B
B
|
|
|
|
PM
|
M/I Pharmacy Provider Segment
|
4314
|
B
|
Pharmacy Provider Segment Invalid With Reversal Request – 5.1 Only
A Pharmacy Provider segment was received with a Reversal request.
|
B
|
B
|
B
|
B
|
|
|
|
PN
|
M/I Prescriber Segment
|
4315
|
B
|
M/I Prescriber Segment
|
D
|
D
|
D
|
D
|
|
|
|
PN
|
M/I Prescriber Segment
|
4316
|
B
|
Prescriber Segment Invalid With Request Type - 5.1 Only
A Prescriber segment was received with an Eligibility or a Reversal request.
|
D
|
D
|
D
|
D
|
|
|
|
PP
|
M/I Pricing Segment
|
4317
|
B
|
Pricing Segment Invalid With Eligibility Request - A Pricing segment was received with an Eligibility request.
Pricing segment only allowed with Billing (B1), Rebill (B3) and PA Req & Billing (P1)
|
D
|
D
|
D
|
D
|
|
|
|
PP
|
M/I Pricing Segment
|
4318
|
B
|
M/I Pricing Segment
|
D
|
D
|
D
|
D
|
|
|
|
PR
|
M/I Prior Authorization Segment
|
4319
|
B
|
M/I Prior Authorization Segment
|
B
|
B
|
B
|
B
|
|
|
|
PR
|
M/I Prior Authorization Segment
|
4320
|
B
|
Prior Authorization Segment Invalid With Request Type – 5.1 Only
A Prior Authorization segment was received with an Eligibility or a Reversal request.
|
B
|
B
|
B
|
B
|
|
|
|
PS
|
M/I Transaction Header Segment
|
4321
|
B
|
Missing Mandatory Transaction Header Segment – 5.1 Only
An Eligibility - Billing - Reversal - or Re-bill request was received without a mandatory Transaction Header segment.
|
D
|
D
|
D
|
D
|
|
|
|
PS
|
M/I Transaction Header Segment
|
4322
|
B
|
Exception code deleted and replace with 4321
Nashville comment:
Is this necessary since this is a mandatory segment and all the fields on the segment have their own edits?
|
D
|
D
|
D
|
D
|
|
|
|
PT
|
M/I Workers’ Compensation Segment
|
4323
|
B
|
A Workers’ Compensation segment was received with an Eligibility or a Reversal request.
Duplicate edit of 4324 (below)
|
B
|
B
|
B
|
B
|
|
|
|
PT
|
M/I Workers’ Compensation Segment
|
4324
|
B
|
Workers’ Compensation Segment Invalid With Request Type – 5.1 Only
A Workers’ Compensation segment was received with an Eligibility or a Reversal request.
A Work's Comp segment is not allowed in an elig or reversal transaction
|
B
|
B
|
B
|
B
|
|
|
|
PV
|
Non-Matched Associated Prescription/Service Date
|
4325
|
B
|
Associated Prescription/Service Date Does Not Match DOS - 5.1 Only
The Associated Prescription/Service Date on a Claim segment with a Dispensing Status of “C” (completion fill) did not match the Date Of Service on the matching partial fill transaction.
|
D
|
D
|
D
|
D
|
|
|
|
PW
|
Non-Matched Employer ID
|
4946
|
B
|
Non-Matched Employer ID
|
B
|
B
|
B
|
B
|
|
|
|
PX
|
Non-Matched Other Payer ID
|
4947
|
B
|
Non-Matched Other Payer ID
|
B
|
B
|
B
|
B
|
|
|
|
PY
|
Non-Matched Unit Form/Route of Administration
|
4948
|
B
|
Non-Matched Unit Form/Route of Administration
|
B
|
B
|
B
|
B
|
|
|
|
PZ
|
Non-Matched Unit Of Measure To Product/Service ID
|
4949
|
B
|
Non-Matched Unit Of Measure To Product/Service ID
|
B
|
B
|
B
|
B
|
|
|
|
P1
|
Associated Prescription/Service Reference Number Not Found
|
4326
|
B
|
The Associated Prescription/Service Reference Number on a Claim segment with a Dispensing Status of “C” (completion fill) did not match the Reference Number on the matching partial fill transaction
|
D
|
D
|
D
|
D
|
|
|
|
P2
|
Clinical Information Counter Out Of Sequence
|
4327
|
B
|
The Clinical segments were not received in the correct numerical sequence.
