Response and Error Codes Anne
FHIR Mapping:
???? Anne to discuss with TWG - do we split adjudication codes and error codes? They are returned in different places wtihin the response message, so I would recommend it. Errors mean that the claim was not adjudicated; it must be corrected and re-submitted. The response will be very different when errors occur.
This can be used as a default system. http://pharmacyeclaims.ca/FHIR/CodeSystem/response-codes
Codes to define responses that identify errors and other reasons that may cause the request to be rejected. Field length of 10 will accommodate 5 response codes
These are, wherever possible, consistent with codes in Field E.06.03. Response Codes - The first two numeric digits of the field/version numbers in sections A, B, C and D reflect error codes which indicate missing or invalid information received in the respective fields. Alphanumeric and alpha combinations provide other response messages.
Removal of Code QJ
The CPHA code QJ has been removed/no longer supported.
Rationale: There is logic in the PMS today CPHA3 that blocks COB if a QJ is returned because the pharmacy software does not know the amount paid to the patient so we cannot properly calculate and submit the previously paid amount on claims to subsequent payors. In FHIR, adjudicators will return the dollar value paid to the patient, so POS vendor software will be able to include that amount in the previously paid field when sending the claim to subsequent payors. This will prevent those subsequent payors from overpaying the claim. The QJ won't be necessary to indicate a deferred payment because the dollar value paid to the patient is known. Pharmacy software will be able to remove the COB restriction because we know the amount.
The first two numeric digits of the field/version numbers in sections A, B, C and D reflect error codes which indicate missing or invalid information received in the respective fields. Alphanumeric and alpha combinations provide other response messages.
List with Kroll Descriptors
code | description | Category | Action? |
---|---|---|---|
01 | BIN error. | FHIR validator | call vendor |
02 | Version number error. | FHIR validator | |
03 | Transaction code error. | FHIR validator | call vendor |
04 | Provider software ID error. | Error | |
05 | Provider software version error. | Error | |
07 | Active device error. | Error | |
08 | PC terminal language error. | Deprecate | |
09 | Test indicator error. | Deprecate | |
10 | Invalid MMI code**??**. | Application error | call |
11 | Invalid MMI/clinical service code. | application error | call |
12 | MMI maximum exceeded. | ???? | |
13 | Invalid clinical service code. | Error | |
14 | Invalid RBRVS parameter count. | Error | |
15 | Invalid original Rx date. | Error | |
16 | Drug not eligible for service. | Adjudication | Human Decision |
17 | Prescriber must be a pharmacist. | ?? | |
18 | Field keyword contains invalid value. | Error | |
19 | Practitioner ID not found. | Error | |
20 | No service agreement identified. | ||
21 | Pharmacy ID code error. Please confirm the pharmacy provider number for this plan | Error | |
21 | Pharmacy ID code error. Please confirm the pharmacy provider number for this plan. The pharamcy ID code is located at the top middle of the Edit / Plans and Pricing menu | Error | |
22 | Provider transaction date error. | Error | |
23 | Trace number error, please call Kroll for support. | Error | |
24 | Service not eligible for veterinary Rx. | Adjudication | No Action |
25 | Invalid dispense reference. | Error? | |
26 | Refusal to fill claim was paid. | Informational | No Action |
27 | MMF claims exceed insurer limit. | ||
28 | Clinical service claims exceed insurer limit. | ||
30 | Carrier ID error. | Error | |
31 | Group number error. | Error | |
32 | Client ID # Error. Please go to the patient card (F3) and confirm client ID # with Patient's physical card including issue number. (Issue Number must be numerical e.g. 01). If this does not resolve this error, please have the patient contact their plan administrator | Error | |
32 | Client ID # Error. Please go to the patient card (F3) and confirm client ID # with Patient's physical card including issue number. (Issue Number must be numerical e.g. 01). If this does not resolve this error, please have the patient contact their plan administrator | Error | |
33 | Patient code error. | Error | |
34 | Patient Date of Birth Error. Please confirm the patient date of birth on the patient card (F3) and have the patient contact the plan administrator with any changes | Error | |
34 | Patient Date of Birth Error. Please confirm the patient date of birth on the patient card (F3) and have the patient contact the plan administrator with any changes | Error | |
36 | Relationship error. | Error | |
37 | Patient first name error | Error | |
38 | Patient last name error, last name on card must match. | Error | |
39 | Provincial health care # error. | Error | |
40 | Patient gender error. | Error | |
41 | Duplicate MMI event. | ? | |
42 | Duplicate clinical service. | Adjudication | |
43 | Invalid dispense details submitted. | error | |
44 | Invalid MMF claim contact type. | error | |
45 | Patient not eligible for service reported. | Adjudication | |
46 | Too many same Rx references submitted. | error | |
47 | Too many same dispense references. | error | |
50 | Medical reason reference error. Should only be used for NFB's. | Error | |
51 | Medical condition/reason code error. | Error | |
52 | New/refill code error. | Error | |
53 | Original prescription number error. | Business Error | Human |
54 | Refill/repeat authorization error. | Error | |
55 | Current Rx number error. | Error | |
56 | Invalid DIN for drug. Please confirm Din number on F5 Drug card or, for mixures, ensure you are using a mixture card with appropriate Mix Type | Error | |
56 | Invalid DIN for Drug. DIN # entered doesn't exist, please confirm the DIN and resubmit, or contact the TELUS Health website support document for a potential pins for consideration | Error | TELUS |
57 | Special service code error. | Error | |
58 | Quantity error. | Error | |
59 | Days supply error. | Error | |
5A | Supply source error, please call Kroll for support. | Error | Kroll |
5B | Designated pharmacy error, please call Krollport. | Error | Kroll |
5C | Source package size error, please call Kroll for support. | Error | Kroll |
5D | Prescription validity date error. | Error | |
60 | Invalid prescriber ID reference code. | Error | |
61 | Prescriber ID error. | Error | |
62 | Product selection code error. | Error | |
63 | Unlisted compound code error. Mix Type is incorrect. Please return to the Mixture Card (F5) and choose the appropriate Mix Type | Error | |
63 | Unlisted compound code error. Mix Type is incorrect. Please return to the Mixture Card (F5) and choose the appropriate Mix Type from the drop down menu. If you are not filling from a Mixture Card please change the drug to a Mixture. | Error | |
