DME/DMS for HCFA 1500 billing - Exception: needles, syringes, blood glucose test strips
Providers can reach the KDP prior authorization staff at 410-767-5000 or 5002, M-F, 8:00 am – 4:30 pm.
SECTION XI
Following an on-line claim submission by a pharmacy, the system will return a message to indicate the outcome of processing. If the claim passes all edits, a “Paid” message will be returned with Maryland Medicaid’s allowed amount for the paid claim. A claim that fails an edit and is rejected (denied) will also return a message. Following is a list of the program’s error codes with their corresponding NCPDP reject codes.
5.1 Reject Code
|
NCPDP Error Description
|
Exception Code
|
Client or Base Edit
|
Internal (long) message
for Help Desk
|
MD
|
BCCDT
|
KDP
|
MADAP
|
|
|
|
01
|
M/I Bin
|
4001
|
B
|
The BIN Number is missing or does not match one of the valid values (ie: 610084)
|
D
|
D
|
D
|
D
|
|
|
|
02
|
M/I Version Number
|
4002
|
B
|
The Version Number is missing (spaces) or it does not match one of the valid values specified for the field
|
D
|
D
|
D
|
D
|
|
|
|
02
|
M/I Version Number
|
4003
|
B
|
The Version Number is not one of the versions that the customer accepts for processing.
|
D
|
D
|
D
|
D
|
|
|
|
03
|
M/I Transaction Code
|
4004
|
B
|
The Transaction Code is missing (zeros) or it does not match one of the valid values specified for the field in Version 3.2.
|
D
|
D
|
D
|
D
|
|
|
|
03
|
M/I Transaction Code
|
4005
|
B
|
The Transaction Code is missing (spaces) or it does not match one of the valid values specified for the field in Version 5.1.
|
D
|
D
|
D
|
D
|
|
|
|
03
|
M/I Transaction Code
|
4006
|
B
|
The Transaction Code is not one of the transaction codes in Version 3.2 or 5.1 that the customer accepts for processing.
|
D
|
D
|
D
|
D
|
|
|
|
04
|
M/I Processor Control Number
|
4007
|
B
|
M/I Processor Control #
DRnnTEST = Test
DRnnPROD = Production
DRnnACCP = Acceptance
|
D
|
D
|
D
|
D
|
|
|
|
05
|
M/I Pharmacy Number
|
4009
|
B
|
The pharmacy provider id does not exist on the provider master table.
|
D
|
D
|
D
|
D
|
|
|
|
05
|
M/I Pharmacy Number
|
4370
|
B
|
The pharmacy id on the replacement or credit request does not match the pharmacy provider number on the claim that is being replaced or credited.
|
B
|
B
|
B
|
B
|
|
|
|
06
|
M/I Group ID
|
4751
|
B
|
M/I Group Id always required
|
D
|
D
|
D
|
D
|
|
|
|
07
|
M/I Cardholder ID
|
4011
|
B
|
The member id is missing (Zero).
|
D
|
D
|
D
|
D
|
|
|
|
07
|
M/I Cardholder ID
|
4010
|
B
|
The member id is missing or equal spaces.
|
D
|
D
|
D
|
D
|
|
|
|
08
|
M/I Person Code
|
4752
|
B
|
M/I Person Code
|
B
|
B
|
B
|
B
|
|
|
|
09
|
M/I Birthdate
|
4012
|
B
|
The Date Of Birth is missing (zeros).
|
D
|
D
|
D
|
D
|
|
|
|
09
|
M/I Birthdate
|
4013
|
B
|
The Date of Birth is greater than the current date or the Date of Birth is not a valid date.
|
D
|
B
|
B
|
B
|
|
|
|
09
|
M/I Birthdate
|
4424
|
B
|
The Date Of Birth does not match participant file DOB.
|
B
|
B
|
B
|
B
|
|
|
|
1C
|
M/I Smoker/Non-Smoker Code
|
4918
|
B
|
M/I Smoker/Non-Smoker Code
|
B
|
B
|
B
|
B
|
|
|
|
1E
|
M/I Prescriber Location Code
|
4919
|
B
|
M/I Prescriber Location Code
|
B
|
B
|
B
|
B
|
|
|
|
10
|
M/I Patient Gender Code
|
4753
|
B
|
Sex code is missing or invaild
|
B
|
B
|
B
|
B
|
|
|
|
11
|
M/I Patient Relationship Code
|
4754
|
B
|
M/I Patient Relationship Code
|
B
|
B
|
B
|
B
|
|
|
|
12
|
M/I Patient Location Code
|
4016
|
B
|
The claim Welfare Customer Location (Patient Location) is missing or does not match one of the valid values specified for the field
|
B
|
B
|
B
|
B
|
|
|
|
13
|
M/I Other Coverage Code
|
4019
|
B
|
The Other Coverage Code is missing or it does not match one of the valid values specified for the field.
|
D
|
D
|
D
|
D
|
|
|
|
14
|
M/I Eligibility Override Code
|
4022
|
B
|
The Eligibility Clarification Code (drug prescription override code) is missing (zero) or it does not match one of the valid values specified for the field.
|
B
|
B
|
B
|
B
|
|
|
|
15
|
M/I Date of Service
|
4023
|
B
|
M/I days supply
|
D
|
D
|
D
|
D
|
|
|
|
15
|
M/I Date of Service
|
4859
|
B
|
Date dispensed is missnig or invalid
|
D
|
D
|
D
|
D
|
|
|
|
15
|
M/I Date of Service
|
4800
|
B
|
Date disp. earlier than prscrbd
|
D
|
D
|
D
|
D
|
|
|
|
15
|
M/I Date of Service
|
4801
|
B
|
Date disp. after billing date
|
D
|
D
|
D
|
D
|
|
|
|
16
|
M/I Prescription/Service Reference Number
|
4025
|
B
|
M/I Rx number. If prescription number is missing (zeros) or not numeric - then post the error.
|
D
|
D
|
D
|
D
|
|
|
|
17
|
M/I Fill Number
|
4028
|
B
|
The Prescription Refill Number (Fill Number) is not numeric.
|
D
|
D
|
D
|
D
|
|
|
|
17
|
M/I Fill Number
|
4027
|
B
|
IP Refill Indicator (Fill Number) is equal to zeros
OR
(IP Refill Indicator (Fill Number) is greater than zeros
AND
IP Provider Number equals History Provider Number
AND
IP Prescription Number equals History Prescription Number
AND
IP GSN equals History GSN
AND
IP Date Prescribed equals History Date Prescribed)
|
D
|
D
|
D
|
D
|
|
|
|
19
|
M/I Days Supply
|
4030
|
X
|
The Submitted Days Supply Amount (Days Supply) is zeroes.
|
D
|
D
|
D
|
D
|
|
|
|
19
|
M/I Days Supply
|
4852
|
B
|
Edit will check for both MISSING and INVALID conditions
|
D
|
D
|
D
|
D
|
|
|
|
19
|
M/I Days Supply
|
4385
|
B
|
The Claim’s Submitted Days Supply Amount (Days Supply) > Plan Header Days Supply Limit (or Maintenance Days Supply Limit for Maintenance Drugs)
AND
A Custom Plan Benefit Limit record exists for this Customer - Plan - and Benefit Limit Type
AND
(The Custom Plan Accumulation Code = ‘No Edit’
OR
The Custom Plan’s Days Submitted Number = Default Days Supply Number (999)
|
D
|
D
|
D
|
D
|
|
|
|