|
B
|
B
|
B
|
B
|
|
|
|
P3
|
Compound Ingredient Component Count Does Not Match Number Of Repetitions
|
4328
|
B
|
The Compound Ingredient Component Count does not match the number of Compound Product ID’s received on a Compound segment.
|
B
|
D
|
B
|
B
|
|
|
|
P4
|
Coordination Of Benefits/Other Payments Count Does Not Match Number Of Repetitions
|
4329
|
B
|
The Coordination Of Benefits/Other Payments Count does not match the number of COB/Other Payment segments received.
|
D
|
D
|
D
|
D
|
|
|
|
P5
|
Coupon Expired
|
4950
|
B
|
Coupon Expired
|
B
|
B
|
B
|
B
|
|
|
|
P6
|
Date Of Service Prior To Date Of Birth
|
4330
|
B
|
DOS Less Than DOB – 5.1 Only
The claim Date Of Service is less than the claim Date Of Birth.
|
D
|
D
|
D
|
D
|
|
|
|
P7
|
Diagnosis Code Count Does Not Match Number Of Repetitions
|
4331
|
B
|
The Diagnosis Code Count does not match the number of Diagnosis Codes on a Clinical segment.
|
B
|
B
|
B
|
B
|
|
|
|
P8
|
DUR/PPS Code Counter Out Of Sequence
|
4332
|
B
|
The sets of DUR/PPS information were received out of numerical sequence.
This error is returned when the DUR/PPS Segment in the inquiry contains an out of sequence DUR/PPS Code Counter. In other words, the data elements in the DUR/PPS Segment can be repeated several times and with each repitition, the counter field should increment by 1, so if you got a series of loops with the counter = 1, 3, 2 vs. 1, 2, 3 then you'd get this error. There's an example on pg 7-24 of the 5.1 Implementation Guide as well as a decription of the DUR/PPS Segment on page 4-4.
|
D
|
D
|
D
|
D
|
|
|
|
P9
|
Field Is Non-Repeatable
|
4333
|
B
|
Error returned when non-repeatable field is repeated.
|
B
|
B
|
B
|
B
|
|
|
|
RA
|
PA Reversal Out Of Order
|
4951
|
B
|
PA Reversal Out Of Order
|
D
|
D
|
D
|
D
|
|
|
|
RB
|
Multiple Partials Not Allowed
|
4334
|
B
|
More than one partial fill transactions were received for the same Prescription/Service ID.
|
D
|
D
|
D
|
D
|
|
|
|
RC
|
Different Drug Entity Between Partial & Completion
|
4335
|
B
|
The Product/Service ID and/or Qualifier on the completion transaction (Dispensing Status of “C”) does not match the Product/Service ID and/or Qualifier on the associated partial fill transaction (Dispensing Status of “P”).
|
D
|
D
|
D
|
D
|
|
|
|
RD
|
Mismatched Cardholder/Group ID-Partial To Completion
|
4336
|
B
|
The member ID and the Group ID on the Insurance segment of a completion transaction (Dispensing Status of “C”) does not match the member ID and Group ID on the Insurance segment of the associated partial fill transaction (Dispensing Status of “P”).
|
D
|
D
|
D
|
D
|
|
|
|
RE
|
M/I Compound Product ID Qualifier
|
4337
|
B
|
The Compound Product ID Qualifier is missing (spaces) or it does not match one of the valid values specified for the field.
