Top 20 D.0 Rejection Reasons

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Top 20 D.0

Rejection

Reasons

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Document History

Writer(s) SMEs / Editors Release Date Version Edition / Changes

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Overview ... 1

Stop Being Rejected! ... 1

R8: Syntax Error ... 1

NX: M/I Submission Clarification Code ... 1

DK: Submission Clarification Code Not Supported ... 1

AK: M/I Software Vendor / Certification ID ... 3

4X: M/I Patient Residence... 3

E2: M/I Route of Administration ... 4

8E: M/I DUR / PPS Level of Effort ... 4

SG: Submission Clarification Code Count Does Not Match Number of Repetitions ... 5

8M: Sum of Compound Ingredient Costs Does Not Equal Ingredient Cost ... 5

C8: Discrepancy Between Other Coverage Code And Other Payor Amt ... 6

NQ: M/I Other Payor-Patient Responsibility ... 7

NP: M/I Other Payor – Patient Responsibility ... 8

MW: M/I Other Benefit Stage Amount ... 8

MX: Benefit Stage Amount does not match number or repetitions ... 10

HB: Other Payor Amount Paid Count Exceeds Number of Supported Groupings... 10

NR: M / I Other Payer – Patient Responsibility ... 11

4C: M / I Coordination of Benefits / Other Payments Count ... 11

RE: Compound Product ID Qualifier Value Not Supported ... 11

6T: Compound Segment Requires For Adjudication ... 12

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1 Top 20 D.0 Rejection Reasons Rev: 8/8/2014

Overview

In order to make the resolution of pharmacy rejections easier, we collected the 20 most common NCPDP claim rejections and created recommendations for resolving them in CPR+. This document is an invaluable resource to use when working claim rejections.

Stop Being Rejected!

The following pages present the top 20 rejection reasons and how to make changes so you won’t be rejected again.

R8: Syntax Error

This error indicates there is invalid data on the claim, and it cannot be processed. When you receive this error, the payor may or may not return a rejection code to specify the field causing this error.

NX: M/I Submission Clarification Code

Populate the Submission Clarification Code (DK) field with a value greater than 0 (zero) to correct this rejection.

DK: Submission Clarification Code Not Supported

Populate the Submission Clarification Code (DK) field with a value greater than 0 (zero) to correct this rejection.

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AK: M/I Software Vendor / Certification ID

Navigate to the Insurance Companies database. Select Payor > Edit Payor > Electronic Setup

button > 1 – 13 sub-tab > #9 Software Certification ID. Select the appropriate value using the

drop-down.

4X: M/I Patient Residence

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E2: M/I Route of Administration

Populate the (E2) Route of Administration field on the Prescriber / Cmpd /Auth tab of the claim.

8E: M/I DUR / PPS Level of Effort

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SG: Submission Clarification Code Count Does Not Match Number of

Repetitions

Populate the (DK) Submission Clarification Code field on the Prescriber / Cmpd /Auth tab of the claim with a value greater than 0 (zero).

8M: Sum of Compound Ingredient Costs Does Not Equal Ingredient

Cost

Review and correct, if applicable, both the (D9) Ingredient Cost field for each line item on the compound claim and the Payor’s Electronic Setup option #10, Calculate Gross Amt Based On field.

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C8: Discrepancy Between Other Coverage Code And Other Payor Amt

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NQ: M/I Other Payor-Patient Responsibility

To avoid this rejection, select the Prescription Data tab > COB / Other Payor > Edit Payor >

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NP: M/I Other Payor – Patient Responsibility

To avoid this rejection, select the Prescription Data tab > COB / Other Payor > Edit Payor >

Patient Resp. Enter or edit the corresponding Patient Responsibility.

MW: M/I Other Benefit Stage Amount

Select the Prescription Data tab > COB / Other Payor > Edit Payor > Benefit Stage > Add. Enter the (MV) Benefit Qualifier and (MW) Benefit Amount fields

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MX: Benefit Stage Amount does not match number or repetitions

This rejection is similar to the MW rejections. See the above screenshot to make corrections. The (MV)

Benefit Qualifier and (MW) Benefit Amount information can be found on the Primary Response.

HB: Other Payor Amount Paid Count Exceeds Number of Supported

Groupings

To avoid this rejection, exclude the payment amount. This is populated on and accessed from the

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NR: M / I Other Payer – Patient Responsibility

This rejection is handled by editing the Patient Resp. field. Select the Prescription Data tab > COB /

Other Payor > Edit Payor > Patient Resp.

4C: M / I Coordination of Benefits / Other Payments Count

This rejection is received when there is missing COB information or when a blank line appears on the COB / Other Payor Information window.

RE: Compound Product ID Qualifier Value Not Supported

This rejection is often found on compounded claims. To resolve this rejection, select Main Menu >

Databases > Insurance Companies > desired payor > Electronic Setup > 14-26 sub-tab and

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6T: Compound Segment Requires For Adjudication

To resolve this rejection, select Main Menu > Databases > Insurance Companies > desired

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E1: M/I Alternative Product Type

This rejection is often found on compound claims. To resolve this rejection is a two step process. You need to edit the payor settings and the claim.

To edit the payor settings, select Main Menu > Databases > Insurance Companies >desired

payor > Electronic Setup > 14-26 sub-tab and populate #17 = Y; #18 = 00; #20 = N.

To correct the claim once the payor settings are applied, change the Product / Service ID Qualifier to

00 on the Prescriber / Cmpd / Auth tab. Enter 2 in the Compound Code field and Related in all other

compound-related fields.