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
QQ 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
QQ 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