Affiliated Computer Services
Pharmacy Provider
Claims Processing Manual For
Maryland Pharmacy
Programs:
Maryland Medical Assistance Program (MA)
Maryland AIDS Drug Assistance Program (MADAP)
Breast and Cervical Cancer Diagnosis and Treatment Program (BCCDT)
Kidney Disease Program (KDP)
Administered By:
Affiliated Computer Services, Inc
Government Healthcare Solutions
Revised 4/03/2007
Page: 1
TABLE OF CONTENTS
Section
Section I
Page
4
Section II
IMPLEMENTATION
5
Section III
MARYLAND PHARMACY PROGRAMS TELEPHONE NUMBERS
6
Section IV
SERVICE SUPPORT
7
Section V
PROGRAM SET-UP
Claim Format
Transaction Types
Required Data Elements
Identification Numbers
Timely Filing Limits
Date Rx Written To Date of Service Edits
ProDUR
8
Section VI
COORDINATION OF BENEFITS
13
Section VII
MARYLAND MEDICAID PROGRAM SPECIFICS
Prospective Drug Utilization Review (ProDUR)
Multiline Compound Claim Submission
Duplicate Claim Processing
Days Supply
Refills
Mandatory Generic Requirements
Copays
Maximum Dollar Amounts
Prior Authorization
Mental Health
Age Limitations
Long Term Care/Hospice Claims
Emergency Fill
Pricing
Dispense Fees
21
22
22
22
23
23
26
27
27
27
28
30
36
36
38
39
40
8
8
9
11
11
12
Page: 2
Return To Stock
Drug Coverage
Compounded Home Infusion (Home IV) Claims
Medicare Recipients
40
41
45
50
Section VIII
BCCDT PROGRAM SPECIFICS
52
Section IX
MADAP PROGRAM SPECIFICS
65
Section X
KDP PROGRAM SPECIFICS
75
Section XI
EDITS
79
APPENDICES
APPENDIX A
PAYER SPECIFICATION SHEET
APPENDIX B
OTHER CARRIER CODE LIST
138
179
Page: 3
SECTION I
INTRODUCTION
Maryland Medicaid (MA), Breast and Cervical Cancer Diagnosis and Treatment Program
(BCCDT), Kidney Disease Program (KDP) and Maryland AIDS Drug Assistance Program
(MADAP) have contracted with AFFILIATED COMPUTER SERVICES, INC. to process all
pharmacy claims using an enhanced point of sale (POS) system. This program will allow
participating pharmacies real-time access to recipient eligibility, drug coverage, pricing and
payment information, Prior Authorizations using our SmartPA technology, and prospective drug
utilization review (ProDUR) across all network pharmacies. Pharmacy providers must be
enrolled in the pharmacy program they are billing and have an active status for any dates of
service submitted.
This manual is intended to provide pharmacy claims submission guidelines to the users of the
Affiliated Computer Services’ (ACS) on-line system as well as to alert pharmacy providers to
new or changed program information. Affiliated Computer Services’ on-line system is used in
conjunction with the pharmacy’s existing system. While there are a variety of different operating
pharmacy systems, the information contained in this manual addresses only the response
messages related to the interaction with ACS’ on-line system, not the technical operation of the
pharmacy-specific system.
AFFILIATED COMPUTER SERVICES, INC. provides assistance through the Technical Call
Center, which is available 24 hours a day, seven days a week. For answers to questions that are
not addressed in this manual or if additional information is needed, contact AFFILIATED
COMPUTER SERVICES, INC. at:
(800) 932-3918
AFFILIATED COMPUTER SERVICES, INC. looks forward to working with you to ensure the
success of the Maryland Medicaid (MA), Breast and Cervical Cancer Diagnosis and Treatment
Program (BCCDT), Kidney Disease Program (KDP) and Maryland AIDS Drug Assistance
Program (MADAP).
Page: 4
SECTION II
IMPLEMENTATION
Effective February 4, 2007, all Maryland Medicaid, BCCDT, MADAP and KDP pharmacy
claims should be processed through AFFILIATED COMPUTER SERVICES, INC. according to
the specifications included in this manual. Check with your software vendor to ensure your
system is ready to process according to the payer specifications. The State of Maryland will
continue to provide payment and remittance advice on a weekly basis for MA, KDP, and
BCCDT. MADAP provides payment on a bi-weekly basis.
Affiliated Computer Services, Inc. will include provisions for the following groups within the
Maryland Pharmacy Programs:
Non-waiver eligible Medical Assistance recipients;
Non-waiver eligible Medical Assistance recipients in long-term care facilities;
Specialty Mental Health drugs for waiver and non-waiver eligible Medical Assistance recipients;
Other drugs as determined by the Department for waiver eligible medical assistance recipients;
PAC Program recipients;
Kidney Disease Program recipients;
Maryland AIDS Drug Assistance Program recipients;
Breast and Cervical Cancer Diagnosis and Treatment Program recipients; and,
Other recipients as determined by the Department
Page: 5
SECTION III
MARYLAND PHARMACY PROGRAMS TELEPHONE NUMBERS
Maryland Medical Assistance: 410-767-1755
Timely Filing Limit 410-767-6028
Maryland AIDS Drug Assistance Program: 410-767-6535
Breast and Cervical Cancer Diagnosis and Treatment: 410-767-6787
