NCPDP Payer Sheet Supplement to the Arkansas Medicaid
advertisement
NCPDP Payer Sheet Supplement to the Arkansas Medicaid Companion Guide for NCPDP 5.1 HP Arkansas Title XIX Account 500 President Clinton Avenue, Suite 400 Little Rock, AR 72201 501.374.6608 Arkansas Medicaid NCPDP Payer Sheet Modification log 1.0 9/25/03 Mary Easterling 1.1 9/26/03 Robert Kirkpatrick 1.2 5/13/04 Mary Easterling Pricing Segment Change in fields 426-DQ and 43Ø –DU; effective date: 7/14/2004 1/7/05 Toni Butler Error codes Replaced error codes with current list 6/8/05 Denise Felton Error codes Replaced error codes with current list 12/1/05 Denise Felton per Toni Butler Field 436-E1 Added value 03 = National Drug Code (NDC) Error codes Added codes Y700 and Y701 3/5/07 Denise Felton per Toni Butler Error codes Added codes Y720 and Z816 4/3/07 Denise Felton per Toni Butler Fields NPI update: Revised fields 202-B2, 201-B1, 466-EZ, 411-DB 4/11/07 Denise Felton per Toni Butler Added error messages 3760 and 3761; edited error message Y070. 4/19/07 Denise Felton per Toni Butler Error code revisions due to NPI. 2/15/08 Denise Felton per Lisa Stewart Field 526FQ Added note Error codes Added 2807 7/17/08 Denise Felton per Mary Alice Easterling Claim Segment Clarified description for field 407-D7 11/6/08 Denise Felton per Toni Butler Error codes Added error code 2223 1/30/09 Denise Felton per Toni Butler Error codes Added error code Q234 12/3/2009 Denise Felton per Angelia Norris Error Codes Added error codes 9073 and 9074 8/6/2010 Denise Felton per Angelia Norris Field 310-CA Changed to required for Arkansas Medicaid Field 311-CB Changed to required for Arkansas Medicaid Error Codes Added error codes Y750, Y751, Y760, Y761, Z620 andZ621. Error Codes Added error code 3690 11/03/2010 11/03/10 Abby Perrine per Angelia Norris Reformatted and minor corrections i Arkansas Medicaid NCPDP Payer Sheet Content Modification log ......................................................................................................................... i Content ...................................................................................................................................... ii This guide .................................................................................................................................. 1 Purpose ........................................................................................................................... 1 Claim Billing Request ............................................................................................................... 2 Mandatory, Required, Situational or Optional fields ......................................................... 2 Separator characters ....................................................................................................... 2 Valid delimiters for NCPDP Transactions ........................................................................ 2 Field Separator example ................................................................................................. 3 Transaction Header Segment .......................................................................................... 3 Patient Segment .............................................................................................................. 4 Insurance Segment ......................................................................................................... 6 Claim Segment ................................................................................................................ 6 Pharmacy Provider Segment ......................................................................................... 10 Prescriber Segment ....................................................................................................... 11 COB/Other Segment ..................................................................................................... 11 Worker’s Compensation Segment ................................................................................. 12 DUR/PPS Segment ....................................................................................................... 13 Pricing Segment ............................................................................................................ 15 Coupon Segment .......................................................................................................... 16 Compound Segment...................................................................................................... 17 Prior Authorization Segment .......................................................................................... 18 Clinical Segment ........................................................................................................... 19 Claim Billing Response .......................................................................................................... 21 Response Header Segment .......................................................................................... 21 Response Message Segment........................................................................................ 22 Response Insurance Segment ...................................................................................... 22 Response Status Segment ............................................................................................ 22 Response Claim Segment ............................................................................................. 24 Response Pricing Segment ........................................................................................... 25 Response DUR/PPS Segment ...................................................................................... 27 Error codes.............................................................................................................................. 