DUR Filter Record)
|
B
|
B
|
B
|
B
|
|
|
|
88
|
DUR Reject Error
|
4432
|
|
Claim failed a Pro-DUR alert
|
B
|
B
|
B
|
B
|
|
|
|
89
|
Rejected Claim Fees Paid
|
4776
|
|
Rejected Claim Fees Paid
|
B
|
B
|
B
|
B
|
|
|
|
90
|
Host Hung Up
|
4777
|
B
|
Host Hung Up
|
B
|
B
|
B
|
B
|
|
|
|
91
|
Host Response Error
|
4778
|
B
|
Host Response Error
|
B
|
B
|
B
|
B
|
|
|
|
92
|
System Unavailable/Host Unavailable
|
4779
|
B
|
System Unavailable/Host Unavailable
|
D
|
D
|
D
|
D
|
|
|
|
93
|
Planned Unavailable
|
4780
|
B
|
Planned Unavailable
|
B
|
B
|
B
|
B
|
|
|
|
94
|
Invalid Message
|
4781
|
B
|
Invalid Message
|
B
|
B
|
B
|
B
|
|
|
|
95
|
Time Out
|
4782
|
B
|
Time Out
|
D
|
D
|
D
|
D
|
|
|
|
96
|
Scheduled Downtime
|
4783
|
B
|
Scheduled Downtime
|
D
|
D
|
D
|
D
|
|
|
|
97
|
Payer Unavailable
|
4784
|
B
|
Payer Unavailable
|
B
|
B
|
B
|
B
|
|
|
|
98
|
Connection to Payer is Down
|
4785
|
B
|
Connection to Payer is Down
|
B
|
B
|
B
|
B
|
|
|
|
99
|
Host Processing Error
|
4786
|
B
|
Host Processing Error
|
B
|
B
|
B
|
B
|
|
|
|
AA
|
Patient Spenddown Not Met
|
4929
|
B
|
Patient Spenddown Not Met
|
B
|
B
|
B
|
B
|
|
|
|
AB
|
Date Written Is After Date Filled
|
4206
|
B
|
The Date Prescription Written is greater than the Date Of Service.
|
D
|
D
|
D
|
D
|
|
|
|
AC
|
Product Not Covered Non-Participating Manufacturer
|
4683
|
B
|
THE PRODUCT/SERVICE ID QUALIFIER INDICATES THAT THE PRODUCT/SERVICE ID FIELD CONTAINS AN 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
**5.1 edit only - see 4684 for equivalent 3.2 edit**
|
D
|
D
|
D
|
D
|
|
|
|
AC
|
Product Not Covered Non-Participating Manufacturer
|
4207
|
B
|
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’)
|
B
|
B
|
B
|
B
|
|
|
|
AD
|
Billing Provider Not Eligible To Bill This Claim Type
|
4930
|
B
|
Billing Provider Not Eligible To Bill This Claim Type
|
B
|
B
|
B
|
B
|
|
|
|
AE
|
QMB (Qualified Medicare Beneficiary)-Bill Medicare
|
4931
|
B
|
QMB (Qualified Medicare Beneficiary)-Bill Medicare
|
B
|
B
|
B
|
B
|
|
|
|
AF
|
Patient Enrolled Under Managed Care
|
4208
|
B
|
Patient Enrolled Under Managed Care
|
B
|
B
|
B
|
B
|
|
|
|
AG
|
Days Supply Limitation For Product/Service
|
4209
|
B
|
Exceeds Custom Days Supplied Limits – 5.1 Only
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
|
|
|
|
AH
|
Unit Dose Packaging Only Payable For Nursing Home Recipients
|
4932
|
B
|
Unit Dose Packaging Only Payable For Nursing Home Recipients
|
D
|
D
|
D
|
D
|
|
|
|
AJ
|
Generic Drug Required
|
4210
|
B
|
Generic Drug Required
|
B
|
B
|
B
|
B
|
|
|
|
AK
|
M/I Software Vendor/Certification ID
|
4211
|
B
|
The Software Vendor/Certification ID is missing (spaces).
|
B
|
B
|
B
|
B
|
|
|
|
AM
|
M/I Segment Identification
|
4212
|
B
|
The segment is a mandatory segment and the segment Identifier is missing (spaces) or it does not match one of the valid values specified for the field
|
D
|
D
|
D
|
D
|
|
|
|
A9
|
M/I Transaction Count
|
4213
|
B
|
The Transaction Count is missing (spaces) or it does not match one of the valid values specified for the field.