Kidney Disease Program: 410-767-5006
Help Desk Responsibility Phone Numbers
Recipient: Refer recipients to their caseworker.
Provider: Contact Member Help Desk MD (410) 767-5800, Option #3
(800) 492-5231, Option #3
8:30am – 5:00pm M-F
BCCDT recipients: BCCDT staff at 410-767-6787
Healthchoice Enrollment/HMO Enrollment
MD (800) 977-7388 7:00am – 7:00pm M-F
Enrollee Action Line
MD (800) 284-4510 7:30am – 5:30pm M-F
Technical Call Center for Providers
ACS (800) 932-3918 24/7/365
ProDur (800) 932-3918 24/7/365
Prior Authorization Technical Call Center
ACS (800) 932-3918 24/7/365
CAMP Office MD (410) 706-3431 M-F, 9:00 am – 4:30 pm
EVS System MD
(866) 710-1447 (Maryland toll free) 24/7/365
Note: If you have any questions regarding your current NABP/ NCPDP Provider Number, or if
you need to obtain an NABP/ NCPDP, please contact the NCPDP offices directly at 480-4771000. The NABP/ NCPDP Pharmacy Provider Number (field # 201-B1) will be required for all
claim submissions.
Page: 6
SECTION IV
SERVICE SUPPORT
ON-LINE SYSTEM NOT AVAILABLE:
If for any reason the on-line system is not available, providers should submit claims when the
on-line capability resumes. In order to facilitate this process, the provider’s software should have
the capability to submit backdated claims.
TECHNICAL PROBLEM RESOLUTION:
In order to resolve technical problems, providers should follow the steps outlined below:
1. Check the terminal and communications equipment to ensure that electrical power and
telephone services are operational. Call the telephone number the modem is dialing and note the
information heard (i.e. fast busy, steady busy, recorded message). Contact the software vendor if
unable to access this information in the system.
2. If the pharmacy provider has an internal Technical Support Department, the provider should
forward the problem to that department. The pharmacy’s technical support staff will coordinate
with Affiliated Computer Services to resolve the problem.
3. If the pharmacy provider’s network is experiencing technical problems, the pharmacy provider
should contact the network’s technical support area. The network’s technical support staff will
coordinate with AFFILIATED COMPUTER SERVICES, INC. to resolve the problem.
4. If unable to resolve the problem after following the steps outlined above, the pharmacy
provider should contact the AFFILIATED COMPUTER SERVICES, INC. Technical Call
Center at:
(800) 932-3918
Page: 7
SECTION V
PROGRAM SET-UP
MA, MADAP, KDP & BCCDT CLAIM FORMAT:
MA, MADAP, KDP & BCCDT will require use of NCPDP v.5.1; AFFILIATED COMPUTER
SERVICES, INC. will not accept any lower versions.
The batch format is NCPDP Batch 1.1. – not currently used by any Maryland Pharmacy
programs
The paper claim format for MADAP is Maryland’s proprietary form on the website. Not all
programs accept Paper Claims – see later information for program specifics
TRANSACTION TYPES:
The following transaction codes are defined according to the standards established by the
National Council for Prescription Drug Programs (NCPDP). Ability to use these transaction
codes will depend on the pharmacy’s software. At a minimum, all providers should have the
capability to submit original claims (Transaction Code B1) and reversals (Transaction Code B2).
Additionally, AFFILIATED COMPUTER SERVICES will also accept re-bill claims
(Transaction Code B3). Please refer to Appendix A and B for each program’s specific Payer
Specifications.
Full Claims Adjudication (Transaction Code B1)
This transaction captures and processes the claim and returns to the pharmacy the dollar amount
allowed under the Maryland Medicaid reimbursement formula.
Claims Reversal (Transaction Code B2)
This transaction is used by the pharmacy to cancel a claim that was previously processed. To
submit a reversal, the provider has to void a claim that has received a Paid status. To reverse a
claim, the provider selects the Reversal (Void) option in the pharmacy’s computer system.
Claims Re-bill (Transaction Code B3)
This transaction is used by the pharmacy to adjust and resubmit a claim that has previously been
processed and received a Paid status. A “claims re-bill” voids the original claim and resubmits
the claim within a single transaction.
REQUIRED DATA ELEMENTS:
The AFFILIATED COMPUTER SERVICES, INC. system has program-specific ‘mandatory/
required’, ‘optional / required when’ and ‘not sent’ data elements for each transaction. The
pharmacy provider’s software vendor will need the program specific payer specifications before
setting up the plan in the pharmacy’s computer system. This will allow the provider access to the
required fields. Please note the following descriptions regarding data elements:
Mandatory = required at all times by NCPDP for the transaction;
Page: 8
Situational = It is necessary to send these fields in noted situations. Some fields designated as