29 11/03/10 ii Arkansas Medicaid NCPDP Payer Sheet This guide Audience Companion documents are intended for information technology and/or systems staff who will be coding billing systems or software for compliance with the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA). Purpose The companion documents are designed to be used with HIPAA Implementation Guides. Companion documents provide Arkansas Medicaid-specific information that details the way to create HIPAA transactions for Arkansas Medicaid and explains how Arkansas Medicaid creates HIPAA transactions. Companion documents clarify the HIPAA-designated standards usage but are not intended to supercede them. The purpose of companion documents is to provide trading partners with a guide to communicate the Arkansas Medicaid-specific information required to successfully exchange transactions electronically with Arkansas Medicaid. Arkansas Medicaid will accept and process any HIPAA-compliant transaction. However, a compliant transaction that doesn't contain Arkansas Medicaid-specific information, though processed, may be denied for payment. For example, a compliant NCPDP claim created without an Arkansas Medicaid recipient identification number will be processed by Arkansas Medicaid, but will be denied payment. Companion documents highlight the data elements significant for Arkansas Medicaid. For transactions created by Arkansas Medicaid, companion documents explain how certain data elements are processed. Please refer to the companion document first if there is a question about how Arkansas Medicaid processes a HIPAA transaction. 11/03/10 Arkansas Medicaid Claim Billing Request Claim Billing Request Billing transactions are used by the Originator to request payment from Arkansas Medicaid for a specific patient for claims or services billed according to appropriate plan parameters. Billing transactions require the submission of the following segments: header, insurance, claim and pricing. Up to four transactions per transmission are permitted. Mandatory, Required, Situational or Optional fields In the segment descriptions, the entries in the Mandatory, Required, Situational or Optional Column are as follows: Mandatory Mandatory for NCPDP Standards Required Required for Arkansas Medicaid Situational Required under described circumstances for Arkansas Medicaid Optional Optional for both NCPDP and Arkansas Medicaid Separator characters A Segment Separator (hex character "1E", decimal "3Ø") delineates each segment within the transaction. A Group Separator (hex character "1D", decimal "29") denotes the start of each transaction in the transmission. A Field Separator (hex character "1C", decimal "28") separates each field in a transaction's segments. Each field has a unique identifier code that, when used in conjunction with the Field Separator, shows the start of a new field in the record (for example, FB refers to Field 511-FB, Reject Code). Valid delimiters for NCPDP Transactions Field Field Name Mandatory or Valid Values and Formats Comments Optional SS Segment Separator Mandatory Decimal Representation = [Ø3Ø] Separates segments from each other. Hex Representation = <1E> Delineates each segment within the transaction. 11/03/10 Arkansas Medicaid Claim Billing Request Field Field Name Mandatory or Valid Values and Formats Comments Optional GS Group Separator Mandatory Decimal Representation = [Ø29] Separates groups from each other. Hex Representation = <1D> Denotes the start of each transaction in the transmission. FS Field Separator Mandatory Decimal Representation = [Ø28] Hex Representation = <1C> Separates fields from each other in a transaction's segment. See example below. Field Separator example Field Field Name Mandatory or Valid Values and Formats Comments Optional FS Field Separator Mandatory, Example: <1C>"AM" if following field Hex <1C> in position 1, then is included. the two (2) character field ID ("AM") in positions 2 thru 3. This Field Separator (as shown by the hex identifier <1C>) states that a "Segment" field (shown by the field ID code "AM") will follow. Mandatory This is the "Segment" field indicated by the Field Separator above. 111-AM SEGMENT IDENTIFICATION Ø1 = Patient Transaction Header Segment NOTE: Truncation within a Transaction Header Segment is not allowed. Field Field Name Mandatory, Required or Optional Valid Values and Formats Comments 1Ø1-A1 BIN NUMBER Mandatory "61ØØ93" 1Ø2-A2 VERSION/RELEASE Mandatory NUMBER 51 = Version 5.1 1Ø3-A3 TRANSACTION CODE B1 = Billing 1Ø4-A4 PROCESSOR Mandatory CONTROL NUMBER 716ØØ7869 1Ø9-A9 TRANSACTION COUNT 1 = One Occurrence 2 = Two Occurrences 3 = Three Occurrences 11/03/10 Mandatory Mandatory Enter the count of prescription claims submitted on the current Arkansas Medicaid Field Field Name Claim Billing Request Mandatory, Required or Optional Valid Values and Formats Comments 4 = Four Occurrences 2Ø2-B2 SERVICE PROVIDER ID QUALIFIER Mandatory transaction. 01 = National Provider ID or 05 – Medicaid Provder ID 2Ø1-B1 SERVICE PROVIDER ID Mandatory 10 character National Provider ID or Enter the 10 character National Provider ID of the entity actually providing the prescription. 9 character Medicaid Provider ID 4Ø1-D1 DATE OF SERVICE Mandatory 11Ø-AK SOFTWARE VENDOR/ CERTIFICATION ID Mandatory Format: CCYYMMDD CC = Century YY = Year MM = Month DD = Day Enter the date filled/date of service. Enter the ID number assigned by the switch or processor to identify the software source. Patient Segment Field Field Name Mandatory, Required or Optional Valid Values and Formats Comments 111-AM SEGMENT IDENTIFICATION Mandatory Ø1 = Patient 331-CX PATIENT ID QUALIFIER Optional Not used by Arkansas Medicaid. 332-CY PATIENT ID Optional Not used by Arkansas Medicaid. 3Ø4-C4 DATE OF BIRTH Required Format: CCYYMMDD CC = Century YY = Year MM = Month DD = Day Enter the patient’s date of birth. 3Ø5-C5 PATIENT GENDER CODE Optional Ø = Not Specified 1 = Male 2 = Female Not used by Arkansas Medicaid. 31Ø-CA PATIENT FIRST NAME 11/03/10 Required Enter the patient’s first name. Arkansas Medicaid Claim Billing Request Field Field Name Mandatory, Required or Optional Valid Values and Formats Comments 311-CB PATIENT LAST NAME Required Enter the patient’s last name. 322-CM PATIENT STREET ADDRESS Optional Not used by Arkansas Medicaid. 323-CN PATIENT CITY ADDRESS Optional Not used by Arkansas Medicaid. 324-CO PATIENT STATE/ PROVINCE ADDRESS Optional Not used by Arkansas Medicaid. 325-CP PATIENT ZIP/ POSTAL ZONE Optional Not used by Arkansas Medicaid. 326-CQ PATIENT PHONE NUMBER Optional Not used by Arkansas Medicaid. 3Ø7-C7 PATIENT LOCATION Optional Valid values for Arkansas Medicaid: Ø = Not Specified Enter the code identifying the location where the patient receives pharmacy services. 1 = Home 2 = Inter-Care 3 = Nursing Home 4 = Long Term/Extended Care 5 = Rest Home 6 = Boarding Home 7 = Skilled Care Facility 8 = Sub-Acute Care Facility 9 = Acute Care Facility 1Ø = Outpatient 11 = Hospice 333-CZ EMPLOYER ID Optional 334-1C SMOKER/NONSMOKER CODE Optional Blank = Not Specified 1 = Non-Smoker 2 = Smoker Not used by Arkansas Medicaid. 