|
D
|
D
|
D
|
D
|
|
|
|
BE
|
M/I Professional Service Fee Submitted
|
4214
|
B
|
The product/service Id qualifier is not NDC and the professional service fee submitted is missing (zeros).
|
D
|
D
|
D
|
D
|
|
|
|
B2
|
M/I Service Provider ID Qualifier
|
4215
|
B
|
The Service Provider ID Qualifier is missing (spaces) or it does not match one of the valid values specified for the field.
|
D
|
D
|
D
|
D
|
|
|
|
CA
|
M/I Patient's First Name
|
4787
|
B
|
Client Specific (IN) First name not edited separately. If the first name is missing on the claim; system returns COB 0238. This edit has been mapped to CB; M/I Patient’s Last name.
|
B
|
B
|
B
|
B
|
|
|
|
CB
|
M/I Patient's Last Name
|
4789
|
B
|
Member name missing
|
B
|
B
|
B
|
B
|
|
|
|
CC
|
M/I CARDHOLDER FIRST NAME
|
4216
|
|
M/I CARDHOLDER FIRST NAME
|
B
|
B
|
B
|
B
|
|
|
|
CD
|
M/I CARDHOLDER LAST NAME
|
4217
|
|
M/I CARDHOLDER LAST NAME
|
B
|
B
|
B
|
B
|
|
|
|
CE
|
HOME PLAN
|
4890
|
|
HOME PLAN
|
B
|
B
|
B
|
B
|
|
|
|
CF
|
EMPLOYER NAME
|
4891
|
|
EMPLOYER NAME
|
B
|
B
|
B
|
B
|
|
|
|
CG
|
EMPLOYER STREET ADDRESS
|
4892
|
|
EMPLOYER STREET ADDRESS
|
B
|
B
|
B
|
B
|
|
|
|
CH
|
EMPLOYER CITY ADDRESS
|
4893
|
|
EMPLOYER CITY ADDRESS
|
B
|
B
|
B
|
B
|
|
|
|
CI
|
EMPLOYER STATE/PROVINCE ADDRESS
|
4894
|
|
EMPLOYER STATE/PROVINCE ADDRESS
|
B
|
B
|
B
|
B
|
|
|
|
CJ
|
EMPLOYER ZIP/POSTAL ZONE
|
4895
|
|
EMPLOYER ZIP/POSTAL ZONE
|
B
|
B
|
B
|
B
|
|
|
|
CK
|
EMPLOYER PHONE NUMBER
|
4896
|
|
EMPLOYER PHONE NUMBER
|
B
|
B
|
B
|
B
|
|
|
|
CL
|
EMPLOYER CONTACT NAME
|
4897
|
|
EMPLOYER CONTACT NAME
|
B
|
B
|
B
|
B
|
|
|
|
CM
|
PATIENT STREET ADDRESS
|
4898
|
|
PATIENT STREET ADDRESS
|
B
|
B
|
B
|
B
|
|
|
|
CN
|
PATIENT CITY ADDRESS
|
4912
|
|
PATIENT CITY ADDRESS
|
B
|
B
|
B
|
B
|
|
|
|
CO
|
PATIENT STATE/PROVINCE ADDRESS
|
4900
|
|
PATIENT STATE/PROVINCE ADDRESS
|
B
|
B
|
B
|
B
|
|
|
|
CP
|
PATIENT ZIP / POSTAL ZONE
|
4901
|
|
PATIENT ZIP / POSTAL ZONE
|
B
|
B
|
B
|
B
|
|
|
|
CQ
|
PATIENT PHONE NUMBER
|
4902
|
|
PATIENT PHONE NUMBER
|
B
|
B
|
B
|
B
|
|
|
|
CR
|
CARRIER ID
|
4903
|
B
|
CARRIER ID
|
D
|
D
|
D
|
D
|
|
|
|
CW
|
M/I Alternate ID
|
4218
|
B
|
The Alternate ID is missing (spaces).
|
B
|
B
|
B
|
B
|
|
|
|
CX
|
M/I Patient ID Qualifier
|
4219
|
B
|
The Patient ID Qualifier is missing (spaces) or it does not match one of the valid values specified for the field.
|
B
|
B
|
B
|
B
|
|
|
|
CY
|
M/I Patient ID
|
4220
|
B
|
The Patient ID is missing (spaces).
|
B
|
B
|
B
|
B
|
|
|
|
CZ
|
M/I Employer ID
|
4221
|
B
|
The Employer ID is missing (spaces).
|
B
|
B
|
B
|
B
|
|
|
|
DC
|
Dispensing Fee Submitted
|
4222
|
B
|
The Dispensing Fee Submitted is missing (zeros).