64 | Special authorization # (personal care home #) error. | Error | |
65 | Intervention/exception code error, please call provider for support. | Error | |
66 | Drug cost/product value error. | Error | |
67 | Cost upcharge error. | Error | |
68 | Professional fee error. | Error | |
70 | Compounding charge error. | Error | |
71 | Compounding time error. | Error | |
72 | Special services fee error. | Error | |
75 | Previously paid error. | Error | |
76 | Pharmacist ID code error/missing. | Error | |
77 | Adjudication date error. | Error | |
80 | Service code & number of DINs do not match. | Error | |
81 | Primary drug product is not insured. | Adjudication | |
82 | Product duplicated in this claim for payment. | ||
83 | DIN is not allowed for the indicated condition. | Adjudication | |
84 | Authorization for this treatment has expired. | Adjudication | |
85 | Therapy (product) is not repeatable. | ||
86 | Confirm provincial drug coverage for DIN. | Adjudication?? | |
87 | Exceeds max. # of prof. fees for this drug. | Adjudication | |
88 | Zero dispensing fee 28-day limit exceeded. | Adjudication | |
90 | Adjudication date error. | Error | |
91 | Beginning record error, call Kroll for support. | Error | |
92 | Ending record error, call Kroll for support. | Error | |
99 | No claims for specified parameters. | ||
A | |||
A1 | Claim too old. Must submit manually. | Adjudication | |
A2 | Claim is post dated. | Error | |
A3 | Identical claim processed. A previous claim submitted by the provider for the same person, same DIN, and the same dispense date has already been paid. | Adjudication | |
A3 | Identical claim processed. Please cancel this prescription. A previous claim submitted by the provider for the same person, same DIN, and the same dispense date has already been paid. | ||
A4 | Claim has not been captured. | ?? | |
A5 | Claim has not been processed. | ?? | |
A6 | Submit manual claim. | Adjudication | |
A7 | Submit manual reversal. | Adjudication | |
A8 | No reversal made, the original claim is missing. | ||
A9 | Reversal processed previously. | Adjudication | |
AA | Duplicate of claim adjudication. | Adjudication | |
AB | Swipe benefit card for payment. | ||
B | |||
B1 | Pharmacy not authorized to submit claims. | Adjudication | |
B2 | Return to first pharmacy requested. | ?? | |
B3 | Invalid PharmaNet Rx ID. | Adjudication Error | |
B4 | PharmaNet Rx ID does not match patient. | PharmaNet | |
B5 | Prescriber differs from Rx. | ?? | |
B6 | Date of service is less than Rx date. | Error | |
B7 | Date of service is less than dispense start date. | Error | |
B8 | Prescription has expired. | Adjudication | |
B9 | Prescription has been adapted. | ??? | |
BA | Chronic disease costs are not a benefit. | Adjudication | |
C | |||
C1 | Patient age over plan maximum. | Adjudication | |
C2 | Service provided before effective date. | Adjudication | |
C3 | Coverage expired before service. | Adjudication | |
C4 | Coverage has been terminated for this patient. Card Termination Date is prior to the Dispense Date of the claim. Verify with patient if a new card was issued. For further details on termination, have patient contact plan administrator | ||
C4 | Coverage has been terminated for this patient. Card Termination Date is prior to the Dispense Date of the claim. Verify with patient if a new card was issued. For further details on termination, have patient contact plan administrator | ||
C5 | Plan maximum exceeded. | ||
C6 | This patient has other coverage. Please submit claim to primary plan first.Please submit the other private insurance first. To change the priority of the card, please refer patient to their insurance or plan administrator. | ||
C6 | This Patient has other coverage. Please submit claim to primary plan first. | ||
C7 | Patient must claim reimbursement. | Adjudication | |
C8 | No record of recipient. Check name, billing number, birth date and relationship code. Please have the patient contact the plan administrator for changes. | Adjudication | Patient Call |
C8 | No record of recipient. This dependant is not enrolled. Please have the patient contact their Employer. | Adjudication | Patient Call |
C9 | Patient not covered for drugs. | Adjudication | No Action |
CA | Needles not eligible, insulin gun used. | Adjudication | No Action |
CB | Only enrolled for single coverage. | Adjudication | No Action |
CC | This spouse not enrolled. Please have the patient contact their Employer Plan administrator | Adjudication | Patient Call |
CC | This Spouse is not enrolled. Please have the patient contact their Employer Plan administrator. | Adjudiation | Patient Call |
CD | Patient not entitled to drug claimed. | Adjudication | No action |
CE | 35 day maximum allowed for welfare client. | Adjudication | |
CF | Quantity exceeds maximum days of treatment. | Adjudication | |
CG | Drug not eligible for long term care facility. | Adjudication | |
CH | Good faith coverage has expired. | Adjudication | |
CI | Patient is not eligible for good faith. | Adjudication | |
CJ | Patient not covered by this plan. | Adjudication | |
CK | Health card version code error. | Error | |
CL | Exceeds good faith limit. | Adjudication | |
CM | Patient is nearing quantity limit. | Informational | |
CN | Patient has attained quantity limit. | Adjudication | |
CO | Patient is over quantity limit. | Adjudication?? | |
CP | Eligible for special authorization. | ?? | |
CQ | Date not covered by premiums paid. | Adjudication | |
CR | Patient is exceeding dosage safety limit. | Informational | |
CS | Patient exclusion prevents payments. | Adjudication | |
CT | Benificiary not eligible to use provider. | Adjudication | |
CU | Beneficiary not elgible to use prescriber. | Adjudication | |
CV | No record of client ID number. | Error | |
CW | No record of group number or code. | Error | |
CX | No record of patient data. | Adjudication | |
CY | No record of patient code. | Adjudication | |
CZ | No record of authorization number. | Adjudication | |
D | |||
D1 | DIN/PIN/GP #SSC not a benefit. This DIN # is not covered under the Cardholder's plan. Please have the patient contact the plan administrator if there are any questions. |
Adjudication | |
D1 | DIN/PIN/GP #SSC not a benefit. This DIN is not covered by patient's plan. Please choose the option to skip plan or cancel prescription. |
Adjudication | |
D2 | DIN/PIN/GP # is discontinued | Adjudication | |
D3 | Prescriber is not authorized. | Adjudication | |
D4 | Refills are not covered. | Adjudication | |
D5 | Co-pay exceeds total value. | Adjudication | |
D6 | Maximum cost is exceeded. | Adjudication | |
D7 | Refilled too soon. Prescription has been refilled too soon. Please cancel the prescription. |
Adjudication | Action - Cancel RX |