|
D
|
D
|
D
|
D
|
|
|
|
RF
|
Improper Order Of ‘Dispensing Status’ Code On Partial Fill Transaction
|
4338
|
B
|
Completion With No Partial – 5.1 Only
A Claim segment with a Dispensing Status of “C” was received but no matching partial fill transaction (Dispensing Status of “P”) could be found
|
D
|
D
|
D
|
D
|
|
|
|
RG
|
M/I Associated Prescription/service Reference Number On Completion Transaction
|
4339
|
B
|
The Associated Prescription/Service Reference Number on a claim segment with a Dispensing Status of “C” is missing (zeros).
|
D
|
D
|
D
|
D
|
|
|
|
RH
|
M/I Associated Prescription/Service Date On Completion Transaction
|
4340
|
B
|
The Associated Prescription/Service Date on a Claim segment with a Dispensing Status of “C” is missing (zeros) or it is not a valid date.
|
D
|
D
|
D
|
D
|
|
|
|
RH
|
M/I Associated Prescription/Service Date On Completion Transaction
|
4417
|
B
|
Partial and Completion not Allowed on Same Day 5.1 Only
First Date of Service equal Associated Prescription/Service Date.
|
D
|
D
|
D
|
D
|
|
|
|
RJ
|
Associated Partial Fill Transaction Not On File
|
4341
|
B
|
A “Paid” or “To Be Paid” claim with a Dispensing Status of “P” and an Associated Prescription/Service Reference Number that matches the In-process claim’s Prescription/Service Reference Number and an Associate Prescription/Service Date that matches the In-process claim’s Date Prescription Written could not be found.
|
D
|
D
|
D
|
D
|
|
|
|
RK
|
Partial Fill Transaction Not Supported
|
4952
|
B
|
Partial Fill Transaction Not Supported
|
B
|
B
|
B
|
B
|
|
|
|
RM
|
Completion Transaction Not Permitted With Same ‘Date Of Service’ As Partial Transaction
|
4953
|
B
|
Completion Transaction Not Permitted With Same ‘Date Of Service’ As Partial Transaction
|
D
|
D
|
D
|
D
|
|
|
|
RN
|
Plan Limits Exceeded On Intended Partial Fill Values
|
4343
|
B
|
Intended Days Supply Exceeds Plan Limits – 5.1 Only
The Days Supply Intended To Be Dispense received on a claim segment with a “P” Dispensing Status exceeds the maximum submitted days limits on the plan for which the participant is eligible.
|
D
|
D
|
D
|
D
|
|
|
|
RN
|
Plan Limits Exceeded On Intended Partial Fill Values
|
4342
|
B
|
Intended Quantity Exceeds Plan Limits
The Quantity Intended To Be Dispense received on a claim segment with a “P” Dispensing Status exceeds the maximum dispensed quantity limits on the plan for which the participant is eligible.
|
D
|
D
|
D
|
D
|
|
|
|
RP
|
Out Of Sequence ‘P’ Reversal On Partial Fill Transaction
|
4344
|
B
|
Partial Reversed Before Completion Reversed – 5.1 Only
A reversal for a partial fill transaction was submitted before the completion transaction was reversed. The Replacement TCN Number on the matching completion TCN is zeros. Note: 5.1 Same day inspect dispensing status in order to reverse correct transaction
|
D
|
D
|
D
|
D
|
|
|
|
RS
|
M/I Associated Prescription/Service Date On Partial Transaction
|
4345
|
B
|
The Associated Prescription/Service Date is missing (zeros) or is an invalid date when a claim segment with a Dispensing Status of “P” was received.
Associated fields are not required on a partial transaction.
|
D
|
D
|
D
|
D
|
|
|
|
RT
|
M/I Associated Prescription/Service Reference Number On Partial Transaction
|
4346
|
B
|
The Associated Prescription/Service Reference Number is missing (zeros) and the Dispensing Status is “P”.