335-2C PREGNANCY INDICATOR Optional Blank = Not Specified 1 = Not pregnant 2 = Pregnant Not used by Arkansas Medicaid. 11/03/10 Not used by Arkansas Medicaid. Arkansas Medicaid Claim Billing Request Insurance Segment Field Field Name Mandatory, Required or Optional Valid Values and Formats Comments 111-AM SEGMENT IDENTIFICATION Mandatory Ø4 = Insurance 3Ø2-C2 CARDHOLDER ID Mandatory Enter the Arkansas Medicaid 1Ø-digit Recipient Identification Number. 312-CC CARDHOLDER FIRST NAME Required Enter the recipient’s first name. The entered data must match the insured’s first name on file. 313-CD CARDHOLDER LAST NAME Required Enter the recipient’s last name. The entered data must match the insured’s last name on file. 314-CE HOME PLAN Optional Not used by Arkansas Medicaid. 524-FO PLAN ID Optional Not used by Arkansas Medicaid. 3Ø9-C9 ELIGIBILITY CLARIFICATION CODE Optional Not used by Arkansas Medicaid. 336-8C FACILITY ID Optional Not used by Arkansas Medicaid. 3Ø1-C1 GROUP ID Optional Not used by Arkansas Medicaid. 3Ø3-C3 PERSON CODE Optional Not used by Arkansas Medicaid. 3Ø6-C6 PATIENT RELATIONSHIP CODE Optional Not used by Arkansas Medicaid. Claim Segment Field Field Name Mandatory, Valid Values and Formats Comments Required, Situational or Optional 111-AM SEGMENT IDENTIFICATION Mandatory 11/03/10 Ø7 = Claim Arkansas Medicaid Claim Billing Request Field Field Name Mandatory, Valid Values and Formats Comments Required, Situational or Optional 455-EM PRESCRIPTION/ SERVICE REFERENCE NUMBER QUALIFIER Mandatory 4Ø2-D2 PRESCRIPTION/ SERVICE REFERENCE NUMBER Mandatory Prescription Number 436-E1 PRODUCT/ SERVICE ID QUALIFIER Mandatory Valid values for Arkansas Medicaid: Valid values for Arkansas Medicaid: 1 = Rx Billing Enter the unique 7-digit prescription/reference number assigned by the provider. Ø3 = National Drug Code (NDC) ØØ = Compounded RX Claim 4Ø7-D7 PRODUCT/ SERVICE ID Mandatory Format: MMMMMDDDDPP MMMMM = Manufacturer's Assigned Number DDDD = Drug ID PP = Package Size Enter the 11-digit National Drug Code (NDC) of the product actually dispensed; for compounded prescription claims, this field should be blank or populated with zeroes. 456-EN ASSOCIATED PRESCRIPTION/ SERVICE REFERENCE # Situational Required for “Completion” transactions of partial fills 457-EP ASSOCIATED PRESCRIPTION/ SERVICE DATE Situational Required for “Completion” transactions of partial fills 458-SE PROCEDURE MODIFIER CODE COUNT Optional Not used by Arkansas Medicaid. 459-ER PROCEDURE MODIFIER CODE Optional Repeating Not used by Arkansas Medicaid. 442-E7 QUANTITY DISPENSED Required Format: 9999999.999 Enter the quantity dispensed, expressed in metric decimal units. 4Ø3-D3 FILL NUMBER Required ØØ = Original dispensing Ø1 to 99 = Refill number Enter a number to specify the sequential fill number of this prescription. 4Ø5-D5 DAYS SUPPLY Required 11/03/10 Enter the estimated number of days the prescription will last. Arkansas Medicaid Claim Billing Request Field Field Name Mandatory, Valid Values and Formats Comments Required, Situational or Optional 4Ø6-D6 COMPOUND CODE Required 1 = Not a Compounded Rx 2 = Compounded Rx If Value = 1 (Not a Compounded Rx), 1 NDC is allowed per prescription, up to 4 prescriptions per transaction. If Value = 2 (Compounded Rx), 2 to 25 NDCs are allowed per prescription, but only 1 prescription per transaction. 4Ø8-D8 DISPENSE AS WRITTEN (DAW)/ PRODUCT SELECTION CODE Required Valid values for Arkansas Medicaid: Ø = No DAW 1 = DAW Arkansas flags DAW 1 as being dispensed "Brand Medically Necessary” 414-DE Format: CCYYMMDD Enter “1” to indicate a prior authorization for Brand Medically Necessary to override the Generic Upper Limit (GUL). Otherwise, enter “Ø” to price without GUL override. DATE PRESCRIPTION WRITTEN Optional 415-DF NUMBER OF REFILLS AUTHORIZED Optional Not used by Arkansas Medicaid. 419-DJ PRESCRIPTION ORIGIN CODE Optional Not used by Arkansas Medicaid. CC = Century YY = Year MM = Month DD = Day 42Ø-DK SUBMISSION CLARIFICATION CODE Situational 46Ø-ET QUANTITY PRESCRIBED Optional 3Ø8-C8 OTHER COVERAGE Required CODE Valid value for Arkansas Medicaid: 8 = Process compounded prescription claim for approved ingredients Enter "8" on a compounded prescription claim to indicate acceptance of payment for only those ingredients covered. Not used by Arkansas Medicaid. Ø = Not specified 1 = No other coverage identified 2 = Other coverage exists — payments collected 3 = Other coverage exists — this claim not covered 4 = Other coverage exists — 11/03/10 Not used by Arkansas Medicaid. Enter a code indicating whether or not the patient has other insurance coverage. Arkansas Medicaid Field Field Name Claim Billing Request Mandatory, Valid Values and Formats Comments Required, Situational or Optional payment not collected 5 = Managed care plan denial 6 = Other coverage denied — not a participating provider 7 = Other coverage exists — not in effect at time of service 8 = Claim is a billing for a copay. 429-DT UNIT DOSE INDICATOR Optional Ø = Not Specified 1 = Not Unit Dose 2 = Manufacturer Unit Dose 3 = Pharmacy Unit Dose 453-EJ ORIGINALLY PRESCRIBED PRODUCT/ SERVICE ID QUALIFIER Optional Not used by Arkansas Medicaid. 445-EA ORIGINALLY PRESCRIBED PRODUCT/ SERVICE CODE Optional Not used by Arkansas Medicaid. 446-EB ORIGINALLY PRESCRIBED QUANTITY Optional Not used by Arkansas Medicaid. 33Ø-CW ALTERNATE ID Optional Not used by Arkansas Medicaid. 454-EK SCHEDULED PRESCRIPTION ID NUMBER Optional Not used by Arkansas Medicaid. 6ØØ-28 UNIT OF MEASURE Optional EA = Each GM = Grams ML = Milliliters Not used by Arkansas Medicaid. 418-DI LEVEL OF SERVICE Optional ØØ = Not Specified Not used by Arkansas Medicaid. Ø1 = Patient consultation Ø2 = Home delivery Ø3 = Emergency Dispense Ø5 = Patient consultation regarding generic product selection Ø6 = In-Home Service 11/03/10 Not used by Arkansas Medicaid. Arkansas Medicaid Claim Billing Request Field Field Name Mandatory, Valid Values and Formats Comments Required, Situational or Optional 461-EU PRIOR AUTHORIZATION TYPE CODE Optional Not used by Arkansas Medicaid. 462-EV PRIOR AUTHORIZATION NUMBER SUBMITTED Optional Not used by Arkansas Medicaid. 463-EW INTERMEDIARY AUTHORIZATION TYPE ID Optional Not used by Arkansas Medicaid. 464-EX INTERMEDIARY Optional AUTHORIZATION ID Not used by Arkansas Medicaid. 