D7 | Refill too soon. Prescription is refilled to soon. Please confirm with the Doctor and use the appropriate intervention code from the Intervention button at the top right of this box or cancel this prescription. |
Adjudication | Action - Cancel RX |
D8 | Reduced to generic cost. | Adjudication | |
D9 | Call adjudicator. Please contact your plan support center | Adjudication | Call Adjudicator |
D9 | Call adjudicator. Please contact your plan support center | Call Adjudicator | |
DA | Adjusted to interchangeable-prov. reg. | DEPRECATE | |
DB | Adjusted to interchangeable-gen. plan | DEPRECATE | |
DC | Pharmacist ID requested. | Error? | |
DD | Insufficient space to send all DUR warnings. Call adjudicator. | Adjudication | Call Adjudicator |
DE | Fill/refill is late, speak to patient re: compliance. | DUR? | |
DF | Insufficient space to send all warnings. Call adjudicator. | Adjudication | Call Adjudicator |
DG | Duplicate prescription number. | error | |
DH | Professional fee adjusted. | Adjudication | |
DI | Deductible not satisfied. | Adjudication | |
DJ | Drug cost adjusted. | Adjudication | |
DK | Cross selection pricing. | Adjudication | |
DL | Collect difference from patient. | Informational | |
DM | Days supply exceeds plan limit. | Adjudication | |
DN | Alternate product is a benefit. | Adjudication | |
DO | Future refills require prior approval. | Adjudication | |
DP | Quantity exceeds maximum per claim. | Adjudication | |
DQ | Quantity is less than minimum per claim. | Adjudication | |
DR | Days supply lower than minumum allowable. | Adjudication | |
DS | Reduced to cost upcharge maximum. | Adjudication | |
DT | Reduced to compounding charge maximum. | Adjudication | |
DU | Maximum compounding time exceeded. | Adjudication | |
DV | Reduced to special services fee maximum. | Adjudication | |
DW | Return to first prescriber requested. | Adjudication | |
DX | Drug must be authorized. Please have the patient contact their employer plan admisitrator for authorization | Adjudication | Patient Instruction |
DX | Drug must be authorized. Please have the patient contact their employer plan admisitrator for authorization | Adjudication | Patient Instruction |
DY | Intervention/exception code missing. | Error | Action |
DZ | Days supply limited due to benefit year end. | Adjudication | |
E | |||
E1 | Host processing error. | Error | Resubmit |
E2 | Claim coordinated with government plan. | Informational | |
E3 | Claim coordinated with other carrier. | Informational | |
E4 | Host time out error, please try again later. | Error | Resubmit |
E5 | Host processing error. Please re-submit. | Error | Resubmit |
E6 | Host processing error. Do not re-submit. | Error | Resubmit |
E7 | Host processor is down. | Resubmit | |
E8 | Patient must remit cash receipt to Trillium. | Resubmit | Patient Instruction |
E9 | Reduced to reference based price. | ||
EZ | Allowed amount paid from an HSA. | Adjudication | Patient Instruction |
F | |||
FA | Conversion successful cognitive fee paid. | ?? | |
FB | Invalid prescription status. | Error | |
FC | Dispensed medication differs from Rx. | Error? | |
FD | Dispensed device differs from Rx. | Error? | |
FE | Prescription is not an adaptation. | ??? | |
FF | Must provide brand ordered – no sub allowed. | ||
FG | Drug cost paid as per provider agreement. | Adjudication | No Action |
FH | Exceeds maximum special service fee allowed. | Adjudication | No Action |
FP | Dosage form not allowed for service claimed | Adjudication | |
FQ | Medical reason reference is not eligible. | Adjudication | |
FR | Condition or risk factor is not eligible. | Adjudication | |
FX | Possible Forgery-Check authenticity | ??? | |
G | |||
GA | Preferred provider network fee paid. | ||
GB | Preferred provider network claim. | ||
GC | Quantity max approval is 40 days supply. | Adjudication | |
GD | Not eligible for a quantity authorization. | Adjudication | |
GE | Drug is not a benefit. | Adjudication | |
GF | Patient must contact program provider | Adjudication | Patient Instruction |
H | |||
H0 | HW Formulary-DIN not a benefit | Adjudication | |
H1 | HW Formulary-DIN on tier 1 | Adjudication | |
H2 | HW Formulary-DIN on tier 2 | Adjudication | |
H3 | HW Formulary-DIN on tier 3 | Adjudication | |
H8 | HW Formulary-special authorization required | Adjudication | |
H9 | HW Formulary-preferred or step drug available | Adjudication | |
HA | Cardholder date of birth is required. | Error | |
HB | Cardholder is over coverage age limit. | Adjudication | |
HC | Require cardholder province of residence. | Error | |
HD | Patient may qualify for gov't program. | Informational | |
HE | Coverage suspended-refer to employer. | Adjudication | |
HF | Patient authorization expired CCYYMMDD. | Adjudication | |
HG | Client has provided consent. | ||
HH | Client has not provided consent. | error | |
HI | Client consent required. | error | |
HJ | Client consent required in future. | Informational | |
HK | Confirm patient status, contact insurer. | Adjudication | No Action - Call |
I | |||
I1 | Beneficiary street address error. | Error | |
I2 | City or municipality error. | Error | |
I3 | Province or state code error. | Error | |
I4 | Postal/zip code error. | Error | |
I5 | Country code error. | Error | |
I6 | Address type error. | Error | |
J | |||
J1 | Invalid PharmaNet Rx ID. | Error | Pharmanet |
J2 | PharmaNet Rx ID does not match patient. | Error | Pharmanet |
J3 | Prescriber ID does not match Rx info. | error | |
J4 | Rx filled prior to issue of Rx. | Adjudication | |
J5 | Rx filled before medication start date. | Adjudication | |
J6 | Requirement for medication has expired. | Adjudication | |
J7 | Rx has been adapted by the pharmacist. | Informational? | |
J8 | Prescription status is no longer valid. | Adjudication | |
J9 | Medication issued differs from Rx. | Adjudication | |
K | |||
K1 | Dispensed device differs from Rx. | Adjudication | |
K2 | Rx submitted is not an adaptation Rx. | Adjudication | |
K6 | Parental relationship and age do not match. | error | |
KA | Does not match patient information. | error | |
KB | Does not match cardholder information. | error | |
KC | Pateint product dollar maximum exceeded. | Adjudication | |
KD | Patient product deductible not satisfied. | Adjudication | |
KE | Authorization dollar max. exceeded-obtain payment from client. | Adjudication | |
KF | Authorization quantity maximum exceeded. | Adjudication | |
KG | Authorization refills exceeded. | Adjudication | |
KH | Authorization costs allowed exceeded. | Adjudication | |
KI | Prior to authorization elegible period. | Adjudication | |
KJ | Authorization eligible period expired. | Adjudication | |
KK | Not eligible for COB. The coordination of benefits is not available under the terms of the contract. Please have the patient contact their Desjardins plan administrator if more information is required. | Adjudication | Desjardins |
