AND
The history claim’s TCN is not equal to In Process claim’s replaced TCN
AND
The custom plan record’s “DUP-CHECK-EXEMPT-IND” is not equal to “Y.”
AND NOT
(If in process claim is a medical supply claim (Generic Code equals 94200)
AND
((The history claim’s therapeutic class code spec is not equal to In Process claim’s therapeutic class code spec)
OR
(The Drug Record’s drug category code is equals “Reuse Syringe Insulin” (Q) or “Dispose Syringe Insulin” (R))
OR
(In Process claim’s Generic Product Indicator equals Non-Drug Item
AND
History Claim’s Generic Product Indicator equals Non-Drug Item
AND
The Drug Record’s Drug Class equals “Over the counter”
AND
The History claim’s NDC is not equal to In Process NDC )))
Affected Invoice Types:
Pharmacy
Claims Edit Exhibit
D
|
D
|
D
|
D
|
|
|
|
84
|
Claim Has Not Been Paid/Captured
|
4834
|
B
|
Claim has not been paid/captured – if matching history claim was a credit or incumbent or mail-order; the error is posted to the claim (financial EOB)
|
B
|
B
|
B
|
B
|
|
|
|
84
|
Claim Has Not Been Paid/Captured
|
4192
|
B
|
The original claim that is attempting to be adjusted/credited was not found or is a credit.
|
D
|
D
|
D
|
D
|
|
|
|
84
|
Claim Has Not Been Paid/Captured
|
4193
|
B
|
The original claim that is attempting to be credited is a mail order claim
|
D
|
D
|
D
|
D
|
|
|
|
84
|
Claim Has Not Been Paid/Captured
|
4374
|
B
|
A credit claim cannot be adjusted. The replacement claim of an adjustment can be voided or replaced - but the credit claim of an adjustment can never be voided or replaced.
This edit can post to provider submitted credit requests - provider submitted replacement claims - online entered credit requests - and online entered replacement requests.
|
D
|
D
|
D
|
D
|
|
|
|
85
|
Claim Not Processed
|
4188
|
B
|
Claim not processed – reject code not found on reject control table or too many reject codes are posted to claim or related history entries exceeded for claim or participant
|
D
|
D
|
D
|
D
|
|
|
|
85
|
Claim Not Processed
|
4187
|
B
|
The maximum number of entries for the related history table have been met or exceeded.
Program: S780C / S780 Add-to-RLTD-Hist
|
D
|
D
|
D
|
D
|
|
|
|
85
|
Claim Not Processed
|
4960
|
B
|
Set if attempting to roll off old history and WS-010-NO-ROLL-OFF
Program: PDDC8622 / S560 Roll-Off-Hist-Section
|
D
|
D
|
D
|
D
|
|
|
|
85
|
Claim Not Processed
|
4363
|
B
|
This edit will post if the header-level override exception location code does not have a matching code on the Reference text location database
|
D
|
D
|
D
|
D
|
|
|
|
85
|
Claim Not Processed
|
4364
|
B
|
This exception can be posted to the claim if a logic error - such as a missing replaced TCN number for a credit transaction - or a credit with a claim status of to-be-denied - occurs.
In some instances - it can be used to denote unexpected SQL codes from DB2 calls - where it might also be used in conjunction with the DB2 error exit routine - which terminates claim processing.
Certain logic error situations dictate that the claim header status be set to suspend at the time of posting this edit.
|
D
|
D
|
D
|
D
|
|
|
|
85
|
Claim Not Processed
|
4375
|
B
|
This exception can be used to suspend the claim if a logic error - such as a subscript out of bounds - occurs
|
D
|
D
|
D
|
D
|
|
|
|
85
|
Claim Not Processed
|
4379
|
B
|
The Member Number on the claim or adjustment being processed is currently being updated by another user or system process. (This situation should rarely occur. Simply trying to process again normally results in this exception not occurring again).
|
B
|
B
|
B
|
B
|
|
|
|
85
|
Claim Not Processed
|
4404
|
B
|
Formulary Type Code for the Plan not = ‘N’ (No Formulary)
AND
No Formulary is found on the Drug Formulary Table
|
B
|
B
|
B
|
B
|
|
|
|
85
|
Claim Not Processed
|
4414
|
B
|
The pharmacy’s physical address information could not be found.
|
D
|
D
|
D
|
D
|
|
|
|
85
|
Claim Not Processed
|
4415
|
B
|
If the loaded exception count is 0.
|
B
|
B
|
B
|
B
|
|
|
|
85
|
Claim Not Processed
|
4445
|
B
|
Claims is system generated
AND
(Transaction Type is Void
OR
Transaction Type is Debit of Adjustment)
AND
Cycle number equal zero
AND
Batch number is less that system generated batch number
|
D
|
D
|
D
|
D
|
|
|
|
86
|
Submit Manual Reversal
|
4775
|
B
|
|
B
|
B
|
B
|
B
|
|
|
|
87
|
Reversal Not Processed
|
4835
|
B
|
Reversal not processed - If the matching history claim was found and was already credited; or was to-be-credited; or the original claim was denied; then the error is posted.
|
D
|
D
|
D
|
D
|
|
|
|
87
|
Reversal Not Processed
|
4836
|
B
|
POS Reversal claim > 60 days
|
B
|
B
|
B
|
B
|
|
|
|
87
|
Reversal Not Processed
|
4837
|
B
|
no POS reversal in fin. cycle
|
B
|
B
|
B
|
B
|
|
|
|
87
|
Reversal Not Processed
|
4189
|
B
|
The original claim that is attempting to be adjusted/credited has already been credited.
|
D
|
D
|
D
|
D
|
|
|
|
87
|
Reversal Not Processed
|
4190
|
B
|
The original claim that is attempting to be adjusted/credited is in the process of being credited.
|
D
|
D
|
D
|
D
|
|
|
|
87
|
Reversal Not Processed
|
4191
|
B
|
The original claim that is attempting to be adjusted/credited was denied.
|
D
|
D
|
D
|
D
|
|
|
|
87
|
Reversal Not Processed
|
4376
|
B
|
The adustment reason code entered on the request is missing or invalid (not numeric or not on valid values table). See the Data Dictionary for a list of valid values.
|
D
|
D
|
D
|
D
|
|
|
|
87
|
Reversal Not Processed
|
4439
|
B
|
An adjustment request record has targeted a history record for adjustment - but the history record has been suspended
|
D
|
D
|
D
|
D
|
|
|
|
87
|
Reversal Not Processed
|
4441
|
B
|
An adjustment request record has targeted a history record for adjustment - but the history record has been voided
|
D
|
D
|
D
|
D
|
|
|
|
87
|
Reversal Not Processed
|
4443
|
B
|
An adjustment request record has targeted a history record for adjustment - but the keyed replaced number (TCN) on the adjustment request record that identifies the history record is equal to zeros.
|
D
|
D
|
D
|
D
|
|
|
|
88
|
DUR Reject Error
|
4974
|
B
|
Error will post when the current refill is filled later than (Previous fill's date of service + (1.25 * its days supply)).
|
B
|
B
|
B
|
B
|
|
|
|
88
|
DUR Reject Error
|
4205
|
B
|
Accompanied by DUR conflict code: ER Early Refills required Prior Authorization from Health Care Excel 800-457-4518
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 “Pay”
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
|
D
|
D
|
D
|
D
|
|
|
|
88
|
DUR Reject Error
|
4202
|
B
|
Accompanied by DUR conflict code: HD
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
Calculated Daily Dose must be more than the Maximum Daily Dose on the Drug Record
|
P
|
P
|
P
|
P
|
|
|
|
88
|
|