343-HD DISPENSING STATUS Situational Blank = Not Specified = Neither a Partial Fill nor a Completion of a Partial Fill Enter “P” or “C” to indicate a partial filling or a completion of a partial filling. P = Partial Fill C = Completion of Partial Fill 344-HF QUANTITY INTENDED TO BE DISPENSED Situational 345-HG DAYS SUPPLY INTENDED TO BE DISPENSED Situational Format: 9999999.999 Enter the quantity that would be dispensed, expressed in metric decimal units. Enter the estimated number of days the prescription would last if the intended quantity were dispensed. Pharmacy Provider Segment Arkansas Medicaid does not use this segment. Field Field Name Mandatory, Required or Optional 111-AM SEGMENT IDENTIFICATION Mandatory Not used by Arkansas Medicaid. 465-EY PROVIDER ID QUALIFIER Optional Not used by Arkansas Medicaid. 444-E9 PROVIDER ID Optional Not used by Arkansas Medicaid. 11/03/10 Valid Values and Formats Comments Arkansas Medicaid Claim Billing Request Prescriber Segment Field Field Name Mandatory, Required or Optional Valid Values and Formats Comments 111-AM SEGMENT IDENTIFICATION Mandatory Ø3 = Prescriber 466-EZ PRESCRIBER ID QUALIFIER Required Values: 01 = National Provider ID or 05 = Medicaid Provider ID 411-DB PRESCRIBER ID Required 10 character National Provider ID or Enter the National Provider ID of the prescribing physician. 9 character Medicaid Provider ID 467-1E PRESCRIBER LOCATION CODE Optional Not used by Arkansas Medicaid. 427-DR PRESCRIBER LAST Optional NAME Not used by Arkansas Medicaid. 498-PM PRESCRIBER PHONE NUMBER Optional Not used by Arkansas Medicaid. 468-2E PRIMARY CARE PROVIDER ID QUALIFIER Optional Not used by Arkansas Medicaid. 421-DL PRIMARY CARE PROVIDER ID Optional Not used by Arkansas Medicaid. 469-H5 PRIMARY CARE PROVIDER LOCATION CODE Optional Not used by Arkansas Medicaid. 47Ø-4E PRIMARY CARE PROVIDER LAST NAME Optional Not used by Arkansas Medicaid. COB/Other Segment Field Field Name Mandatory, Valid Values and Formats Comments Required, Situational or Optional 111-AM SEGMENT IDENTIFICATION Mandatory 11/03/10 Ø5 = Coordination of Benefits/Other Payments Arkansas Medicaid Claim Billing Request Field Field Name Mandatory, Valid Values and Formats Comments Required, Situational or Optional 337-4C COORDINATION OF Mandatory BENEFITS/OTHER PAYMENTS COUNT 338-5C OTHER PAYER COVERAGE TYPE Mandatory Repeating Enter the count of other payment occurrences. Ø1 = Primary Ø2 = Secondary Enter the code describing the other payer type. Ø3 = Tertiary 98 = Coupon 99 = Composite 339-6C OTHER PAYER ID QUALIFIER Optional Repeating Not used by Arkansas Medicaid. 34Ø-7C OTHER PAYER ID Optional Repeating Not used by Arkansas Medicaid. 443-E8 OTHER PAYER DATE Situational Repeating Payment or denial date of the claim submitted to the other payer. 341-HB OTHER PAYER AMOUNT PAID COUNT Situational Arkansas Medicaid Valid Value: Ø1 Enter the count of other payer amount paid occurrences. 342-HC OTHER PAYER AMOUNT PAID QUALIFIER Situational Repeating Arkansas Medicaid Valid Value: Enter the amount of any payment known by the pharmacy from other sources (including coupons). 431-DV OTHER PAYER AMOUNT PAID Situational Enter the amount of any payment known by the pharmacy from other sources (including coupons). 471-5E OTHER PAYER REJECT COUNT Optional Not used by Arkansas Medicaid. 472-6E OTHER PAYER REJECT CODE Optional Repeating Not used by Arkansas Medicaid. Ø7 = Drug Benefit Worker’s Compensation Segment Arkansas Medicaid does not use this segment. 11/03/10 Arkansas Medicaid Claim Billing Request Field Field Name Mandatory, Required or Optional Valid Values and Formats Comments 111-AM SEGMENT IDENTIFICATION Mandatory Not used by Arkansas Medicaid. 434-DY DATE OF INJURY Mandatory Not used by Arkansas Medicaid. 315-CF EMPLOYER NAME Optional Not used by Arkansas Medicaid. 316-CG EMPLOYER STREET Optional ADDRESS Not used by Arkansas Medicaid. 317-CH EMPLOYER CITY ADDRESS Optional Not used by Arkansas Medicaid. 318-CI EMPLOYER STATE/ Optional PROVINCE ADDRESS Not used by Arkansas Medicaid. 319-CJ EMPLOYER ZIP/ POSTAL ZONE Optional Not used by Arkansas Medicaid. 32Ø-CK EMPLOYER PHONE Optional NUMBER Not used by Arkansas Medicaid. 321-CL EMPLOYER CONTACT NAME Optional Not used by Arkansas Medicaid. 327-CR CARRIER ID Optional Not used by Arkansas Medicaid. 435-DZ CLAIM/REFERENCE Optional ID Not used by Arkansas Medicaid. DUR/PPS Segment Field Field Name Mandatory, Valid Values and Formats Comments Required, Situational or Optional 111-AM SEGMENT IDENTIFICATION Mandatory Ø8 = DUR/PPS 473-7E DUR/PPS CODE COUNTER Situational Valid Arkansas Medicaid value = 1 11/03/10 Maximum is 1 for both compounds and noncompounds. Arkansas Medicaid Claim Billing Request Field Field Name Mandatory, Valid Values and Formats Comments Required, Situational or Optional 439-E4 REASON FOR SERVICE CODE Situational Valid Arkansas Medicaid Reason for Service Code: HD = High Dose ER = Early Refill Enter the code identifying the type of utilization conflict detected or the reason for the pharmacist’s professional service. TD = Therapeutic Duplication DD = Drug-Drug Interaction MX = Incorrect Duration DC = Drug-Disease (inferred) AT = Additive Toxicity (clinical misuse) LR = Late Refill (underutilization) LD = Low Dose 44Ø-E5 PROFESSIONAL SERVICE CODE Situational Valid Arkansas Medicaid Professional Service Code: MØ = Prescriber consulted PØ = Patient consulted Enter the code identifying the pharmacist intervention when a conflict code has been identified or service has been rendered. RØ = Pharmacist consultant, other sources used, or pharmacist used own professional judgment 441-E6 RESULT OF SERVICE CODE Situational Valid Arkansas Medicaid Result of Service Codes: Enter the code identifying the action taken by a pharmacist in response to a 1A = Filled As Is, False conflict or the result of a Positive pharmacist’s professional 1B = Filled Prescription As Is service. 1C = Filled, With Different Dose 1D = Filled, With Different Directions 1E = Filled, With Different Drug 1F = Filled, With Different Quantity 1G = Filled, With Prescriber Approval 2A = Prescription Not Filled 2B = Not Filled, Directions Clarified 11/03/10 Arkansas Medicaid Claim Billing Request Field Field Name Mandatory, Valid Values and Formats Comments Required, Situational or Optional 474-8E DUR/PPS LEVEL OF Optional EFFORT Repeating Not used by Arkansas Medicaid. 475-J9 DUR CO-AGENT ID QUALIFIER Optional Repeating Not used by Arkansas Medicaid. 476-H6 DUR CO-AGENT ID Optional Repeating Not used by Arkansas Medicaid. Pricing Segment Field Field Name Mandatory, Required or Optional Valid Values and Formats Comments 111-AM SEGMENT IDENTIFICATION Mandatory 11 = Pricing 4Ø9-D9 INGREDIENT COST Optional SUBMITTED Not used by Arkansas Medicaid. 