KK | Not eligible for coordination of benefit. The coordination of benefits is not available under the terms of the contract. Please have the patient contact their plan administrator if more information is required. | Adjudication | |
KL | Age/relationship discrepancy. | error? | |
KM | Exceeds days supply limit for this drug. | Adjudication | |
KN | Days supply limit for period exceeded. | Adjudication | |
KO | Good faith was used previously. | Adjudication | |
KP | Obtained at other pharmacy - refill to soon. | Adjudication | |
KQ | Good faith not valid. | Adjudication | |
KR | Patient not eligible for product. | Adjudication | |
KS | Client is deceased. | Adjudication | |
KT | Assess patient SDP eligibilty. | ||
KU | Patient at $... of a $... max* | Adjudication | |
KV | Patient has met max of $...* | Adjudication | |
KW | Patient exceeds max of $...* | Adjudication | |
KX | Consider dispensing maintenance days supply. | Adjudication | |
KY | Dependant covered by spouses insurer. | Adjudication | |
KZ | Student eligibility to be confirmed. | Adjudication | |
L | |||
LA | Adjudicated to $0.00 as requested. | Adjudication | |
LB | Use generic - patient has generic plan. | ||
LC | Reduced to generic cost - no exceptions. | Adjudication | |
LD | Do not collect copay - item is exempt. | Adjudication | Action |
LE | Trial Rx second fee not allowed. | Adjudication | |
LF | Prescriber ID reference is missing. | error | |
LG | Lowest cost equivalent pricing. | Adjudication | |
LH | Authorization required - call adjudicator. | Adjudication | Call Adjudicator |
LI | Select network fee paid. | Adjudication | |
LJ | Resubmit to WCB with DE intervention code. | Adjudication | Re-submit |
LK | Claim processed. Net payable is zero. | Adjudication | |
LL | Drug covered by RAMQ. | Adjudication | |
LM | AIA - upcharge adjusted. | Adjudication | |
LN | Check potential benefit criteria. | Adjudication?? | |
LO | Benefit maximum exceeded. | Adjudication | |
LP | Lifetime plan maximum exceeded. | Adjudication | |
LQ | Exceeds NRT time limit. | Adjudication | |
LR | Exceeds NRT reimbursement period. | Adjudication | |
LS | Exceeds NRT xx day use limit. | Adjudication | |
LT | See trace #xxxxxx-exceeds NRT use period. | Adjudication | |
LU | Other pharmacy trace#xxxxxx-exceeds NRT use period. | Adjudication | |
LV | Exceeds annual NRT product limit. | Adjudication | |
LW | Authorization for drug expires CCYYMMDD. | Adjudication | |
LX | Predetermination - drug is eligible. | Adjudication | |
LY | Claim EC drug in separate transaction. | error? | |
LZ | Claim adjusted to plan type fee cap. | Adjudication | |
M | |||
MA | Patient should avoid alcohol while taking this drug. | DUR | |
MB | Patient should avoid tobacco while taking this drug. | DUR | |
MC | Possible drug/lab interaction. | DUR | |
MD | Possible drug/food interaction. | DUR | |
ME | Possible drug/drug interaction. Please verify the drug interaction and use appropriate intervention code. | DUR | |
ME | Possible drug/drug interaction. Please verify the drug interaction and use appropriate intervention code. | DUR | |
MF | Patient may be exceeding Rx dosage. | DUR | |
MG | Patient may be taking less than the Rx dosage. | DUR | |
MH | May be double doctoring. | DUR | |
MI | Poly-pharmacy use indicated. | DUR | |
MJ | Dose appears high. | DUR | |
MK | Dose appears low. | DUR | |
ML | Drug incompatibility indicated. | DUR | |
MM | Prior ADR on record. | DUR | |
MN | Drug allergy recorded. | DUR | |
MP | Duration of therapy may be insufficient. | DUR | |
MQ | Duration of therapy may be excessive. | DUR | |
MR | Potential drug/disease interaction. | DUR | |
MS | Potential drug/pregnancy concern. | DUR | |
MT | Drug/gender conflict indicated. | DUR | |
MU | Age precaution indicated. | DUR | |
MV | Addictive effect possible. | DUR | |
MW | Duplicate Drug. | DUR | |
MX | Duplicate therapy. | DUR | |
MY | Duplicate drug at other pharmacy. | DUR | |
MZ | Duplicate therapy at other pharmacy. | DUR | |
N | |||
NA | Duplicate ingredient same pharmacy. | DUR | |
NB | Duplicate ingredient other pharmacy. | DUR | |
NC | Dosage exceeds maximum allowable. | Adjudication | |
ND | Dosage is lower than minimum allowable. | Adjudication | |
NE | Potential overuse/abuse indicated. | DUR | |
NF | Quantity-treatment period discrepancy. | ||
NG | Product-form prescribed do not match. | ||
NH | Quantity error - indicate package size. | error | |
NI | Only one service code is allowed. | error | |
NJ | Request is inconsistent with other service. | error | |
NK | Service requires compounding. | error | |
NL | Service and compound type do not match. | ||
NM | Service and medication type do not match. | ||
NN | Intervention inconsistent with service. | ||
NO | Service requires controlled use drug. | ||
NP | Services to beneficiary are restricted. | Adjudication | |
NQ | Drug not eligible for trial Rx. | Adjudication | |
NR | Drug not suitable for dosette packaging. | Adjudication | |
NS | Refusal and opinion claimed on same data. | ||
NT | Not suitable - similar item on recent trial rx. | ||
NU | Too soon after previous therapy. | DUR | |
NV | Potential duplicate claim. | ||
NW | Quantity - trial Rx days do not match. | ||
NX | Quantity exceeds trial days period. | ||
NY | Insuffient quantity for trial days period. | ||
NZ | Trial balance given too late. | Adjudication | |
O | |||
OA | Trial balance given too soon. | Adjudication | |
OB | Reject trial Rx - days supply exceeded. | Adjudication | |
OC | Quantity reduction required. | Adjudication | |
OD | Not trial Rx on record, balance rejected. | Adjudication | |
OE | Trial balance already dispensed. | Adjudication | |
OF | Initial Rx days supply exceeded. | Adjudication | |
OG | Duration exceeds high DOT - no max available. | Adjudication | |
OH | Duration exceeds high DOT but not max. | Adjudication | |
OI | Claim precedes start of current period. | Adjudication | |
OJ | Claim begins new limited supply period. | Adjudication | |
OK | Maximum allowable AIA exceeded. | Adjudication | |
OL | Max allowable dispensing fee exceeded. | Adjudication | |
OM | Special services fee not allowed. | Adjudication | |
ON | Compounding fee not valid in this field. | error | |
OP | Last supply (NCE) issued in pillbox. | DUR? | |
OQ | Special auth eligible under other coverage. | Adjudication | |
OR | Exception drug, submit to provincial plan. | Adjudication | |
OS | Submit future claims to provincial plan. | Adjudication | |
OT | Maximum fee paid - do not claim balance. | Adjudication | |
OU | Refills is X days early. | Adjudication | |
OV | Verbal prescription not permitted | Adjudication | |
OW | Verbal renewal not permitted | Adjudication | |
OX | Total claimed exceeds prescription price | Adjudication | |
OY | Special services fee has been adjusted | Adjudication | |
OZ | Patient now covered by successor payor | Adjudication | |
P | |||
PA | Prescriber restriction for this drug | Adjudication | |
PB | No match to prescriber id and name found | error | |