situational by NCPDP may be required for all MARYLAND Medicaid transactions.
M or S***R*** = The “R***” indicates that the field is repeating. One of the other designators,
Mandatory ‘M’, ‘or Situational ‘S’ will precede it.
Maryland Medicaid, KDP, BCCDT and MADAP pharmacy claims will not be processed without
all the required data elements. Required fields may or may not be used in the adjudication
process. The complete Payer Specifications, including NCPDP field number references, is in
Appendix A and B.
IDENTIFICATION NUMBERS:
BIN #:
610084 – ALL PROGRAMS
610084 (Coordinated ProDUR)
Processor Control #:
Group #:
BCCDT
MADAP
Maryland Medicaid
BCCDT
MADAP
KDP
Maryland Medicaid
KDP
MDBCCDT
MADAP
DRMDPROD
DRDTPROD
DRAPPROD
DRKDPROD
MDMEDICAID
MDKDP
Maryland Pharmacy Programs BIN/PCN/Group ID combinations Under ACS
Types of
Compoun
Claims
Accepted
FH
GROUP
ACS
BIN
PCN from
Pharm to
ACS
P012010454
MDBCCDT
610084
DRDTPROD
MDBCCDT
3
010454
P012010454
MDKDP
610084
DRKDPROD
MDKDP
4
MADAP
010454
P012010454
MADAP
610084
DRAPPROD
MADAP
4
OOEP
009753
P010009753
MDMEDICAID
610084
DRMDPROD
MDMEDICAID
3
Bioscrip
800002
CLAIMNE
P101
610084
CLAIMNE
P101
2
Bioscrip
800002
CLAIMNE
Q9016
610084
CLAIMNE
Q9016
2
Caremark
800002
CRK
CVTY
610084
CRK
CVTY
2
Caremark
800002
CRK
CVTY
610084
CVTY
CVTY
2
Caremark
800002
PCS
F810MDSC
610084
PCS
F810MDSC
2
Caremark
800002
PCS
F810MDSS
610084
PCS
F810MDSS
2
Caremark
800002
PCS
F810MDTC
610084
PCS
F810MDTC
2
Caremark
800002
PCS
F810M1AM
610084
PCS
F810M1AM
2
FH
BIN
FH
PCN
BCCDT
010454
KDP
Who
Page: 9
NCPDP group
ID from Pharm
Caremark
800002
PCS
T2400001
610084
PCS
T2400001
2
Caremark
800002
PCS
W7573000
610084
PCS
W7573000
2
Caremark
800002
PCS
W7573001
610084
PCS
W7573001
2
Caremark
800002
PCS
W7573002
610084
PCS
W7573002
2
Caremark
800002
PCS
W7573004
610084
PCS
W7573004
2
Caremark
800002
PCS
W7573008
610084
PCS
W7573008
2
Caremark
800002
PCS
W7573011
610084
PCS
W7573011
2
Caremark
800002
PCS
W7573012
610084
PCS
W7573012
2
Caremark
800002
PCS
W7573018
610084
PCS
W7573018
2
Caremark
800002
PCS
W7573019
610084
PCS
W7573019
2
Caremark
800002
PCS
W7573024
610084
PCS
W7573024
2
Caremark
800002
PCS
W7579999
610084
PCS
W7579999
2
ExpressScripts
800002
MDC
610084
A4
MDC
2
Medco
800002
A4
not
applicable
PRODUR1
610084
PRODUR1
PRODUR1
2
Provider ID #:
NCPDP / NABP Number – All Programs
Prescriber ID #:
The system will take the following steps if the DEA number submitted on the claim is not found:
1. Deny the claim with NCPDP edit 25 (Missing/Invalid Prescriber ID) message
2. The provider may then either:
a. Resubmit the claim with a valid DEA number; or
b. Call the ACS Call Center and request assistance in determining the
Prescriber DEA number
c. If no valid DEA number is found, the Call Center will provide a dummy
DEA number
Cardholder ID #:
The system will ensure each recipient has his/her own identification number depending on which
program they belong to (i.e. – MADAP, BCCDT, etc). In the case of a newborn child please
follow the rules below:
The system will ensure claims for newborns will be submitted with the newborn’s ID:
Claims cannot be submitted with the mother’s ID.
If the mother is eligible, there is presumptive eligibility for the newborn. The pharmacist must
Page: 10
hold the claims until such time as the newborn has an ID number.
Maryland Medicaid
KDP
BCCDT
MADAP
MD Medicaid ID Number
Recipient Number & 5 leading zeros
BCCDT Recipient ID
MADAP ID
Product Code National Drug Code (NDC)
TIMELY FILING LIMITS:
(Definition: “Timely Filing Limits” indicates the maximum timeframe from DOS to the date the
claim is entered into the processing system.)
Most providers submit their point of sale claims at the time of dispensing. However there may be
legitimate reasons that require a claim to be submitted after the fact. For such instances the
following limits are in place:
MA Timely Filing Limits:
Original claims (NCPDP transaction B1) 279 days
Reversal and Re-bill claims (NCPDP transactions B2 and B3) 279 days
Note: Claims that exceed the prescribed timely filing limit will deny.
Requests for timely filing limit overrides should be directed to Maryland Medical Assistance at
(410) 767-6028.
KDP Timely Filing Limits:
Original claims (NCPDP transaction B1) 183 days
Reversal and Re-bill claims (NCPDP transactions B2 and B3) 183 days
Note: Claims that exceed the prescribed timely filing limit will deny. Overrides are not allowed
for Timely Filing Limits.
BCCDT Timely Filing Limits:
Original claims, reversals, and adjustments ( B1, B2, B3) 279 days
For BCCDT call 410-767-6787
MADAP Timely Filing Limits:
Original claims, reversals, and adjustments: (B1, B2, B3) 279 days
DATE WRITTEN TO DATE OF SERVICE EDITS:
This edit applies to original DOS prescriptions and not refills. The amount of time between the
DATE RX WRITTEN (NCPDP field # 414-DE) and the DATE OF SERVICE (NCPDP field #