412-DC DISPENSING FEE SUBMITTED Optional Not used by Arkansas Medicaid. 477-BE PROFESSIONAL SERVICE FEE SUBMITTED Optional 433-DX PATIENT PAID AMOUNT SUBMITTED Optional Not used by Arkansas Medicaid. 438-E3 INCENTIVE AMOUNT SUBMITTED Optional Not used by Arkansas Medicaid. 478-H7 OTHER AMOUNT Optional CLAIMED SUBMITTED COUNT Not used by Arkansas Medicaid. 479-H8 OTHER AMOUNT CLAIMED SUBMITTED QUALIFIER Optional Repeating Not used by Arkansas Medicaid. 48Ø-H9 OTHER AMOUNT CLAIMED SUBMITTED Optional Repeating Not used by Arkansas Medicaid. 481-HA FLAT SALES TAX AMOUNT SUBMITTED Optional Not used by Arkansas Medicaid. 11/03/10 Format: s$$$$$$cc Not used by Arkansas Medicaid. Arkansas Medicaid Claim Billing Request Field Field Name Mandatory, Required or Optional 482-GE PERCENTAGE SALES TAX AMOUNT SUBMITTED Optional Not used by Arkansas Medicaid. 483-HE PERCENTAGE SALES TAX RATE SUBMITTED Optional Not used by Arkansas Medicaid. 484-JE PERCENTAGE SALES TAX BASIS SUBMITTED Optional Not used by Arkansas Medicaid. 426-DQ USUAL AND CUSTOMARY CHARGE Required Format: s$$$$$$cc Enter the pharmacy’s usual and customary price. (effective 7/14/2004) 43Ø-DU GROSS AMOUNT DUE Optional Format: s$$$$$$cc Not used by Arkansas Medicaid. (effective 7/14/2004) 423-DN Optional BASIS OF COST DETERMINATION Valid Values and Formats Comments Not used by Arkansas Medicaid. Coupon Segment Field Field Name Mandatory, Valid Values and Formats Comments Required, Situational or Optional 111-AM SEGMENT IDENTIFICATION Mandatory Ø9 = Coupon 485-KE COUPON TYPE Mandatory Blank = Not Specified Enter the type of coupon. Ø1 = Price Discount Ø2 = Free Product 99 = Other 486-ME COUPON NUMBER Mandatory 487-NE COUPON VALUE AMOUNT Situational 11/03/10 Enter the unique serial number assigned to the prescription coupon. Format: s$$$$$$cc Enter the value of the coupon. Arkansas Medicaid Claim Billing Request Compound Segment Field Field Name Mandatory, Required or Optional Valid Values and Formats Comments 111-AM SEGMENT IDENTIFICATION Mandatory 1Ø = Compound 45Ø-EF COMPOUND DOSAGE FORM DESCRIPTION CODE Mandatory Blank = Not Specified Ø1 = Capsule Ø2 = Ointment Enter the code identifying the dosage form of the complete compound mixture. Ø3 = Cream Ø4 = Suppository Ø5 = Powder Ø6 = Emulsion Ø7 = Liquid 1Ø = Tablet 11 = Solution 12 = Suspension 13 = Lotion 14 = Shampoo 15 = Elixir 16 = Syrup 17 = Lozenge 18 = Enema 451-EG COMPOUND DISPENSING UNIT FORM INDICATOR Mandatory 1 = Each 2 = Grams Enter the code identifying the dispensing units. 3 = Milliliters 452-EH COMPOUND ROUTE Mandatory OF ADMINISTRATION Ø = Not Specified 1 = Buccal 2 = Dental 3 = Inhalation 4 = Injection 5 = Intraperitoneal 6 = Irrigation 7 = Mouth/Throat 8 = Mucous Membrane 9 = Nasal 1Ø = Ophthalmic 11/03/10 Enter the code for the route of administration of the complete compound mixture. Arkansas Medicaid Claim Billing Request 11 = Oral 12 = Other/Miscellaneous 13 = Otic 14 = Perfusion 447-EC COMPOUND INGREDIENT COMPONENT COUNT Mandatory Enter the number of ingredients in the compounded prescription. 488-RE COMPOUND PRODUCT ID QUALIFIER Mandatory Repeating Enter the code qualifying the type of product dispensed, e.g., Ø3 = National Drug Code (NDC). 489-TE COMPOUND PRODUCT ID Mandatory Repeating Enter the product identification (e.g., NDC) of each ingredient in the prescription. 448-ED COMPOUND INGREDIENT QUANTITY Mandatory Repeating Enter the quantity of the ingredient in the prescription. 449-EE COMPOUND Optional INGREDIENT DRUG Repeating COST Enter the drug cost of the ingredient. (optional) 49Ø-UE COMPOUND Optional INGREDIENT BASIS Repeating OF COST DETERMINATION Not used by Arkansas Medicaid. Prior Authorization Segment Arkansas Medicaid does not use this segment. Field Field Name Mandatory, Required or Optional 111-AM SEGMENT IDENTIFICATION Mandatory Not used by Arkansas Medicaid. 498-PA REQUEST TYPE Mandatory Not used by Arkansas Medicaid. 498-PB REQUEST PERIOD DATE-BEGIN Mandatory Not used by Arkansas Medicaid. 498-PC REQUEST PERIOD DATE-END Mandatory Not used by Arkansas Medicaid. 498-PD BASIS OF REQUEST Mandatory Not used by Arkansas Medicaid. 11/03/10 Valid Values and Formats Comments Arkansas Medicaid Claim Billing Request Field Field Name Mandatory, Required or Optional Valid Values and Formats Comments 498-PE AUTHORIZED REPRESENTATIVE FIRST NAME Optional Not used by Arkansas Medicaid. 498-PF AUTHORIZED REPRESENTATIVE LAST NAME Optional Not used by Arkansas Medicaid. 498-PG AUTHORIZED REPRESENTATIVE STREET ADDRESS Optional Not used by Arkansas Medicaid. 498-PH AUTHORIZED REPRESENTATIVE CITY ADDRESS Optional Not used by Arkansas Medicaid. 498-PJ AUTHORIZED REPRESENTATIVE STATE/PROVINCE ADDRESS Optional Not used by Arkansas Medicaid. 498-PK AUTHORIZED REPRESENTATIVE ZIP/POSTAL ZONE Optional Not used by Arkansas Medicaid. 498-PY PRIOR AUTHORIZATION NUMBER-ASSIGNED Optional Not used by Arkansas Medicaid. 5Ø3-F3 AUTHORIZATION NUMBER Optional Not used by Arkansas Medicaid. 498-PP PRIOR AUTHORIZATION SUPPORTING DOCUMENTATION Optional Not used by Arkansas Medicaid. Clinical Segment Field Field Name Mandatory, Valid Values and Formats Comments Required, Situational or Optional 111-AM SEGMENT IDENTIFICATION Mandatory 491-VE DIAGNOSIS CODE COUNT Situational 13 = Clinical Fields included in the set/logical grouping are: ‘Diagnosis Code Qualifier’ (492-WE) 11/03/10 Arkansas Medicaid Field Field Name Claim Billing Request Mandatory, Valid Values and Formats Comments Required, Situational or Optional ‘Diagnosis Code’ (424-DO) 492-WE DIAGNOSIS CODE QUALIFIER Situational Repeating Arkansas Medicaid Valid Values: Ø1 = International Classification of Diseases (ICD-9) 424-DO DIAGNOSIS CODE Situational Repeating DIAG-CODE-ICD-9 A submitted pregnancy diagnosis enables co-pay exemption. All decimal points are explicit. 493-XE CLINICAL INFORMATION COUNTER Optional Repeating Not used by Arkansas Medicaid. 494-ZE MEASUREMENT DATE Optional Repeating Not used by Arkansas Medicaid. 495-H1 MEASUREMENT TIME Optional Repeating Not used by Arkansas Medicaid. 496-H2 MEASUREMENT DIMENSION Optional Repeating Not used by Arkansas Medicaid. 497-H3 MEASUREMENT UNIT Optional Repeating Not used by Arkansas Medicaid. 499-H4 MEASUREMENT VALUE Optional Repeating Not used by Arkansas Medicaid. 