PC | Not a benefit for this prescriber type | Adjudication | |
PD | Cost reduced-pt. elected therapeutic option | ||
PM | No-Private-Insurance-Attestation Missing | ||
PN | Assess Recipient IMD Eligibility | ||
Q | |||
QA | Matches health spending account funds | ||
QB | Nearing health spending account funds maximum | ||
QC | Exceeds health spending account funds | ||
QD | Prior to health spending account period | Adjudication | |
QE | Health spending account period expired | Adjudication | |
QF | Monthly maximum has been reached. | Adjudication | |
QG | Drug not allowed by this program. | Adjudication | |
QH | Calculated product price is too high. | Adjudication | |
QI | Claim processed previously is cancelled. | Adjudication | |
QJ | Deferred payment - patient to pay pharmacist. | DEPRECATED | |
QK | Sent to insurer to reimburse $999.99 | ||
QL | Patient consultation suggested | ||
QM | No record of required prior therapy | ||
QN | Agency restriction for this drug. | ||
QO | Preference or step drug available | ||
QP | Drug ineligible - funded by hospital budget | ||
Drug ineligible - specialty program drug | |||
QR | Maximum allowable cost (MAC) paid | ||
QS | Claim over $9999.99, send as 2 claims | DEPRECATED | |
QT | Reduced to quantity limit maximum | ||
QU | Reduced to $ limit maximum | ||
QV | Patient has reached category $ limit. | ||
QW | Special authorization - long term. | ||
QX | Conditional eligibility period exceeded. | ||
QY | Exception drug - submit claim to insurer. | ||
QZ | Renewal denied | ||
R | |||
RA | Exceeds max. number of Rx per day. | ||
RB | Exceeds max. number of active Rx allowed. | ||
RC | Transmitted to insurer. | ||
RD | Eligible for prior approval. | ||
RE | Will pay insured if covered by drug plan. | ||
RF | Consideration to add drug is in progress. | ||
RG | Plan will advise client of benefit status. | ||
RH | Not presently an eligible benefit. | ||
RI | DIN removed from market/discontinued. | ||
RJ | Herbal, homeo, naturo products not covered. | ||
RK | This product is not covered by VAC. | ||
RL | This formulation not covered. | ||
RM | Exceeds daily limit. | ||
RN | Exceeds annual limit. | ||
RO | LRB, future fills require special authorization. | ||
RP | LRB, max exceeded, requires special authorization. | ||
RQ | Call VAC for special authorization. | ||
RR | Residual amount based on annual limit. | ||
RS | Annual limit reached with current claim. | ||
RT | Annual limit reached with previous claim. | ||
RU | Special COB, refers to plan pays amount only. | ||
RV | Non designated phys future fills need SA. | ||
RW | Special authorization (SA) required. | ||
RX | SA needed after transition period. | ||
RZ | Request for coverage logged. | ||
S | |||
SA | Preferred or step drug must be submitted. | ||
SB | Preferred drug or step drug processed. | ||
SC | Prof. fee for preferred/step drug exceeds max. | ||
SD | Days supply exceeds quantity authorized. | ||
SE | Max.allowable upcharge exceeded | ||
T | |||
TA | Unfilled balance submitted, balance portion already processed. | ||
TB | Trial portion submitted, trial portion already processed. | ||
TC | Unfilled balance submitted, already elected not to participate. | ||
TD | Drug cost claimed > drug cost on reporting claim. | ||
TE | Upcharge on trial exceeds limit. | ||
TF | Professional fee on trial exceeds limit. | ||
TG | Quantity does not match reference quantity. | ||
TH | Current claim for unfilled balance processed. | ||
TI | Balance reversal pending. | ||
TJ | Trial claim processed. | ||
TK | Days supply does not match reference days supply. | ||
TL | No trial or reporting claim found. | ||
TM | More than one matching claim found. | ||
TN | Trial portion already submitted. | ||
TO | No matching claim found. | ||
TP | Patient is eligible for trial Rx. | ||
TQ | Trial quantity claimed exceeds limit. | ||
TS | Filled balance submitted, already elected not to participate. | ||
TT | Unfilled balance submitted, trial portion not yet processed. | ||
TU | Patient has declined trial Rx program. | ||
TV | Upcharge adjusted. | ||
TX | Trial Rx reporting claim already exists. | ||
TY | Copay to collect adjusted. | ||
TZ | Filled balance submitted, balance portion already processed. | ||
U | |||
UA | Stolen special authorization #/code. | ||
UB | Optional special authorization required. | ||
UC | Void special authorization #/code. | ||
UE | Duplicate special authorization #/code. | ||
UF | Inactive special authorization #/code. | ||
UG | Missing special authorization #/code. | ||
UH | Original special authorization #/code not found. | ||
UJ | Pharmacy not authorized under program. | ||
UK | Pharmacist is not authorized. | ||
UL | Zero dispensing fee – monthly limit exceeded | ||
UM | Please document adherence counselling | ||
V | |||
VA | Days supply lower than minimum allowable of 7 | ||
W | |||
WA | Long acting formulation not appproved | ||
WB | Plan pays amt reduced by program policy | ||
WC | Other program coverage may be available | ||
WD | Drug subject to MAC pricing | ||
Z | |||
Z3 | 1st fill of trial drug > 7 days supply. Voluntary Program. Use MG code to override. | ||
Z4 | 2nd fill of trial drug > 23 days supply. | ||
ZA | Unable to resolve code. | ||
ZB | DIN does not resolve to a drug product. | ||
ZC | Cancel date can not be future dated. | ||
ZD | Cannot process claim - internal order. | ||
ZE | Transaction date cannot be future dated. | ||
ZF | Quantity error - must be one or more. | ||
ZG | Days supply error - must be one or more. | ||
ZH | Cannot find Rx with physician's Rx #. | ||
ZI | Physician's Rx # is for another patient. | ||
ZJ | Provider software is non-conformant. | ||
ZK | Cannot cancel another pharmacy's record. | ||
ZL | Compound PIN Rx already exists. | ||
ZM | Cannot cancel non-pharmacy batch record. | ||
ZN | No further payment for program period. | ||
ZO | Patient must call adjudicator re coverage. | ||
ZP | $.... left to satisfy deductible | ||
ZR | Submit receipt to TDP or attest to no PI |
Other Notes found in the Response Code Listing --- look at these next time - move up, clarify, etc**
MMF= Medication Management Fee
MMI = Medication Management Issues
re EJ – May be expressed as EJCCYYMMDD (i.e. max field length) if EJ is only code sent. Otherwise expiry date should be shown in Field E.20.03 >br>
re EK – May be expressed as EK_XXX (i.e. 6 of max field length) if only EK and two (or less) other codes are sent. Otherwise “XXX” should be shown in Field E.20.03
re ES – message in Field E.20.03 refers to a Trace Number
*re EZ – HSA refers to a “Healthcare Spending Account”
re HF – May be expressed as HFCCYYMMDD (i.e. max field length) if HF is only code sent. Otherwise expiry date should be shown in Field E.20.03
re LQ, LR, LS, LT & LV NRT = Nicotine Replacement Therapy
*re LS – May be expressed as LSnn (i.e. up
to max field length of 10). Otherwise day
use limit should be defined in Field
E.20.03.