401-D1) may not exceed the following:
If DEA = 2 (CII) – 5 (CV), then 30 days.
If DEA = 0, then 120 days.
KDP Date Rx Written To Date Of Service Edits:
Page: 11
This edit applies to original DOS prescription and not refills.
The amount of time between the DATE RX WRITTEN and the DATE OF SERVICE may not be
greater than 10 days.
PROSPECTIVE DRUG UTILIZATION REVIEW (ProDUR):
Prospective Drug Utilization Review (ProDUR) encompasses the detection, evaluation, and
counseling components of pre-dispensing drug therapy screening. The ProDUR system of
Affiliated Computer Services assists the pharmacist in these functions by addressing situations in
which potential drug problems may exist. ProDUR performed prior to dispensing helps
pharmacists ensure that their patients receive appropriate medications. This is accomplished by
providing information to the dispensing pharmacist that may NOT have been previously
available.
ACS will ensure that the system alerts the pharmacist regarding each specific patient at the time
a prescription is being filled of any evidence documenting, but not limited to, suspected drug
over utilization, prescription underutilization, duplicate therapy, drug to diagnosis
contraindication, drug to drug interaction, drug-age contraindication, drug - pregnancy
contraindication and excessive utilization, iatrogenic effects, adverse reactions or treatment
failures.
Because Affiliated Computer Services’ ProDUR system examines claims from all participating
pharmacies, drugs that interact or are affected by previously dispensed medications can be
detected. AFFILIATED COMPUTER SERVICES, INC. recognizes that the pharmacist uses
his/her education and professional judgment in all aspects of dispensing. ProDUR is offered as
an informational tool to aid the pharmacist in performing his/her professional duties.
Page: 12
SECTION VI
COORDINATION OF BENEFITS (COB)
On-line COB (cost avoidance) will be a part of this program.
If MA, MADAP, BCCDT & KDP is the patient’s secondary carrier; claims for COB
(coordination of benefits) will be accepted.
MA, MADAP, BCCDT & KDP are always the payer of last resort.
Other coverage will be identified by the presence of other carrier information on the recipient
eligibility file and/ or information communicated by the provider on the claim.
The system will deny a claim if the recipient shows other coverage on the DOS and will return
error 41 (bill other processor), a carrier code identifying the other carrier, the patient’s policy
number and the carrier name in the additional message text field if no other coverage information
is submitted on the claim.
Note 1: BCCDT will return a carrier ID of “77777” for Medicare D and a carrier ID of “88888”
for all other carriers
Note 2: MADAP will not return carrier information
The system will deny claims for recipients with more than one active other carrier and will return
the first carrier code on file in the response if not all other coverage information is submitted on
the claim. Once the first carrier information is entered then the second line of information, and
continue until all carriers have been submitted.
If the recipient shows other coverage on the DOS, AFFILIATED COMPUTER SERVICES, INC
will deny the claim. AFFILIATED COMPUTER SERVICES, INC. will return a unique clientidentified carrier code identifying the other carrier, the patient’s policy number and the carrier
name in the additional message field. It is possible that a recipient may have more than one
active other carrier; in that case, AFFILIATED COMPUTER SERVICES, INC. would initially
return the code of the first hit; subsequent codes will be returned until fully exhausted. Providers
will be required to submit this code in the OTHER PAYER ID (NCPDP field #340-7C) field as
part of the override process (see the TPL Processing Grid).
Even if no “other insurance” is indicated on the eligibility file, AFFILIATED COMPUTER
SERVICES, INC. will process the claim as a TPL claim if the pharmacist submits TPL data as
indicated in the TPL Processing Grid.
If other insurance is indicated on the eligibility file, then AFFLIATED COMPUTER
SERVICES, INC will process as TPL regardless of what TPL codes the pharmacist submits as
indicated on the TPL Processing Grid.
In all cases, AFFILIATED COMPUTER SERVICES, INC. will use the system calculated
“Allowed Amount” when calculating payment.
Note: In some cases, this may result in a ‘0’ payment.
Following are values and claim dispositions based on pharmacist submitted submission of the
standard NCPDP TPL codes.
Page: 13
TPL PROCESSING GRID v. 5.1:
Other
Payer
Amount
Paid
(field #
431DV)
Other
Coverage
indicated on
Maryland
Pharmacy
Programs
Recipient
Record
Other
Payer
Date
(field #
443-E8)
Other
Claim
Payer ID Disposition
(field #
340-7C)
0 = Not
Specified
0
Yes
M/I or
null
M/I or
null
0 = Not
Specified
0 = Not
Specified
0
No
Null
Null
>0

