M1
Patient Not Covered in this Aid Category
|
4289
|
C
|
Aid Category Message Plans
If the “70 - Claim First Date Of Service Less Than Date of Injury” exception code (4111) was posted and the claim Plan ID equals one of the Aid Category Message Plans specified below:
001, 002, 102, 106, 109, 110, 111, 119, 202, 206, 209, 210, 211, 219
|
B
|
B
|
B
|
B
|
|
|
|
M1
|
Patient Not Covered in this Aid Category
|
4290
|
C
|
Category Of Eligibility
The claim Category of Eligibility (COE) is equal to one of the values specified below:
19, 22, 23, 24, 25, 35, 63, 70, 72, 73, 74, 75, 76, 77, 78, 88, 89, 96, 97
or the Plan is a No COA Plan = ‘001’ or ‘002’.
|
B
|
B
|
B
|
B
|
|
|
|
M1
|
Patient Not Covered in this Aid Category
|
4291
|
C
|
If the “70” reject code was posted and the claim Plan ID equals one of the Aid Category Message Plans specified below:
001, 002, 102, 106, 109, 110, 111, 119, 202, 206, 209, 210, 211, 219
|
B
|
B
|
B
|
B
|
|
|
|
M1
|
Patient Not Covered in this Aid Category
|
4428
|
C
|
If Prior Authorization matching the claim is found
And
The Plan Id = ‘001’ or ‘002’
|
B
|
B
|
B
|
B
|
|
|
|
M2
|
Member Locked into Specific Provider
|
4987
|
B
|
Member locked to specific DR
|
B
|
B
|
B
|
B
|
Future Use
|
|
|
M2
|
Member Locked into Specific Provider
|
4857
|
B
|
Member Locked into Specific Provider
|
D
|
D
|
D
|
D
|
|
|
|
M2
|
Member Locked into Specific Provider
|
4293
|
B
|
Participant/Provider Lockin Mismatch
The claim First Date Of Service fell within the date range of one of the providers in the lockin table but the claim Provider Number is not equal to the provider number in the lockin table.
|
D
|
D
|
D
|
D
|
|
|
|
M3
|
HOST PA/MC ERROR
|
4908
|
B
|
HOST PA/MC ERROR
|
B
|
B
|
B
|
B
|
|
|
|
M4
|
Maximum number of refills has been reached
|
4294
|
B
|
Prescription Number Time Limit
If the drug is a schedule II drug and refills have been authorized.
OR
If the drug is a schedule 0, or V, or VI drug
AND
The number of refills authorized is greater than 11
OR
The days supplied plus the refills would last for more than 366 days
OR
It has been more than 366 days since the prescription was written.
OR
If the drug is a schedule III, or IV drug
AND
The number of refills authorized is greater than 5
OR
The days supplied plus the refills would last for more than 185 days
OR
It has been more than 185 days since the prescription was written.
|
B
|
B
|
B
|
B
|
|
|
|
M5
|
Requires Manual Claim
|
4793
|
B
|
Edit posted for compounds in 3.2 which require a manual / paper claim. Ignore for 5.1 claims.
|
B
|
B
|
B
|
B
|
|
|
|
M5
|
Requires Manual Claim
|
4956
|
C
|
Edit posted when spenddown date is same as date of service.
Should accompany edit 65 (Patient not covered) - exception code 4808 - EOB 0385 (Spenddown date same as DOS).