*re LT, LU – Trace number may be
expressed as LTnnnnnnnn or Lunnnnnnnn
(i.e. up to max field length). Otherwise
Trace Number should be indicated in Field
E.20.03.
*re LW – may be expressed as
LWCCYYMMDD (i.e. max field length) if
LW is the only code sent. Otherwise trace
number should be indicated in Field
E.20.03.
*re LY – EC = Emergency Contraceptive
*Re OG & OH
DOT = Duration of Time
*Re OK
AIA = Additional Inventory Allowance
*Re OP
NCE = This is a sequential transaction
number, to identify the “last supply”,
assigned and inserted by RAMQ
*re RO & RP
LRB = Limited Restricted Benefit
*re RR, RS & RT
Codes refer to status of deductibles and
co-pays
*re RV “phys” = physician
*re RW & RX
“SA” = special authorization
*re RW & RX
“SA” = special authorization
*Re Code ZL PIN = Pharmaceutical Information Network<br
List from CPHA Spec
code | description | Error |
---|---|---|
01 | IIN error | yes |
02 | version number error | yes |
03 | transaction code error | |
04 | provider software ID error | |
05 | provider software version error | |
07 | active device ID error | |
08 | PC terminal language error | |
09 | test indicator error | |
10 | invalid MMI code | |
11 | invalid MMI/clinical service code | |
12 | MMI maximum exceeded | |
13 | invalid clinical service code | |
14 | invalid RBRVS parameter count | |
15 | invalid original Rx date | |
16 | drug not eligible for service | |
17 | prescriber must be a pharmacist | |
18 | field keyword contains invalid value | |
19 | practitioner ID not found | |
20 | no service agreement identified | |
21 | pharmacy ID code error | |
22 | provider transaction date error | |
23 | trace number error | |
24 | service not eligible for veterinary Rx | |
25 | invalid dispense reference | |
26 | "refusal to fill" claim was paid | |
27 | MMF claims exceed insurer limit | |
28 | clinical service claims exceed insurer limit | |
30 | carrier ID error | |
31 | group number error | |
32 | client ID # error | |
33 | patient code error | |
34 | patient DOB error | |
35 | cardholder identity error | |
36 | relationship error | |
37 | patient first name error | |
38 | patient last name error | |
39 | provincial health care # error | |
40 | patient gender error | |
41 | duplicate MMI event | |
42 | duplicate clinical service | |
43 | invalid dispense details submitted | |
44 | invalid MMF claim contact type | |
45 | patient not eligible for service reported | |
46 | too many same Rx references submitted | |
47 | too many same dispense references | |
50 | medical reason reference error | |
51 | medical condition/reason code error | |
52 | new/refill code error | |
53 | original prescription number error | |
54 | refill/repeat authorization error | |
55 | current Rx # error | |
56 | DIN/GP #/PIN error | |
57 | SSC error | |
58 | quantity error | |
59 | days supply error | |
60 | invalid prescriber ID reference code | |
61 | prescriber ID error | |
62 | product selection code error | |
63 | unlisted compound code error | |
64 | special authorization #/code error | |
65 | intervention/exception code error | |
66 | drug cost/product value error | |
67 | cost upcharge error | |
68 | professional fee error | |
70 | compounding charge error | |
71 | compounding time error | |
72 | special services fee error | |
75 | previously paid error | |
76 | pharmacist ID code error/missing | |
77 | adjudication date | |
80 | service code & number of DINs do not match | |
81 | primary drug product is not insured | |
82 | product duplicated in this claim for payment | |
83 | DIN is not allowed for the indicated condition | |
84 | authorization for this treatment has expired | |
85 | therapy (product) is not repeatable | |
86 | confirm provincial drug coverage for DIN | |
87 | exceeds max. # of prof. fees for this drug | |
88 | Zero Dispensing Fee 28-Day Limit Exceeded | |
90 | adjudication date error | |
99 | no claims for specified parameters | |
5A | supply source error | |
5B | designated pharmacy error | |
5C | source package size error | |
5D | prescription validity date error | |
A1 | claim is too old | |
A2 | claim is post dated | |
A3 | identical claim has been processed | |
A4 | claim has not been captured | |
A5 | claim has not been processed | |
A6 | submit manual claim | |
A7 | submit manual reversal | |
A8 | no reversal made-orig. claim missing | |
A9 | reversal processed previously | |
AA | duplicate of claim adjudication | |
AB | swipe benefit card for payment | |
B1 | pharmacy not authorized to submit claims | |
B2 | return to first pharmacy requested | |
B3 | invalid PharmaNet Rx ID | |
B4 | PharmaNet Rx ID does not match patient | |
B5 | prescriber differs from Rx | |
B6 | date of service is less than Rx date | |
B7 | date of service is less than disp. start date | |
B8 | prescription has expired | |
B9 | prescription has been adapted | |
BA | chronic disease costs are not a benefit | |
C1 | patient age over plan maximum | |
C2 | service provided before effective date | |
C3 | coverage expired before service | |
C4 | coverage terminated before service | |
C5 | plan maximum exceeded | |
C6 | patient has other coverage | |
C7 | patient must claim reimbursement | |
C8 | no record of this beneficiary | |
C9 | patient not covered for drugs | |
CA | needles not eligible-insulin gun used | |
CB | only enrolled for single coverage | |
CC | this spouse not enrolled | |
CD | patient not entitled to drug claimed | |
CE | 35 Day Maximum Allowed for Welfare Client | |
CF | Quantity Exceeds Maximum Days of Treatment | |
CG | Drug Not Eligible for LTC Facility | |
CH | Good Faith Coverage has Expired | |
CI | Program Not Eligible for Good Faith | |
CJ | Patient Not Covered by this Plan | |
CK | Health Card Version Code Error | |
CL | Exceeds Good Faith Limit | |
CM | Patient is nearing quantity limit | |
CN | Patient has attained quantity limit | |
CO | Patient is over quantity limit | |
CP | eligible for special authorization | |
CQ | date not covered by premiums paid | |
CR | patient is exceeding dosage safety limit | |
CS | patient exclusion prevents payment | |
CT | beneficiary not eligible to use provider | |
CU | beneficiary not eligible to use prescriber | |
CV | no record of client ID number | |
CW | no record of group number or code | |
CX | no record of patient data | |
CY | no record of patient code | |
CZ | no record of authorization number | |
D1 | DIN/PIN/GP #/SSC not a benefit | |
D2 | DIN/PIN/GP # is discontinued | |
D3 | prescriber is not authorized | |
D4 | refills are not covered | |
D5 | co pay exceeds total value | |
D6 | maximum cost is exceeded | |
D7 | refill too soon | |
D8 | reduced to generic cost | |
D9 | call adjudicator | |
DA | adjusted to interchangeable-prov. reg. | |
DB | adjusted to interchangeable-gen. plan | |
DC | pharmacist ID requested | |
DD | insufficient space for all DUR Warnings | |
DE | Fill/Refill Too Late-Noncompliant | |
DF | Insufficient Space for All Warnings | |
DG | Duplicate prescription number | |