No
M/I or
null
M/I or
null
0 = Not
Specified
>0

Yes
M/I or
null
M/I or
null
1 = No other
coverage
identified
0
Yes
M/I or
null
M/I or
null
1 = No other
coverage
identified
0
Yes
Valid
Date
Valid TPL
Carrier
Code
1 = No other
coverage
identified
1 = No other
coverage
identified
0
No
M/I or
null
M/I or
null
Pay
>0
No
M/I or
null
M/I or
null
1 = No other
>0
Yes
M/I or
M/I or
Deny, M/I
Other Payer
Date, M/I
Other Payer
Amount
Deny, Bill
Other
Coverage
Code (field #
308-C8)
Page: 14
Deny, Bill
Primary, M/I
Other Payer
Date
Pay
Comments
This code will
not override
TPL.
Deny, M/I
Other Payer
Date
Deny, Bill
Primary, M/I
Other Payer
Date, M/I
Other Payer
Amount
Deny, Bill
Primary, M/I
Other Payer
Date
Pay
Use when
primary does
not show
coverage.
Other
Coverage
Code (field #
308-C8)
Other
Payer
Amount
Paid
(field #
431DV)
Other
Coverage
indicated on
Maryland
Pharmacy
Programs
Recipient
Record
coverage
identified
Other
Payer
Date
(field #
443-E8)
Other
Claim
Payer ID Disposition
(field #
340-7C)
null
null
1 = No other
coverage
identified
0
Yes
Valid
Date
M/I or
null
1 = No other
coverage
identified
1 = No other
coverage
identified
0
No
Valid
Date
M/I or
null
0
No
M/I or
null
1 = No other
coverage
identified
0
Yes
M/I or
null
Valid
TPL
Carrier
Code
Valid
TPL
Carrier
Code
1 = No other
coverage
identified
0
Yes
Valid
Date
1 = No other
coverage
identified
0
Yes
Date >
Adjudicat
ion Date
2 = Other
coverage
exists,
payment
collected
>0
Yes or No
Valid
Date
Page: 15
Comments
Primary, M/I
Other Payer
Date, M/I
Other Payer
Amount
Deny, Bill
Primary, M/I
Other Payer
Date
Deny, M/I
Other Payer
Date
Deny, M/I
Other Payer
Date
Date, M/I
Other Payer
Date
Invalid
TPL
Carrier
Code
Valid TPL
Carrier
Code
Deny, Bill
Primary
Valid
TPL
Carrier
Code
Pay
(Will pay
when all
Carriers have
been
overridden)
Deny, M/I
Other Payer
Date
Will pay the
difference
between the
Maryland
Pharmacy
Programs
Allowed
Amount and
Other
Coverage
Code (field #
308-C8)
Other
Payer
Amount
Paid
(field #
431DV)
Other
Coverage
indicated on
Maryland
Pharmacy
Programs
Recipient
Record
Other
Payer
Date
(field #
443-E8)
Other
Claim
Payer ID Disposition
(field #
340-7C)
Comments
the Other
Payer Amount
(and
optionally the
Patient Paid
Amount).
2 = Other
coverage
exists,
payment
collected
2 = Other
coverage
exists,
payment
collected
2 = Other
coverage
exists,
payment
collected
2 = Other
coverage
exists,
payment
collected
2 = Other
coverage
exists,
payment
collected
>0
No
Valid
Date
M/I or
null
Deny, M/I
Other Payer
Date
>0
Yes
Valid
Date
M/I or
null
Deny, Bill
Primary, M/I
Other Payer
Date
>0
Yes or No
M/I or
null
Valid
TPL
Carrier
Code
Deny, M/I
Other Payer
Date
0
No
M/I or
null
M/I or
null
0
Yes
N/A
N/A
Date, M/I
Other Payer
Date, MI
Other Payer
Amount
Deny, Bill
Primary, M/I
Other Payer
Date, M/I
Other Payer
Amount
2 = Other
coverage
exists,
payment
>0
Yes
Valid
Date
Invalid
TPL
Carrier
Code
Page: 16
Deny, Bill
Primary
Other
Payer
Amount
Paid
(field #
431DV)
Other
Coverage
indicated on
Maryland
Pharmacy
Programs
Recipient
Record
Other
Payer
Date
(field #
443-E8)
Other
Claim
Payer ID Disposition
(field #
340-7C)
>0
Yes
Denial >
Adjudicat
ion Date
Valid TPL
Carrier
Code
Deny, M/I
Other Payer
Date
3 = Other
coverage
exists, this
claim not
covered
0
Yes or No
Valid
Date
Valid
TPL
Carrier
Code
Pay
3 = Other
coverage
exists, this
claim not
covered
3 = Other
coverage
exists, this
claim not
covered
3 = Other
coverage
exists, this
claim not
covered
3 = Other
coverage
exists, this
claim not
covered
3 = Other
coverage
exists, this
0
No
Valid
Date
M/I
Deny, M/I
Other Payer
Date
0
Yes
Valid
Date
M/I
Deny, Bill
Primary, M/I
Other Payer
Date
0
Yes or No
M/I or
null
Valid
TPL
Carrier
Code
Deny, M/I
Other Payer
Date
>0