|
B
|
B
|
B
|
B
|
|
|
|
M6
|
HOST ELIGIBILITY ERROR
|
4909
|
B
|
HOST ELIGIBILITY ERROR
|
B
|
B
|
B
|
B
|
|
|
|
M8
|
Host Provider File Error
|
4850
|
B
|
Host Provider File Error
|
B
|
B
|
B
|
B
|
|
|
|
ME
|
M/I Coupon Number
|
4943
|
B
|
M/I Coupon Number
|
B
|
B
|
B
|
B
|
|
|
|
MZ
|
Error Overflow
|
4899
|
B
|
Error Overflow
|
B
|
B
|
B
|
B
|
|
|
|
NE
|
M/I Coupon Number
|
4944
|
B
|
M/I Coupon Number
|
B
|
B
|
B
|
B
|
|
|
|
NN
|
Transaction Rejected At Switch Or Intermediary
|
4945
|
B
|
Transaction Rejected At Switch Or Intermediary
|
B
|
B
|
B
|
B
|
|
|
|
PA
|
PA Exhausted/Not Renewable
|
4295
|
B
|
PA Exhausted/Not Renewable
|
B
|
B
|
B
|
B
|
|
|
|
PB
|
Invalid Transaction Count For This Transaction Code
|
4297
|
B
|
The Transaction Count is greater than 4 for a Billing - Reversal - or Rebill request.
|
D
|
D
|
D
|
D
|
|
|
|
PC
|
M/I Claim Segment
|
4298
|
B
|
A Claim Segment was not received with a billing request.
|
D
|
D
|
D
|
D
|
|
|
|
PC
|
M/I Claim Segment
|
4299
|
B
|
A Claim segment was received with an Eligibility request.
|
D
|
D
|
D
|
D
|
|
|
|
PD
|
M/I Clinical Segment
|
4300
|
B
|
A Clinical segment was received with an Eligibility, a Reversal, a Prior Authorization Reversal, or a Prior Authorization Inquiry request.
|
D
|
D
|
D
|
D
|
|
|
|
PE
|
M/I COB/Other Payments Segment
|
4302
|
B
|
M/I COB/Other Payments Segment
|
D
|
D
|
D
|
D
|
|
|
|
PE
|
M/I COB/Other Payments Segment
|
4303
|
B
|
A COB/Other Payments Segment was received with an Eligibility - a Reversal - or a Prior Authorization Reversal request.
|
D
|
D
|
D
|
D
|
|
|
|
PF
|
M/I Compound Segment
|
4304
|
B
|
M/I Compound Segment
|
D
|
D
|
D
|
D
|
|
|
|
PF
|
M/I Compound Segment
|
4305
|
B
|
A Compound Segment was received with an Eligibility or a Reversal request.
|
D
|
D
|
D
|
D
|
|
|
|
PG
|
M/I Coupon Segment
|
4306
|
B
|
A Coupon segment was received and the customer does not process Coupon segments.
|
B
|
B
|
B
|
B
|
|
|
|
PH
|
M/I DUR/PPS Segment
|
4307
|
B
|
This error is similar to other M/I Segment errors indicating the segment was malformed or not sent correctly in the claim.
|
D
|
D
|
D
|
D
|
|
|
|
PH
|
M/I DUR/PPS Segment
|
4308
|
B
|
DUR/PPS Segment Invalid With Eligibility Request – 5.1 Only
A DUR/PPS segment was received with an Eligibility request.
DUR/PPS segment is not allowed for eligibility transactions (E1) and we don't accept E1 transactions.
|
D
|
D
|
D
|
D
|
|
|
|
PJ
|
M/I Insurance Segment
|
4309
|
B
|
M/I Insurance Segment
|
D
|
D
|
D
|
D
|
|
|
|
PJ
|
M/I Insurance Segment
|
4310
|
B
|
M/I Insurance Segment
|
D
|
D
|
D
|
D
|
|
|
|
PK
|
M/I Patient Segment
|
4311
|
B
|
M/I Patient Segment
|
B
|
B
|
B
|
B
|
|
|
|
PK
|
M/I Patient Segment
|
4312
|
B
|
M/I Patient Segment
|
B
|
B
|
B
|
B
|
|
|
|
PM
|
M/I Pharmacy Provider Segment
|
4313
|
B
|
M/I Pharmacy Provider Segment
|
B
|
B
|
|