Associated fields are not required on a partial transaction. This edit does not make sense.
|
D
|
D
|
D
|
D
|
|
|
|
RU
|
Mandatory Data Elements Must Occur Before Optional Data Elements In A Segment
|
4347
|
B
|
Optional Fields Precede Mandatory Fields
A segment of any type was received with an optional field or fields preceding the mandatory fields.
|
D
|
D
|
D
|
D
|
|
|
|
R1
|
Other Amount Claimed Submitted Count Does Not Match Number Of Repetitions
|
4348
|
B
|
The Other Amount Claimed Submitted Count does not match the number of Other Amount Claimed Submitted fields received on a Pricing segment.
|
D
|
D
|
D
|
D
|
|
|
|
R2
|
Other Payer Reject Count Does Not Match Number Of Repetitions
|
4349
|
B
|
The Other Payer Reject Count does match the number of Other Payer Reject Codes received on a COB/Other Payments segment
|
D
|
D
|
D
|
D
|
|
|
|
R3
|
Procedure Modifier Code Count Does Not Match Number Of Repetitions
|
4350
|
B
|
The Procedure Modifier Code Count does not match the number of Procedure Modifier Codes received on a Claim segment.
If the client isn't supporting Procedure Code Modifiers then this can be set to Ignore.
|
D
|
D
|
D
|
D
|
|
|
|
R4
|
Procedure Modifier Code Invalid For Product/Service ID
|
4351
|
B
|
The Procedure Code Identifies special circumstances related to the performance of the service. List of codes available from: Health Care Financing Administration (HCFA)
|
D
|
D
|
D
|
D
|
|
|
|
R5
|
Product/Service ID Must Be Zero When Product/Service ID Qualifier Equals Ø6
|
4352
|
B
|
The Product/Service ID on the Claim Segment was not zeros when the Product/Service ID Qualifier indicated that the claim was for DUR/Professional Pharmacy Service.
When submitting a claim with a DUR/PPS segment (for DUR conflict resolution or professional billing), the product/service id qualifier (436-E1) must be 06 (DUR/PPS - Drg Use Review/ Prof pharm svc) vs. the 03 (NDC#) and the actual DUR/PPS code would go in the produce/service id (407-D7). The NDC# would go in the Originally Prescribed Product/Service Code and qualifier fields (453-EJ AND 445-EA) in the Claim Segment.
See page 4-4 in the Implementation Guide for more info
|
D
|
D
|
D
|
D
|
|
|
|
R6
|
Product/Service Not Appropriate For This Location
|
4353
|
B
|
Drug to Patient Location
Drug not appropriate for patient location (field 307-C7):
1=Home
2=Inter-Care
3=Nursing Home
4=Long Term/Extended Care
5=Rest Home6=Boarding Home
7=Skilled Care Facility
8=Sub-Acute Care Facility
9=Acute Care Facility
1Ø=Outpatient11=Hospice
|
D
|
D
|
D
|
D
|
|
|
|
R7
|
Repeating Segment Not Allowed In Same Transaction
|
4354
|
B
|
An identical segment was submitted on a single transaction.
|
D
|
D
|
D
|
D
|
|
|
|
R8
|
Syntax Error
|
4954
|
B
|
Syntax Error
|
D
|
D
|
D
|
D
|
|
|
|
R9
|
Value In Gross Amount Due Does Not Follow Pricing Formulae
|
4355
|
B
|
Gross Amount Due for RX = ingredient cost submitted
+ dispensing fee submitted
+ flat sales tax amount submitted
+ percentage sales tax submitted
+ incentive amount submitted
+ other amount claimed
Gross Amount Due for PPS = PPS fee submitted
+ flat sales tax submitted
+ percentage sales tax amount submitted
+ other amount claimed
|
D
|
D
|
D
|
D
|
|
|
|
SE
|
M/I Procedure Modifier Code Count
|
4356
|
B
|
The Procedure Modifier Code Count is missing (zeros) and a procedure modifier is present.