|
B
|
B
|
B
|
B
|
|
|
|
DN
|
M/I Basis Of Cost Determination
|
4223
|
B
|
The Basis Of Cost Determination is missing (spaces) or it does not match one of the valid values specified for the field.
|
B
|
B
|
B
|
B
|
|
|
|
DQ
|
M/I Usual & Customary Charge
|
4790
|
B
|
M/I Usual & Customary Charge
|
D
|
D
|
D
|
D
|
|
|
|
DQ
|
M/I Usual & Customary Charge
|
4872
|
B
|
Edit will check for both MISSING and INVALID conditions
|
B
|
B
|
B
|
B
|
|
|
|
DQ
|
M/I Usual & Customary Charge
|
4844
|
B
|
Claim priced at zero
|
B
|
B
|
B
|
B
|
|
|
|
DQ
|
M/I Usual & Customary Charge
|
4917
|
B
|
M/I Usual & Customary Charge
|
B
|
B
|
B
|
B
|
|
|
|
DR
|
M/I DOCTORS LAST NAME
|
4225
|
B
|
M/I DOCTORS LAST NAME
|
B
|
B
|
B
|
B
|
|
|
|
DT
|
M/I UNIT DOSE INDICATOR
|
4568
|
B / FL
|
If the unit dose indicator on the drug file is set to manufacturer packaging and a unit dose indicator is submitted on the claim; then the error posts.
|
B
|
B
|
B
|
B
|
|
|
|
DT
|
M/I UNIT DOSE INDICATOR
|
4226
|
B
|
The Unit Dose Indicator is missing or it does not match one of the valid values specified for the field.
|
B
|
B
|
B
|
B
|
|
|
|
DU
|
M/I GROSS AMOUNT DUE
|
4227
|
B
|
Client Specific (NM) The Gross Amount Due is missing (zeros).
|
B
|
B
|
B
|
B
|
|
|
|
DV
|
M/I Other Payer Amount Paid
|
4855
|
B
|
If the other insurance indicator = 3 or 4; and the primary payer date not numeric or not > zeroes or the other amount is not equal to zeroes; then the error is posted.
|
D
|
D
|
D
|
D
|
|
|
|
DV
|
M/I Other Payer Amount Paid
|
4229
|
B
|
Missing Deny Date
(If the Other Coverage Code is “3” (other coverage exists - This claim not covered) OR
“4” (other coverage exists - Payment not collected))
AND
The payerid date is not numeric
OR
The payerid date is not greater than zeros
OR
The payerid paid amount is greater than zeros.
|
D
|
D
|
D
|
D
|
|
|
|
DV
|
M/I Other Payer Amount Paid
|
4959
|
|
Edit needed to create additinoal reports for PA Subsystem (CSR 14).
|
B
|
B
|
B
|
B
|
|
|
|
DV
|
M/I Other Payer Amount Paid
|
4231
|
C
|
If the Other Coverage Code is 2 (Other Coverage Exists – Payment Collected)
AND
The payerid paid amount is missing (zero).
OR
If the Other Coverage Code is ‘0’ (Not specified) OR ‘1’ (No other coverage identified) ‘3’ (Other coverage exists - this clam not covered) OR ‘4’ (Other coverage exists - payment not collected)
AND
The payerid paid amount is greater than zero.
|
D
|
D
|
D
|
D
|
|
|
|
DX
|
M/I Patient Paid Amount Submitted
|
4233
|
B
|
The Patient Paid Amount Submitted not numeric
OR
Patient Paid Amount Submitted is numeric and is greater than $0.00 and less than $2.00
|
B
|
B
|
B
|
B
|
|
|
|
DY
|
INJURY DATE
|
4234
|
B
|
The claim is a workers compensation claim and the Date Of Injury is missing (zeros).
|
B
|
B
|
B
|
B
|
|
|
|
DZ
|
CLAIM / REFERENCE ID
|
4235
|
B
|
The claim is a workers compensation claim and the Claim/Reference ID is missing (spaces).
|
B
|
B
|
B
|
B
|
|
|
|
EA
|
M/I Originally Prescribed Product/Service Code
|
4933
|
B
|
M/I Originally Prescribed Product/Service Code
|
D
|
D
|
D
|
D
|
|
|
|
EB
|
M/I Originally Prescribed Quantity
|
4934
|
B
|
M/I Originally Prescribed Quantity
|
D
|
D
|
D
|
D
|
|
|
|
EC
|
Compound Ing Component Count
|
4236
|
B
|
A compound segment is present and the Compound Ingredient Component Count is zeros.
|
D
|
D
|
D
|
D
|
|
|
|
ED
|
Compound Ing Quantity
|
4237
|
B
|
The Compound Ingredient Quantity is missing (zeros).