No
M/I or
null
M/I or
null
>0

Yes
M/I or
null
M/I or
null
Deny M/I
Other Payer
Date, M/I
Other Payer
Amount
Deny, Bill
Primary, M/I
Other Payer
Other
Coverage
Code (field #
308-C8)
collected
2 = Other
coverage
exists,
payment
collected
Page: 17
Comments
Pay the
Maryland
Pharmacy
Programs
Allowed
Amount.
Other
Coverage
Code (field #
308-C8)
Other
Payer
Amount
Paid
(field #
431DV)
Other
Coverage
indicated on
Maryland
Pharmacy
Programs
Recipient
Record
Other
Payer
Date
(field #
443-E8)
Other
Claim
Payer ID Disposition
(field #
340-7C)
claim not
covered
3 = Other
coverage
exists, this
claim not
covered
3 = Other
coverage
exists, this
claim not
covered
3 = Other
coverage
exists, this
claim not
covered
3 = Other
coverage
exists, this
claim not
covered
3 = Other
coverage
exists, this
claim not
covered
3 = Other
coverage
exists, this
claim not
covered
4 = Other
coverage
exists,
Date, M/I
Other Payer
Amount
Deny, M/I
Other Payer
Amount
>0

Yes
or
No
Valid
Valid
>0

Yes
Valid
Invalid
Deny, Bill
Primary, M/I
Other Payer
Amount
>0

No
Valid
Invalid
Deny, M/I
Other Payer
Amount
>0

Yes
or
No
Invalid
Valid
Deny, M/I
Other Payer
Date, M/I
Other Payer
Amount
0
Yes
Valid
Date
Invalid
TPL
Carrier
Code
Deny, Bill
Primary
Payer
0
Yes
Denial >
Adjudicat
ion Date
Valid TPL
Carrier
Code
Deny, M/I
Other Payer
Date
M/I or
null
M/I or
null
Deny, M/I
Other Payer
Date, M/I
>0

No
Page: 18
Comments
Other
Coverage
Code (field #
308-C8)
payment not
collected
4 = Other
coverage
exists,
payment not
collected
WLL4 =
Other
coverage
exists,
payment not
collected
4 = Other
coverage
exists,
payment not
collected
4 = Other
coverage
exists,
payment not
collected
4 = Other
coverage
exists,
payment not
collected
4 = Other
coverage
exists,
payment not
collected
4 = Other
coverage
Other
Payer
Amount
Paid
(field #
431DV)
Other
Coverage
indicated on
Maryland
Pharmacy
Programs
Recipient
Record
Other
Payer
Date
(field #
443-E8)
Other
Claim
Payer ID Disposition
(field #
340-7C)
Other Payer
Amount
Deny, Bill
Primary, M/I
Other Payer
Date, M/I
Other Payer
Amount
Deny, M/I
Other Payer
Amount
>0