11/03/10 Arkansas Medicaid Claim Billing Response Claim Billing Response Depending upon the particular claim or service submission request, Arkansas Medicaid will provide one of the following general types of responses: Paid - This occurs when Arkansas Medicaid captures and processes the claim or service, and returns to the Originator the dollar amounts allowed under the terms of the plan. Duplicate of Paid - This occurs when Arkansas Medicaid has previously received the request and processed the transaction, but the response did not return to the Originator. The Duplicate response contains the same information as returned in the Paid original response. Rejected - This occurs when Arkansas Medicaid has encountered an error in the transaction or processing. Response Header Segment NOTE: Truncation is not allowed in Response Header Segment. Field Field Name Mandatory, Required or Optional Valid Values and Formats Comments 1Ø2-A2 VERSION/RELEASE Mandatory NUMBER 51 = Version 5.1 1Ø3-A3 TRANSACTION CODE Mandatory B1 = Billing 1Ø9-A9 TRANSACTION COUNT Mandatory 1 = One Occurrence 2 = Two Occurrences 3 = Three Occurrences 4 = Four Occurrences 5Ø1-F1 HEADER RESPONSE STATUS Mandatory A = Accepted R = Rejected 2Ø2-B2 SERVICE PROVIDER ID QUALIFIER Mandatory 01 = National Provider ID 2Ø1-B1 SERVICE PROVIDER ID Mandatory 4Ø1-D1 DATE OF SERVICE Mandatory Ø5 = Medicaid Provider ID 10 character National Provider ID or 9 character Medicaid Provider ID Format: CCYYMMDD CC = Century YY = Year MM = Month DD = Day 11/03/10 Date Filled/Date of Service Arkansas Medicaid Claim Billing Response Response Message Segment Field Field Name Mandatory, Required or Optional Valid Values and Formats Comments 111-AM SEGMENT IDENTIFICATION Mandatory 2Ø = Response Message 5Ø4-F4 MESSAGE Optional Variable-length free-form message is from 1-2ØØ characters. Response Insurance Segment Field Field Name Mandatory, Required or Optional Valid Values and Formats Comments 111-AM SEGMENT IDENTIFICATION Optional Not used by Arkansas Medicaid. 3Ø1-C1 GROUP ID Optional Not used by Arkansas Medicaid. 524-FO PLAN ID Optional Not used by Arkansas Medicaid. 545-2F NETWORK REIMBURSEMENT ID Optional Not used by Arkansas Medicaid. 568-J7 PAYER ID QUALIFIER Optional Not used by Arkansas Medicaid. 569-J8 PAYER ID Optional Not used by Arkansas Medicaid. Response Status Segment Field Field Name Mandatory, Required or Optional Valid Values and Formats Comments 111-AM SEGMENT IDENTIFICATION Mandatory 21 = Response Status 11/03/10 Arkansas Medicaid Claim Billing Response Field Field Name Mandatory, Required or Optional Valid Values and Formats Comments 112-AN TRANSACTION RESPONSE STATUS Mandatory A = Approved C = Captured D = Duplicate of Paid F = PA Deferred P = Paid Q = Duplicate of Capture R = Rejected S = Duplicate of Approved 5Ø3-F3 AUTHORIZATION NUMBER Optional Arkansas Medicaid will provide the Internal Control Number (ICN) assigned to identify the authorized transaction. 51Ø-FA REJECT COUNT Optional Arkansas Medicaid will provide the count of the reject code occurrences. 511-FB REJECT CODE Optional Repeating 546-4F REJECT FIELD OCCURRENCE INDICATOR Optional Repeating Arkansas Medicaid will identify the number of occurrences of the field that is being rejected. 547-5F APPROVED MESSAGE CODE COUNT Optional Not used by Arkansas Medicaid. 548-6F APPROVED MESSAGE CODE Optional Repeating Not used by Arkansas Medicaid. 526-FQ ADDITIONAL MESSAGE INFORMATION Optional See NCPDP Data Dictionary NCPDP reject code Appendix F - Reject Codes identifying the error for Telecommunication encountered. Standard. Variable length is from 1-2ØØ Arkansas Medicaid may characters. provide additional information as a free-form text message. NOTE: If a claim denies for EDS error code 2800, the other insurance information will follow in this order: Carrier code Policy number Subscriber number Group name Group number Subscriber name Begin date end date and Arkansas Medicaid 2-digit coverage code. 11/03/10 Arkansas Medicaid Claim Billing Response Field Field Name Mandatory, Required or Optional Valid Values and Formats Comments 549-7F HELP DESK PHONE Optional NUMBER QUALIFIER Code qualifying the Help Desk phone number. 55Ø-8F HELP DESK PHONE Optional NUMBER Ten-digit phone number of the Help Desk. Response Claim Segment Field Field Name Mandatory, Required or Optional Valid Values and Formats Comments 111-AM SEGMENT IDENTIFICATION Mandatory 22 = Response Claim 455-EM PRESCRIPTION/ SERVICE REFERENCE NUMBER QUALIFIER Mandatory Valid values for Arkansas Medicaid: 4Ø2-D2 PRESCRIPTION/ SERVICE REFERENCE NUMBER Mandatory 551-9F PREFERRED PRODUCT COUNT Optional Not used by Arkansas Medicaid. 552-AP PREFERRED PRODUCT ID QUALIFIER Optional Repeating Not used by Arkansas Medicaid. 553-AR PREFERRED PRODUCT ID Optional Repeating Not used by Arkansas Medicaid. 554-AS PREFERRED PRODUCT INCENTIVE Optional Repeating Not used by Arkansas Medicaid. 555-AT PREFERRED PRODUCT COPAY INCENTIVE Optional Repeating Not used by Arkansas Medicaid. 556-AU PREFERRED PRODUCT DESCRIPTION Optional Repeating Not used by Arkansas Medicaid. 11/03/10 1 = Rx Billing Arkansas Medicaid Claim Billing Response Response Pricing Segment Field Field Name Mandatory, Required or Optional Valid Values and Formats 111-AM SEGMENT IDENTIFICATION Mandatory 23 = Response Pricing 5Ø5-F5 PATIENT PAY AMOUNT Optional Format: s$$$$$$cc Total amount to be paid to the pharmacy by the recipient. 5Ø6-F6 INGREDIENT COST Optional PAID Format: s$$$$$$cc Drug ingredient cost paid included in the total amount paid 5Ø7-F7 DISPENSING FEE PAID Optional Format: s$$$$$$cc Dispensing fee included in the total amount paid 557-AV TAX EXEMPT INDICATOR Optional Not used by Arkansas Medicaid. 558-AW FLAT SALES TAX AMOUNT PAID Optional Not used by Arkansas Medicaid. 559-AX PERCENTAGE SALES TAX AMOUNT PAID Optional Not used by Arkansas Medicaid. 56Ø-AY PERCENTAGE SALES TAX RATE PAID Optional Not used by Arkansas Medicaid. 561-AZ PERCENTAGE SALES TAX BASIS PAID Optional Not used by Arkansas Medicaid. 521-FL INCENTIVE AMOUNT PAID Optional 562-J1 PROFESSIONAL Optional SERVICE FEE PAID Not used by Arkansas Medicaid. 563-J2 OTHER AMOUNT PAID COUNT Optional Not used by Arkansas Medicaid. 564-J3 OTHER AMOUNT PAID QUALIFIER Optional Repeating Not used by Arkansas Medicaid. 565-J4 OTHER AMOUNT PAID Optional Repeating Not used by Arkansas Medicaid. 