If you include a procedure code modifier, then you must indicate the count. But since most clients only accept NDCs (vs. procedure/CPT codes), this can probably be set to Ignore.
|
D
|
D
|
D
|
D
|
|
|
|
TE
|
M/I Compound Product ID
|
4357
|
B
|
The Compound Product ID is missing (spaces).
|
D
|
D
|
D
|
D
|
|
|
|
UE
|
M/I Compound Ingredient Basis Of Cost Determination
|
4358
|
B
|
The Compound Ingredient 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
|
|
|
|
VE
|
M/I Diagnosis Code Count
|
4359
|
B
|
The Diagnosis Code Count is missing (zeros) and a diagnosis code is present.
|
D
|
D
|
D
|
D
|
|
|
|
WE
|
M/I Diagnosis Code Qualifier
|
4360
|
B
|
The Diagnosis Code Qualifier is missing (spaces) or it does not match one of the valid values specified for the field.
|
D
|
D
|
D
|
D
|
|
|
|
XE
|
M/I Clinical Information Counter
|
4361
|
B
|
The Clinical Information Counter is missing (zeros) or it does not match the number of sets of measurement fields on a Clinical segment.
|
D
|
D
|
D
|
D
|
|
|
|
ZE
|
M/I Measurement Date
|
4362
|
B
|
The Measurement Date is missing (zeros).
|
D
|
D
|
D
|
D
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
5.1 New (N) or (C) - (3rd column)
|
|
|
|
|
|
|
|
|
|
|
|
"N" = new 5.1 edits, "C" = field name change from 3.2.
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Client or Base Edit - (5th column)
|
|
|
|
|
|
|
|
|
|
|
|
"B" = base edit, "C" or cilent abbrev. = client specific edit
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Disposition Legend - (last 3 columns)
|
|
|
|
|
|
|
|
|
|
|
|
D Post Exception and Deny
I Ignore Exception (Pay)
P Post Exception and Pay
S Suspend and Recycle
Note 1: Disposition reflect Base Exception Code, not Client-Specific
Note 2: Management override can be set to YES for paper claims
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
5.1 Exception Table - General Info
|
|
|
|
|
|
|
|
|
|
|
|
Deletions - entries for the following edits were deleted as they're no longer supported in 5.1:
18 (M/I Metric Quantity) replaced by edit E7 (Quantity Dispensed/Metric Decimal Quantity)
30 (M/I PA/MC Code) replaced by EU (m/i pa type code) and EV (m/i pa number submitted)
57 (Non-Matched PA/MC Number) replaced by EU (m/i pa type code) and EV (m/i pa number submitted)
Deleted 3.2 exception codes can be viewed in the table: Deleted Entries from 3.2.xls on the P drive (Mapping Docs dir)
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Name changes: Approx 31 edits have been renamed. The edit#s and exception codes stayed the same. Look for "C" entries in column C.
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
The following reference docs are on the LAN: 5.1 Deleted Fields, 5.1 Field Name Change Cross Reference, 5.1 Error Codes (P:\PDCS\Indiana Medicaid\Systems\Mapping Docs\Exception Tables)
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
The complete 5.1 data dictionary is at: P:\ PDCS \ NCPDP \ NCPDP \ DOWNLOAD
|
|
|
|
|
|
|
|
|
|
|
When denials for ProDUR edits are received, providers may override these denials using the appropriate DUR Reason of Service (Conflict), Professional Results (Intervention), and Result of Service (Outcome Codes).
Early Refill (ER) –Providers must contact the ACS Technical Call Center to request overrides. (provider overrides not allowed.)
Therapeutic Duplication (TD)- selected therapeutic classes deny, others return warning message only.
88 DUR Reject Error
Note: Provider overrides are on a per claim (date of service only) basis. For quality of care purposes, pharmacists are required to retain documentation relative to these overrides.
(NCPDP field 439).
The DUR Result of Service is used to define the action taken by the pharmacist in response to a ProDUR Reason for Service or the Result of Service (NCPDP field 441).
Override Codes for both Maryland Medicaid and KDP: the following codes will be used to allow for provider level overrides for Therapeutic Duplication (TD) denials
Professional Service/ Description (NCPCP field #440-E5)
Result of Service/ Description (NCPDP field #441-E6)