|
D
|
D
|
D
|
D
|
|
|
|
EE
|
M/I Compound Ingredient Drug Cost
|
4238
|
B
|
The Ingredient Drug Cost is missing (zeros).
|
B
|
B
|
B
|
B
|
|
|
|
EF
|
M/I Compound Dosage Form Description Code
|
4935
|
B
|
The Compound Dosage Form Description Code does not match one of the NCPDP Valid Values
|
D
|
D
|
D
|
D
|
|
|
|
EG
|
M/I Compound Dispensing Unit Form Indicator
|
4936
|
B
|
The Compound Dosage Form Description Code does not match values of 1-18.
|
D
|
D
|
D
|
D
|
|
|
|
EH
|
Compound Route of Administration
|
4937
|
B
|
The Compound Dispensing Unit Form Indicator does not match one of the NCPDP Valid Values
|
D
|
D
|
D
|
D
|
|
|
|
EJ
|
M/I Originally Prescribed Product/Service Id Qualifier
|
4938
|
B
|
M/I Originally Prescribed Product/Service Id Qualifier
|
D
|
D
|
D
|
D
|
|
|
|
EK
|
Scheduled Prescription ID Number
|
4939
|
B
|
Scheduled Prescription ID Number
|
B
|
B
|
B
|
B
|
|
|
|
EM
|
M/I Prescription/Service Reference Number Qualifier
|
4239
|
B
|
The Prescription/Service Reference Number Qualifier does not match one of the valid values specified for the field.
|
D
|
D
|
D
|
D
|
|
|
|
EN
|
M/I Associated Prescription/Service Reference Number
|
4240
|
B
|
The Associated Prescription/Service Reference Number is missing (zeros) on a reversal for a completion transaction.
Used for Partial Fills
When dispensing a partial fill, the Dispensing Status code is submitted to indicate the transaction is for an “initial” partial fill. When the “outstanding” quantity is dispensed, the transaction 1) indicates the Dispensing Status code is for the “completion” of the partial fill; 2) identifies the Associated Prescription/Service Reference Number; and 3) identifies the Associated Prescription/Service Date.
|
D
|
D
|
D
|
D
|
|
|
|
EP
|
M/I Associated Prescription/Service Date
|
4241
|
B
|
The Associated Prescription/Service Date is missing (zeros) on the reversal of a completion transaction
Used for Partial Fills
|
D
|
D
|
D
|
D
|
|
|
|
ER
|
M/I Procedure Modifier Code
|
4242
|
B
|
The Procedure Modifier Code is missing (spaces).
|
B
|
B
|
B
|
B
|
|
|
|
ET
|
M/I Quantity Prescribed
|
4243
|
B
|
The Quantity Prescribed is missing (zeros).
|
D
|
D
|
D
|
D
|
|
|
|
EU
|
M/I Prior Authorization Type Code
|
4244
|
B
|
The Prior Authorization Type Code does not match one of the valid values specified for the field (see below)
OR
The Prior Authorization type code is missing and the Prior Authorization number is present.
Edits 30 (m/i pa/mc code and number) and 57 (pa/mc#) are not supported in 5.1. The corresponding 5.1 edits are EU (m/i pa type code - 1 byte) and EV (m/i pa number submitted - 11 bytes )
valid values
Ø=Not Specified1=Prior Authorization
2=Medical Certification
3=EPSDT (Early Periodic Screening Diagnosis Treatment)
4=Exemption from Copay
5=Exemption from RX
6=Family Plan. Indic.
7=AFDC (Aid to Families with Dependent Children)
8=Payer Defined Exemption
|
D
|
D
|
D
|
D
|
|
|
|
EU
|
M/I Prior Authorization Type Code
|
4584
|
B
|
IN Medicaid: valid values = 0 or 6 - family planning (pregnancy indicator now uses field 2C)
|
B
|
B
|
B
|
B
|
|
|
|
EV
|
M/I Prior Authorization Number Submitted
|
4245
|
B
|
The Prior Authorization Number Submitted is missing and the prior authorization type code equals ‘PA’.
|
B
|
B
|
B
|
B
|
|
|
|
EW
|
M/I Intermediary Authorization Type ID
|
4940
|
B
|
M/I Intermediary Authorization Type ID
|
B
|
B
|
B
|
B
|
|
|
|
EX
|
M/I Intermediary Authorization ID
|
4941
|
B
|
M/I Intermediary Authorization ID
|
B
|
B
|
B
|
B
|
|
|
|
EY
|
M/I Provider ID Qualifier
|
4246
|
B
|
The Pharmacy Provider ID Qualifier is missing or it does not match one of the valid values specified for the field
OR
The Pharmacy Provider Id Qualifier is missing and the Pharmacy Provider Id is present.