566-J5 OTHER PAYER AMOUNT RECOGNIZED Optional Total dollar amount of any payment from another source, including coupons 5Ø9-F9 TOTAL AMOUNT PAID Optional 11/03/10 Format: s$$$$$$cc Format: s$$$$$$cc Comments Total amount of the differential dispensing fee included in the total amount paid. Total amount to be paid by the claims processor (i.e., pharmacy receivable) Arkansas Medicaid Claim Billing Response Field Field Name Mandatory, Required or Optional 522-FM BASIS OF REIMBURSEMENT DETERMINATION Optional Code identifying how the reimbursement amount was calculated for ingredient cost paid 523-FN AMOUNT ATTRIBUTED TO SALES TAX Optional Not used by Arkansas Medicaid. 512-FC ACCUMULATED DEDUCTIBLE AMOUNT Optional Not used by Arkansas Medicaid. 513-FD REMAINING DEDUCTIBLE AMOUNT Optional Not used by Arkansas Medicaid. 514-FE REMAINING BENEFIT AMOUNT Optional Not used by Arkansas Medicaid. 517-FH AMOUNT APPLIED TO PERIODIC DEDUCTIBLE Optional Not used by Arkansas Medicaid. 518-FI AMOUNT OF COPAY/COINSURANCE Optional 519-FJ AMOUNT ATTRIBUTED TO PRODUCT SELECTION Optional Not used by Arkansas Medicaid. 52Ø-FK AMOUNT Optional EXCEEDING PERIODIC BENEFIT MAXIMUM Not used by Arkansas Medicaid. 346-HH BASIS OF CALCULATION— DISPENSING FEE Optional Code identifying how the reimbursement amount was calculated for dispensing fee paid 347-HJ BASIS OF CALCULATION— COPAY Optional Not used by Arkansas Medicaid. 348-HK BASIS OF CALCULATION— FLAT SALES TAX Optional Not used by Arkansas Medicaid. 349-HM BASIS OF CALCULATION— PERCENTAGE SALES TAX Optional Not used by Arkansas Medicaid. 11/03/10 Valid Values and Formats Format: s$$$$$$cc Comments Amount to be collected from the patient that is included in the patient pay amount. Arkansas Medicaid Claim Billing Response Response DUR/PPS Segment Field Field Name Mandatory, Required or Optional Valid Values and Formats Comments 111-AM SEGMENT IDENTIFICATION Mandatory 24 = Response DUR/PPS 567-J6 DUR/PPS RESPONSE CODE COUNTER Optional Repeating Fields included in the set/logical grouping are: ‘Reason for Service Code’ (439-E4) ‘Clinical Significance Code’ (528-FS) ‘Other Pharmacy Indicator’ (529-FT) ‘Previous Date of Fill’ (53ØFU) ‘Quantity of Previous Fill’ (531-FV) ‘Database Indicator’ (532FW) ‘Other Prescriber Indicator’ (533-FX) ‘DUR Free Text Message’ (544-FY) 439-E4 REASON FOR SERVICE CODE Optional Repeating Valid Arkansas Medicaid Reason for Service Code: HD = High Dose ER = Early Refill TD = Therapeutic Duplication DD = Drug-Drug Interaction MX = Incorrect Duration DC = Drug-Disease (inferred) AT = Additive Toxicity (clinical misuse) LR = Late Refill (underutilization) LD = Low Dose 528-FS 11/03/10 CLINICAL SIGNIFICANCE CODE Optional Repeating Blank = Not Specified 1 = Major 2 = Moderate 3 = Minor Arkansas Medicaid Claim Billing Response Field Field Name Mandatory, Required or Optional Valid Values and Formats Comments 529-FT OTHER PHARMACY Optional INDICATOR Repeating Ø = Not Specified 1 = Your Pharmacy 2 = Other Pharmacy in Same Chain 3 = Other Pharmacy 53Ø-FU PREVIOUS DATE OF FILL Optional Repeating Format: CCYYMMDD 531-FV QUANTITY OF PREVIOUS FILL Optional Repeating Format: 9999999.999 532-FW DATABASE INDICATOR Optional Repeating Blank = Not Specified 1 = First Databank 2 = Medi-Span 3 = Redbook 4 = Processor Developed 5 = Other 533-FX OTHER PRESCRIBER INDICATOR Optional Repeating Ø = Not Specified 1 = Same Prescriber 2 = Other Prescriber 544-FY DUR FREE TEXT MESSAGE Optional Repeating Length is up to 3Ø characters. CC = Century YY = Year MM = Month DD = Day Response data may provide: Drug names involved in an interaction; Reported disease contraindication; Other applicable DUR information. 11/03/10 Arkansas Medicaid Claim Billing Response Error codes When a transaction is rejected, the response may return up to 5 of the following 4-digit Arkansas Medicaid error codes in the message field. Error Code Error Message 0430 Billed amount must be greater than zero. 0431 Billed amount must be numeric. 0432 TPL amount must be equal to or greater than zero. 0433 TPL amount must be numeric. 0610 ARKids recipient age is inappropriate. 0640 Recipient limited to family planning drugs. 0760 CMS Non-Medicaid recipient ineligible for service. 0781 CMS Non-Medicaid service for under age 21. 0790 Non-Medicaid drugs require CMS prior authorization. 0800 Provider cannot bill CMS Non-Medicaid service. 0810 Recipient or provider ineligible for DDS Non-Medicaid service. 0840 Electronic funds transfer required. 1000 Detail date of service is invalid. 1001 Date of service cannot be a future date. 1170 Provider is canceled for date of service billed. 1499 Drug inappropriate for recipient’s age. 1509 Drug inappropriate for recipient’s sex. 1519 NDC is invalid for date of service. 1529 NDC is not on file. 2040 Service not covered for recipients over age 20. 2080 Recipient limited to TB related services only. 2210 Provider deceased on date of service billed. 2220 Provider cancelled on date of service billed. 2223 Billing provider is canceled due to an expired license or DEA 2260 Claim type invalid for provider. 2280 Provider ineligible on date of service billed. 2290 Provider number invalid or not on file. 2480 Eligible for Medicare only – no Medicaid or QMB benefits. 11/03/10 Arkansas Medicaid Claim Billing Response Error Code Error Message 2490 Claim type invalid for recipient’s aid category. 2500 Recipient Medicaid ID number not on file. 2501 Recipient Medicaid ID number missing or invalid. 2510 Recipient has unusable record – contact Office of Medical Services. 2520 Recipient’s Medicaid ID number invalid for recipient’s last name. 2580 Recipient locked in to another pharmacist. 2590 Recipient’s Medicaid ID number invalid for recipient’s first name. 2610 Recipient deceased before date of service. 2620 Recipient ineligible for date of service. 2800 Recipient has other medical coverage. Bill other carrier first. 2801 Invalid other coverage (TPL) code. 2802 Other coverage (TPL) amount must be numeric. 2803 Other coverage (TPL) denial date is required. 2804 Other coverage (TPL) denial date cannot be a future date. 2805 Other coverage (TPL) denial date is invalid. 2806 Other coverage (TPL) amount cannot be equal to or greater than the billed amount. 2807 TPL Amount present / TPL indicator missing" to phar 3690 Service Non-Payable for this PACE Recipient and/or Provider 2820 Recipient has Medicare coverage. Bill Medicare first. 3760 No crosswalk match for billing provider’s NPI to legacy ID. 3761 Billing provider’s NPI is required. 3767 Prescribing provider’s NPI is required / no crosswalk match to legacy ID 3890 Prior authorization/pre-certification number not on PA master file. 3970 Prior authorization required. 