DH | Professional Fee Adjusted | |
DI | Deductible Not Satisfied | |
DJ | Drug Cost Adjusted | |
DJ - Call Adjudicator - duplicate page 42 of spec????* DK | cross selection pricing | |
DL | collect difference from patient | |
DM | days supply exceeds plan limit | |
DN | alternate product is a benefit | |
DO | future refills require prior approval | |
DP | quantity exceeds maximum per claim | |
DQ | quantity is less than minimum per claim | |
DR | days supply lower than minimum allowable | |
DS | reduced to Cost Upcharge maximum | |
DT | reduced to Compounding Charge maximum | |
DU | maximum Compounding Time Exceeded | |
DV | reduced to Special Services Fee maximum | |
DW | return to first prescriber requested | |
DX | drug must be authorized | |
DY | intervention/exception code missing | |
DZ | days supply limited due to benefit yr end | |
E1 | host processing error | |
E2 | claim coordinated with govt plan | |
E3 | claim coordinated with other carrier | |
E4 | Host Timeout Error | |
E5 | Host Processing Error - Please Re-submit | |
E6 | Host Processing Error-Do Not Re-submit | |
E7 | host processor is down | |
E8 | patient must remit cash receipt to Trillium | |
E9 | reduced to reference based price | |
EA | benefits coordinated internally | |
EB | Limited use drug. Time has expired | |
EC | Limited use drug. Approaching time limit | |
ED | concurrent therapy required | |
EE | questionable concurrent therapy | |
EF | inappropriate concurrent therapy | |
EG | no record of trying first line therapy | |
EH | claim cost reduced to days supply limit | |
EI | reverse original claim and resubmit | |
EJ | calculated renewal date is CCYYMMDD* | |
EK | extended prescription term for XXX* days | |
EL | prior to pro-rated start date | |
EM | ODB pricing - TDP deductible reached | |
EN | insurer requires provincial plan enrolment | |
EO | failure to enrol may suspend payment | |
EP | last claim, must enrol with prov. plan | |
EQ | reject, prov. plan enrolment required | |
ER | program coverage validation is down | |
ES | Call service already paid (see field E-20) | |
ET | submit invoice for price verification | |
EU | quantity &/or days supply not permitted | |
EV | claim exceeds ODB legislated pricing | |
EW | prof. fee exceeds ODB legislated pricing | |
EX | handicap authorization is required | |
EY | max cost/upcharge paid, do not claim balance | |
EZ | allowed amount paid from an HAS | |
FA | conversion successful cognitive fee paid | |
FB | invalid prescription status | |
FC | dispensed medication differs from Rx | |
FD | dispensed device differs from Rx | |
FE | prescription is not an adaptation | |
FF | must provide brand ordered – no sub allowed | |
FG | drug cost paid as per provider agreement | |
FH | exceeds maximum special service fee allowed | |
FP | dosage form not allowed for service claimed | |
FQ | medical reason reference is not eligible | |
FR | condition or risk factor is not eligible | |
FX | possible forgery-check authenticity | |
GA | preferred provider network fee paid | |
GB | preferred provider network claim | |
GC | quantity max approval is 40 days supply | |
GD | not eligible for a quantity authorization | |
GE | drug is not a benefit | |
GF | patient must contact program provider | |
HA | cardholder date of birth is required | |
HB | cardholder is over coverage age limit | |
HC | require cardholder province of residence | |
HD | patient may qualify for gov't program | |
HE | coverage suspended-refer to employer | |
HF | patient authorization expired CCYYMMDD | |
HG | client has provided consent | |
HH | client has not provided consent | |
HI | client consent required | |
HJ | client consent required in future | |
HK | confirm patient status, contact Insurer | |
H0 | HW Formulary-DIN not a benefit | |
H1 | HW Formulary-DIN on tier 1 | |
H2 | HW Formulary-DIN on tier 2 | |
H3 | HW Formulary-DIN on tier 3 | |
H8 | HW Formulary-special authorization required | |
H9 | HW Formulary-preferred or step drug available | |
I1 | beneficiary street address error | |
I2 | city or municipality error | |
I3 | province or state code error | |
I4 | postal/zip code error | |
I5 | country code error | |
I6 | address type error | |
LA | adjudicated to $0.00 as requested* | |
LB | use generic - patient has generic plan | |
LC | reduced to generic cost - no exceptions | |
LD | do not collect co pay - item is exempt | |
LE | trial Rx second fee not allowed | |
LF | prescriber ID reference is missing | |
LG | lowest cost equivalent pricing | |
LH | authorization required - call adjudicator | |
LI | select network fee paid | |
LJ | resubmit to WCB with DE intervention code | |
LK | claim processed - net payable is 0.00 | |
LL | drug covered by RAMQ | |
LM | AIA - upcharge adjusted | |
LN | check potential benefit criteria | |
LO | benefit maximum exceeded | |
LP | lifetime plan maximum exceeded | |
LQ | exceeds NRT time limit | |
LR | exceeds NRT reimbursement period | |
LS | exceeds NRT xx day use limit* | |
LT | see trace # xxxxxx, exceeds NRT use period* | |
LU | other pharmacy trace # xxxxxx-exceeds NRT use period * | |
LV | exceeds annual NRT product limit | |
LW | authorization for drug expires CCYYMMDD | |
LX | predetermination - drug is eligible | |
MB | avoidance of tobacco indicated | |
MC | drug/lab interaction potential | |
MD | drug/food interaction potential | |
ME | drug/drug interaction potential | |
MF | may be exceeding Rx dosage | |
MG | may be using less than Rx dosage | |
MH | may be double doctoring | |
MI | poly-pharmacy use indicated | |
MJ | dose appears high | |
MK | dose appears low | |
ML | drug incompatibility indicated | |
MM | prior ADR on record | |
MN | drug allergy recorded | |
MP | duration of therapy may be insufficient | |
MQ | duration of therapy may be excessive | |
MR | potential drug/disease interaction | |
MS | potential drug/pregnancy concern | |
MT | drug/gender conflict indicated | |
MU | age precaution indicated | |
MV | additive effect possible | |
MW | duplicate drug | |
MX | duplicate therapy | |
MY | duplicate drug other pharmacy | |
MZ | duplicate therapy other pharmacy | |
**MMF | Medication Management Fee** | |
**MMI | Medication Management Issues** | |
NA | duplicate ingredient same pharmacy | |
NB | duplicate ingredient other pharmacy | |
NC | dosage exceeds maximum allowable | |
ND | dosage is lower than minimum allowable | |
NE | potential overuse/abuse indicated | |
NF | quantity-treatment period discrepancy | |
NG | product-form prescribed do not match | |
NH | quantity error-indicate package size | |
NI | only one service code is allowed | |
NJ | request is inconsistent with other service | |
NK | service requires compounding | |
NL | service and compound type do not match | |
NM | service & medication type do not match | |
NN | intervention inconsistent with service | |
NO | service requires controlled use drug | |
NP | services to beneficiary are restricted | |