This field is used in the Pharmacy Provider Segment which we aren't using (unless there's a bus. case for it). The pharmacy id is contained in the Transaction Header Segment, field 201-B1 qualified by 202-B2 (Ø7=NCPDP Provider ID). So, the edit can probably be set to Ignore.
|
B
|
B
|
B
|
B
|
|
|
|
EZ
|
M/I Prescriber ID Qualifier
|
4247
|
B
|
The Prescriber ID Qualifier is missing and a prescriber id exists
OR
or it does not match one of the valid values specified for the field
|
D
|
D
|
D
|
D
|
|
|
|
E1
|
M/I Product/Service ID Qualifier
|
4248
|
B
|
The Product/Service ID Qualifier is missing or it does not match one of the valid values specified for the field.
|
D
|
D
|
D
|
D
|
|
|
|
E3
|
M/I Incentive Amount Submitted
|
4249
|
B
|
The Incentive Amount Submitted is present but is not numeric.
|
B
|
B
|
B
|
B
|
|
|
|
E4
|
M/I Reason for Service Code
|
4250
|
B
|
The Reason For Service Code(DUR Conflict) is present and does not match one of the valid values specified for the field
|
D
|
D
|
D
|
D
|
|
|
|
E4
|
M/I Reason for Service Code
|
4251
|
B
|
A Reason For Service Code does not match one of the valid values specified for the field.
|
B
|
B
|
B
|
B
|
|
|
|
E4
|
M/I Reason for Service Code
|
4430
|
B
|
DUR Override Conflict
The reason for service is missing and the DUR intervene code or DUR outcome code is present.
|
D
|
D
|
D
|
D
|
|
|
|
E5
|
M/I Professional Service Code
|
4252
|
B
|
The Professional Service Code(DUR Intervene Code) is present and does not match one of the valid values specified for the field
OR
The professional service code is missing and the DUR conflict code or DUR outcome code is present.
|
D
|
D
|
D
|
D
|
|
|
|
E5
|
M/I Professional Service Code
|
4253
|
B
|
Client Specific (MA) The Professional Service Code is missing (spaces) or it does not match one of the valid values specified for the field.
|
B
|
B
|
B
|
B
|
|
|
|
E6
|
M/I Result of Service Code
|
4254
|
B
|
Client Specific (IN) The Result of Service Code(DUR Outcome) is present and does not match one of the valid values specified for the field
OR
The result of service code is missing and the DUR intervene code or DUR conflict code is present.
|
D
|
D
|
D
|
D
|
|
|
|
E6
|
M/I Result of Service Code
|
4255
|
B
|
Client Specific (MA) The Result Of Service Code is missing (spaces) or it does not match one of the valid values specified for the field.
DUR Outcome Code was rename to Result Of Service Code in Version 5.1.
|
B
|
B
|
B
|
B
|
|
|
|
E7
|
M/I Quantity Dispensed
|
4873
|
B
|
Edit will check for both MISSING and INVALID conditions
|
D
|
D
|
D
|
D
|
|
|
|
E7
|
M/I Quantity Dispensed
|
4847
|
C
|
quant > estimd price by 800%
|
B
|
B
|
B
|
B
|
|
|
|
E7
|
M/I Quantity Dispensed
|
4256
|
X
|
The Quantity Dispensed is missing (zeros).
|
D
|
D
|
D
|
D
|
|
|
|
E8
|
M/I Other Payer Date
|
4257
|
B
|
If the carrier is found on the carrier table
AND
The Other Payerid Date is greater than 0001-01-01
AND
The Other Payerid Date is not greater than the batch Julian date portion of the transaction control number (TCN).
Primary Deny Date has been renamed Other Payer Date.
|
D
|
D
|
D
|
D
|
|
|
|
E8
|
M/I Other Payer Date
|
4258
|
B
|
Invalid Other Payerid Date – 5.1 Only
If the other payerid date is greater than 0001-01-01
AND
The other payerid date is greater than the batch Julian date portion of the transaction control number (TCN).
|
D
|
D
|
D
|
D
|
|
|
|
E8
|
M/I Other Payer Date
|
4259
|
B
|
Other payer date – If other insurance indicator = 0 or 1 and primary payer deny date is numeric and > zero; or other amount is not equal to zero; error is posted.
|
D
|
D
|
D
|
D
|
|
|
|
E8
|
M/I Other Payer Date
|
4261
|
|