3971 Quantity exceeded requires prior authorization. 3975 CMS non-Medicaid recipient requires prior authorization. 4410 Anti-ulcer acute dosage requires prior authorization. 4630 Prescription/service (RX) number limit exceeded. New RX number required. 4910 Duplicate claim paid. 4911 Duplicate claim paid. 4930 Duplicate prescription/service (RX) number for same date of service. 8710 Monthly limit exceeded for therapeutic class dose. 9010 Drug quantity cannot be zero. 11/03/10 Arkansas Medicaid Claim Billing Response Error Code Error Message 9011 Drug quantity must be numeric. 9030 Estimated supply cannot exceed 31 days. 9031 Estimated supply cannot be zero. 9032 Estimated supply must be numeric. 9050 Drug discontinued prior to date of service. 9070 Prescribing provider not on file. 9071 Prescribing provider invalid. 9072 Prescribing provider specialty is invalid specialty required for drug. 9073 Prescribing prescriber NPI is not numeric. 9074 Prescribing provider is deceased. 9110 Refill indicator invalid. 9150 DESI drug discontinued prior to date of service. 9190 Over the counter drugs not payable to long term care recipients. 9200 Coverage restricted drug not covered for recipients over age 20. 9300 Medical necessity indicator invalid. 9400 Medical necessity claim requires prior authorization. 9500 Invalid DUR conflict/reason code. 9501 Invalid DUR intervention/professional code. 9502 Invalid DUR outcome/result code. 9510 No alert found for conflict/reason code. 9511 Claim to cancel not found for DUR conflict/reason code. 9520 Claim to cancel not found for DUR outcome/result code. 9521 Outcome/result code indicated no changes but changes were detected. 9522 Outcome/result code indicated changes but no changes were detected. 9999 Host system error. Contact EDS. A030 Recipient’s prescription limit exceeded. A031 Recipient’s benefit extension exceeded. A032 Recipient’s waiver prescription limit exceeded. P370 Recipient limited to one device per year. Q230 Day supply exceeds maximum allowable for emergency supply. Q231 Quantity exceeds maximum allowable for emergency supply. Q232 Same drug class for emergency supply within 60 days for LTC recipient. Q233 Same drug class for emergency supply within 365 days for non-LTC recipient. 11/03/10 Arkansas Medicaid Error Code Error Message Q234 Prior authorization required – emergency supply not allowed R230 Early refill requires prior authorization. R240 Multiple partial fills with same script number not allowed. R250 Completion claim can have only one related partial claim in history. R260 Completion claim and partial claim cannot be for same date. R270 Completion fill date must be within 31 days of partial fill date. S050 Therapeutic duplicate Zyban/Wellbutrin S060 NRT maximum dosage exceeded Y010 Dosage form description code invalid. Y020 Compound dispensing unit form indicator invalid. Y030 Compound route of administration invalid. Y040 Compound ingredient component count invalid. Y050 Compound product ID qualifier invalid. Y060 Compound ingredient quantity invalid. Y070 Compound NDCs are non-covered. Y080 Clinical segment invalid. Y090 Diagnosis code count invalid. Y100 Diagnosis code qualifier invalid. Y120 Clinical information counter invalid. Y130 Measurement date invalid. Y140 Measurement time invalid. Y150 Measurement dimension invalid. Y160 Measurement unit invalid. Y170 Prescription/service (RX) number invalid. Y440 Compound drug NDC invalid. Y450 Days supply exceeds maximum allowable for emergency supply. Y590 Recipient age inappropriate for NDC. Y600 Days supply inappropriate for NDC. Y610 Duration inappropriate for NDC. Y620 Recipient gender inappropriate for NDC. Y630 NDC covered by Medicare. Bill Medicare first. Y640 Dosage inappropriate for NDC. Y650 Quantity inappropriate for NDC. 11/03/10 Claim Billing Response Arkansas Medicaid Claim Billing Response Error Code Error Message Y660 Cumulative quantity inappropriate for NDC. Y680 Non-preferred drug. See additional message field for details. Y681 PA required for non-preferred drug. See additional message field for details. Y690 Invalid pharmacy provider specialty. Y691 No pricing information for pharmacy provider specialty. Contact EDS. Y700 Drug not covered for dual eligible recipients. Recipient has Medicare Part D. Y701 Drug requires a Medicare denial date to be covered for Medicare recipients Y720 Quantity billed must be a multiple of the package size Y750 Patient last name missing Y751 Patient last name does not match recipient file Y760 Patient first name missing Y761 Patient first name does not match recipient file Z060 Coupon indicator invalid. Z090 Net billed amount invalid. Z100 EPSDT indicator invalid. Z300 Date cannot be over one year in the past. Z590 Insurance segment not found. Z600 Service provider ID qualifier invalid. Z620 Patient DOB is missing Z621 Patient DOB does not match recipient file Z630 Patient location invalid. Z640 Claim segment invalid. Z650 Prescription/service reference number qualifier invalid. Z660 Prescription/service reference number invalid. Z670 Product/service ID qualifier invalid. Z680 Associated prescription/service reference number invalid. Z690 Associated prescription/service date invalid. Z700 New refill code/fill number invalid. Z710 Days supply invalid. Z720 Compound code invalid. Z730 Submission clarification code invalid. Z740 Prescribing provider segment invalid. Z750 Prescribing provider ID qualifier invalid. 11/03/10 Arkansas Medicaid Claim Billing Response Error Code Error Message Z760 COB/other payments segment invalid. Z770 COB/other payments count invalid. Z780 Other payer coverage type invalid. Z790 Other payer amount paid count invalid. Z800 Prescription/service (RX) number denied or previously reversed. Z801 Prescription/service (RX) number is not on file. Z802 Duplicate prescription/service (RX) numbers on file. Cannot reverse. Z816 Claim cannot be adjusted until it appears as paid on remittance advice. Z820 Recipient’s Medicaid ID number invalid. Z830 Provider’s Medicaid ID invalid. Z850 Other payer amount paid qualifier invalid. Z860 DUR/PPS segment invalid. Z880 DUR conflict code invalid. Z890 DUR intervention code invalid. Z900 DUR outcome code invalid. Z910 Pricing segment invalid. Z920 Ingredient cost invalid. Z930 Incentive amount invalid. Z940 Usual and customary charge invalid. Z950 Coupon segment invalid. Z960 Coupon type invalid. Z970 Coupon number invalid. Z980 Coupon value amount invalid. Z990 Internal error – detail count invalid. 11/03/10