Yes
M/I or
null
M/I or
null
>0

Yes
or
No
Valid
Valid
>0

Yes
Valid
Invalid
Deny, Bill
Primary, M/I
Other Payer
Amount
>0

No
Valid
Invalid
Deny, M/I
Other Payer
Amount
>0

Yes
or
No
Invalid
Valid
Deny, M/I
Other Payer
Date, M/I
Other Payer
Amount
0
Yes
Valid
Date
Valid
TPL
Carrier
Code
Pay
0
Yes
Valid
Date
M/I or
null
Deny, Bill
Primary, M/I
Page: 19
Comments
Use if primary
is full
deductible or
100% copay.
Other
Coverage
Code (field #
308-C8)
exists,
payment not
collected
4 = Other
coverage
exists,
payment not
collected
4 = Other
coverage
exists,
payment not
collected
4 = Other
coverage
exists,
payment not
collected
4 = Other
coverage
exists,
payment not
collected
New 5.1
codes:
5 = Managed
care plan
denial
Other
Payer
Amount
Paid
(field #
431DV)
Other
Coverage
indicated on
Maryland
Pharmacy
Programs
Recipient
Record
Other
Payer
Date
(field #
443-E8)
Other
Claim
Payer ID Disposition
(field #
340-7C)
Other Payer
Date
0
No
Valid
Date
M/I or
null
Deny, M/I
Other Payer
Date
0
Yes or No
M/I or
null
Valid
TPL
Carrier
Code
Deny, M/I
Other Payer
Date
0
Yes
Valid
Date
Invalid
TPL
Carrier
Code
Deny, Bill
Primary
0
Yes
Date >
Adjudicat
ion Date
Valid TPL
Carrier
Code
Deny, M/I
Other Payer
Date
Deny, Drug
Not Covered
Additional
Message:
OCC 5/ 6 Not
Allowed for
Override
Deny, Drug
Not Covered
Additional
Message:
OCC 5/ 6 Not
Allowed for
Override
6 = Other
coverage
denied – not
a
participating
Page: 20
Comments
Other
Coverage
Code (field #
308-C8)
Other
Payer
Amount
Paid
(field #
431DV)
Other
Coverage
indicated on
Maryland
Pharmacy
Programs
Recipient
Record
Other
Payer
Date
(field #
443-E8)
Other
Claim
Payer ID Disposition
(field #
340-7C)
Comments
provider
7 = Other
coverage
exists – not
in effect on
DOS
8 = Claim is
billing for
copay
NOTE: Copay only claim submissions will only be allowed for BCCDT, KDP, and MADAP
recipients. The process and required fields are outlined in each individual section of this manual
Page: 21
SECTION VII
MARYLAND MEDICAID PROGRAM SPECIFICS
PRODUR EDITS:
Maryland Medicaid will deny for Therapeutic Duplication (TD) and Early Refill (ER) only. Alert
messages will be returned for other ProDUR problem types.
ProDUR edits that deny may be overridden by the pharmacy provider at POS using the
interactive NCPDP DUR override codes for selected conflict types.
To request an Early Refill override, contact AFFILIATED COMPUTER SERVICES, INC.: 1800-932-3918.
Days supply information is critical to the edit functions of the ProDUR system. Submitting
incorrect days supply information in the days supply field can cause false ProDUR messages or
claim denial for that particular claim or for drug claims that are submitted in the future.
Technical Call Center:
Affiliated Computer Services’ Technical Call Center is available 24 hours per day, seven days
per week.
The telephone number is: 1-800-932-3918
Alert message information is available from the Call Center after the message appears. If you
need assistance with any alert or denial messages, it is important to contact the Call Center about
Affiliated Computer Services’ ProDUR messages at the time of dispensing. The Call Center can
provide claims information on all error messages which are sent by the ProDUR system. This
information includes: NDCs and drug names of the affected drugs, dates of service, whether the
calling pharmacy is the dispensing pharmacy of the conflicting drug, and days supply.
The Technical Call Center is not intended to be used as a clinical consulting service and cannot
replace or supplement the professional judgment of the dispensing pharmacist. AFFILIATED
COMPUTER SERVICES, INC has used reasonable care to accurately compile ProDUR
information. Because this information is unique; it is intended for pharmacists to use at their own
discretion in the drug therapy management of their patients.
Affiliated Computer Services’ ProDUR is an integral part of the Maryland Medical Assistance
Pharmacy Program’s claims adjudication process. ProDUR includes: reviewing claims for
therapeutic appropriateness before the medication is dispensed, reviewing the available medical
history, focusing on those patients at the highest severity of risk for harmful outcome, and
intervening and/or counseling when appropriate.
Coordinated ProDUR:
Coordinated ProDUR (CPD) provides a mechanism to link all of a recipient’s pharmacy history,
regardless of payer, for purposes of performing ProDUR. This includes all:
MCO Services
Specialty Mental Health Services
Medical Assistance Program Services
Coordinated ProDUR editing is “message only” (i.e. no denials).
MULTI-LINE COMPOUND CLAIM SUBMISSION
Page: 22
Maryland Medicaid will accept multi-line Compound claims. If providers submit a compound
claim with a single ingredient the claim will be denied.
The system will accept up to 40 line items (individual ingredients) in each compound claim. The
system will allow providers to use Submission Clarification code 8 (process compound for
approved ingredients) to override denials for compound ingredients that are not covered.
DUPLICATE CLAIM PROCESSING
The system will use the following standard methodology to determine Duplicate paid claims:
Response Status: D (retransmission NCPDP Duplicate Response)
Match on: Pharmacy ID (NCPDP field # 201-B1), RX # (NCPDP field #402-D2),
Patient ID (NCPDP field #302-C2), NDC (NCPDP field #407-D7), DOS
(NCPDP field #401-D1) and New/Refill Code (NCPDP field #601-57)
Error 83: Duplicate RX
Match on: Pharmacy ID (NCPDP field # 201-B1), RX # (NCPDP field #402-D2),
Patient ID (NCPDP field #302-C2), GSN (Not on claim; FDB) and DOS (NCPDP
field #401-D1)
Error: 83: Different Pharmacy Search
Match on: RX # (NCPDP field #402-D2), Patient ID (NCPDP field #302-C2),
GSN (Not on claim; FDB) and DOS (NCPDP field #401-D
Error 83: Duplicate Fill
Match on: Patient ID (NCPDP field #302-C2), GSN (Not on claim; FDB) and
DOS (NCPDP field #401-D1)
DAYS SUPPLY
The system will ensure up to a 34 day supply is allowed for non-maintenance medications and a
100-day supply for maintenance medications. Exceptions:
Oral contraceptives = 180 day supply
14 day supply, as identified through drug file analysis (see below)
28 day supply, as identified through drug file analysis (see below)
90 day supply as identified through drug file analysis (see below)
100 day supply, as identified through drug file analysis (see below)
120 day supply, as identified through drug file analysis (see below)
180 day supply, as identified through drug file analysis (see below)
Max Days 14
Max Days 14 NCPDP 76- Plan Limitations Exceeded /For PA, Call ACS at 1-800-932-3918
HSN = 011796
Helidac
Page: 23
Max Days 28
Max Days 28 NCPDP 76- Plan Limitations Exceeded /For PA, Call ACS at 1-800-932-3918
HSN = 004834
Clozaril (clozapine)
Max Days 90
Max Days 90 NCPDP 76- Plan Limitations Exceeded /For PA, Call ACS at 1-800-932-3918
GSN 017584.
Depo-Provera
CCM FH015 – status is
pending.
Max Days 100
Max Days 100 NCPDP 76- Plan Limitations Exceeded (includes Maintenance Medications) /For
PA, call ACS at 1-800-932-3918. Note: When AHFS codes are used, all sub classifications
beginning with the digits specified are included.
DEA = 2
All Schedule II Narcotics
GSN = 004964, 044980
Leuprolide 3-month kit
DCC = R
Insulin Syringes
AHFS = 24:04
Cardiac Drugs
AHFS = 24:06
Antilipemic Agents
AHFS = 24:08
Hypotensive agents
AHFS = 24:12
Vasodilating agents
Vasodilating Agents
AHFS = 24:12.08
AHFS = 24:16
Sclerosin Agents
AHFS = 24:20
Alpha-adrenergic blocking
agents
AHFS = 24:24
Beta-adrenergic blocking
agents
AHFS = 24:28
Calcium channel blocking
agents
AHFS = 24:32
Renin-angiotensinaldosterone system
inhibitors
AHFS = 28:12:12
Hydantoins
AHFS = 28:12:16
Oxazolidinediones
AHFS = 28:12:92
Anticonvulsants
miscellaneous
HIC3 = C1D
AHFS 40:12 (Replacement
Solutions)
Potassium supplements
only
AHFS = 40:28
Diuretics
Page: 24
Listed products only
AHFS = 56:24
Lipotropic agents
AHFS = 68:16
Estrogens and
antiestrogens
AHFS = 68:20
Antidiabetic agents
AHFS = 68:20.08
Insulins
AHFS = 68:20.20
Sulfonylureas
AHFS = 68:22
Antihypoglycemic agents
AHFS = 68:24
Parathyroid
AHFS = 68:32
Progestins
AHFS = 68:36
Thyroid and Antithyroid
agents
AHFS = 68:36.04
Thyroid Agents
AHFS = 88:00
Vitamins
Legend products only
HSN = 001879, 001878, AHFS 28:12.12
(Hydantoins) Phenytoin
001877
Listed products only
Phenytoin Sodium



