Programs: Maryland Medical Assistance Program (MA)



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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



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