NQ | drug not eligible for trial Rx | |
NR | drug not suitable for dosette packaging | |
NS | refusal and opinion claimed on same date | |
NT | not suitable-similar item on recent trial Rx | |
NU | too soon after previous therapy | |
NV | potential duplicate claim | |
NW | quantity - trial Rx days do not match | |
NX | quantity exceeds trial days period | |
NY | insufficient quantity for trial days period | |
NZ | trial balance given too late | |
OA | trial balance given too soon | |
OB | reject trial Rx - days supply exceeded | |
OC | quantity reduction required | |
OD | no trial Rx on record, balance rejected | |
OE | trial balance already dispensed | |
OF | initial Rx days supply exceeded | |
OG | duration exceeds high DOT- no max available | |
OH | duration exceeds high DOT but not max. | |
OI | claim precedes start of current period | |
OJ | claim begins new limited supply period | |
OK | maximum allowable AIA exceeded | |
OL | max allowable dispensing fee exceeded | |
OM | special services fee not allowed | |
ON | compounding fee not valid in this field | |
OP | last supply (NCE) issued in pillbox | |
OQ | special auth eligible under other cvg. | |
OR | exception drug, submit to provincial plan | |
OS | submit future claims to provincial plan | |
OT | maximum fee paid – do not claim balance | |
OU | refill is X days early | |
OV | verbal prescription not permitted | |
OW | verbal renewal not permitted | |
OX | total claimed exceeds prescription price | |
OY | special services fee has been adjusted | |
OZ | patient now covered by successor payor | |
PA | prescriber restriction for this drug | |
PB | no match to prescriber ID and name found | |
PC | not a benefit for this prescriber type | |
PD | cost reduced-pt. elected therapeutic option | |
PM | No-Private-Insurance-Attestation | |
QA | matches health spending account funds | |
QB | nearing health spending acct. funds max. | |
QC | exceeds health spending account funds | |
QD | prior health spending account | |
QE | health spending account period expired | |
QF | monthly maximum has been reached | |
QG | drug not allowed by this program | |
QH | calculated product price is too high | |
QI | claim processed previously is cancelled | |
QJ | deferred payment - patient to pay pharmacist - *remove | |
QK | sent to insurer to reimburse $999.99 | |
QL | patient consultation suggested | |
QM | no record of required prior therapy | |
QN | agency restriction for this drug | |
QO | preference or step drug available | |
QP | drug ineligible - funded by hospital budget | |
drug ineligible - specialty program drug | ||
QR | maximum allowable cost (MAC) paid | |
QS | claim over $9999.99, send as 2 claims | |
QT | reduced to quantity limit maximum | |
QU | reduced to $ limit maximum | |
QV | patient has reached category $ limit | |
QW | special authorization - long term | |
QX | conditional eligibility period exceeded | |
QY | exception drug - submit claim to insurer | |
QZ | renewal denied | |
RA | exceeds max. number of Rx per day | |
RB | exceeds max. number of active Rx allowed | |
RC | transmitted to insurer | |
RD | eligible for prior approval | |
RE | will pay insured if covered by drug plan | |
RF | consideration to add drug is in progress | |
RG | plan will advise client of benefit status | |
RH | not presently an eligible benefit | |
RI | DIN removed from market/discontinued | |
RJ | herbal, homeo, naturo products not covered | |
RK | this product is not covered by VAC | |
RL | this formulation not covered | |
RM | exceeds daily limit | |
RN | exceeds annual limit | |
RO | LRB, future fills require spec auth | |
RP | LRB, max exceeded, requires spec auth | |
RQ | call VAC for special authorization | |
RR | residual amount based on annual limit | |
RS | annual limit reached with current claim | |
RT | annual limit reached with previous claim | |
RU | Special COB, refers to Plan Pays amount only | |
RV | Non designated phys future fills need SA | |
RW | Special Authorization (SA) required | |
RX | SA needed after transition period | |
RZ | request for coverage logged | |
SA | preferred or step drug must be submitted | |
SB | preferred drug or step drug processed | |
SC | prof. fee for preferred/step drug exceeds max. | |
SD | days supply exceeds quantity authorized | |
SE | max. allowable upcharge exceeded | |
TA | balance of trial was processed previously | |
TB | trial claim already sent and processed | |
TC | patient declined trial, bal. Claim invalid | |
TD | drug cost on trial exceeds MAC | |
TE | upcharge on trial exceeds limit | |
TF | professional fee on trial exceeds limit | |
TG | quantity does not match ref. quantity | |
TH | current claim for unfilled bal. Processed | |
TI | balance reversal pending | |
TJ | trial claim processed | |
TK | days supply does not match reference days supply | |
TL | no trial or reporting claim found | |
TM | more than one matching claim found | |
TN | trial portion already claimed | |
TO | no matching claim found | |
TP | patient is eligible for trial Rx | |
TQ | trial quantity claimed exceeds limit | |
TT | trial not processed, bal. Claim invalid | |
TU | patient has declined trial Rx program | |
TV | upcharge adjusted | |
TX | trial Rx reporting claim already exists | |
TY | co pay to collect adjusted | |
UA | stolen special authorization #/code | |
UB | optional special authorization required | |
UC | void special authorization #/code | |
UE | duplicate special authorization #/code | |
UF | inactive special authorization #/code | |
UG | missing special authorization #/code | |
UH | original spec.auth. #/code not found | |
UJ | pharmacy not authorized under program | |
UK | pharmacist is not authorized | |
UL | zero dispensing fee – monthly limit exceeded | |
UM | please document adherence counselling | |
UN | claim does not comply with terms of Spec Auth | |
VA | days supply lower than minimum allowable of 7 | |
WA | long acting formulation not approved | |
WB | plan pays amt reduced by program policy | |
WC | other program coverage may be available | |
WD | drug subject to MAC pricing | |
Z3 | 1st fill of trial drug > 7 days supply | |
Z4 | 2nd fill of trial drug > 23 days supply | |
ZA | unable to resolve code | |
ZB | DIN does not resolve to a drug product | |
ZC | cancel date can not be future dated | |
ZD | cannot process claim – internal order | |
ZE | transaction date cannot be future dated | |
ZF | quantity error – must be one or more | |
ZG | days supply error – must be one or more | |
ZH | cannot find Rx with physician's Rx # | |
ZI | physician's Rx # is for another patient | |
ZJ | provider software is non-conformant | |
ZK | cannot cancel another pharmacy's record | |
ZL | compound PIN Rx already exists | |
ZM | cannot cancel non-pharmacy batch record | |
ZN | no further payment for program period | |
ZO | patient must call adjudicator re coverage | |
ZP | $.... left to satisfy deductible | |
ZR | Submit receipt to TDP or attest to no PI |