HSN = 000739; and
Route = oral
HIC3 = C3B; or HSN = 001025,
001029, 006485, 001024,
001095, 001086; and
Dosage Form = TC
AHFS 20:04.04 (Iron
preparations)
Oral products in which
ferrous sulfate is the only
active ingredient
Chewable tablets of any
ferrous salt when
combined with vitamin C,
multivits, multivits +
minerals, or other minerals
in the formulation
AHFS = 24:20
Alpha-Adrenergic Blocking
Agents
AHFS = 24:24
Beta-Adrenergic Blocking
Agents
AHFS = 24:28
Calcium-Channel Blocking
Agents
AHFS = 24:32
Renin-Angiotensin System
Inhibitors
AHFS = 24:32.04
Angiotensin-Converting
Enzyme Inhibitors
AHFS = 24:32.08
Angiotensin II Receptor
Page: 25
Listed products only
Note: OTC is not a requirement
for these chewable Fe products
(per regs)
Antagonists
AHFS = 88:08:00
Vitamin B Complex
AHFS = 88:28:00
Multivitamin Preparations
GSN 026098
Depo-Provera
Contraceptive 150mg/ml
Disposable Syringe
GSN 017584
Depo-Provera
Contraceptive 150mg/ml
Vial
Max Days 120
Max Days 120 NCPDP 76- Plan Limitations Exceeded/For PA, Call ACS at 1-800-932-3918
GSN = 2605, 2607, 2615,
Sodium Fluoride
2616, 2617, 2618, 2619, 2621,
2622, 2623, 13383, 16025,
18743, 23716, 24145, 41627
GSN = 044968, 058789
Leuprolide 4 month kit
Max Days 180
Max Days 180 NCPDP 76- Plan Limitations Exceeded/For PA, Call ACS at 1-800-932-3918
DCC = C
Contraceptives, Oral
TC = 36
Systemic Contraceptives
Claims that deny for exceeding the max day limit will return edit 76 (plan limitations exceeded)
and the message text: Max Daily Limit Exceeded/For PA, call DHMH at 1-410-767-1755
Requests to override Days Supply are directed to Maryland Medicaid at (410) 767-1755.
Providers will have the ability to override Days Supply Limits and/or PA required conditions by
entering a value of ‘5’ (exemption from prescription limits) in the Prior Auth Type Code field
(NCPDP field # 416-DG). Note:
This override situation applies to TPL processing only
A value of 5 in the Prior Auth Type Code field is valid only if Other Coverage Code
= 2 (other coverage exists-payment collected)
A value of 8 in the Prior Auth Type Code field is valid only if recipient is pregnant
(this will override both coverage limitations and copay)
REFILLS:
ACS will ensure the following rules for refills
· Non-Controlled Covered Drugs:
Max 11 refills
Max 360 days supply total with refills
Page: 26
Do not allow a refill on a prescription to be filled 360 days or more from the date prescribed.
· Controlled Covered Drugs- Schedules III, IV and V:
Max 5 refills
Max 180 days supply total with refills
Do not allow a refill on a prescription to be filled 180 days or more from the date prescribed.
Do not fill original prescription greater than 30 days from the day prescribed
· Controlled Covered Drugs- Schedule II
No refills allowed
Max 100 days supply on the original prescription
Do not fill original prescription greater than 30 days from the day prescribed
MANDATORY GENERIC REQUIREMENTS:
Maryland Medicaid has a mandatory generic substitution policy.
Accepted DAW codes for MD Medicaid are:
DAW 0
Default, no product selection
DAW 1
Physician request
DAW 5
Brand used as generic
DAW 6
Override
The system will deny brand drugs when a generic is available with edit 22 (M/I /DAW code) and
the message text: “Generic Available – Call State at 410-767-1755, MedWatch form required”
when submitted as Brand Medically Necessary (DAW = 1) with the exception of the following
(pay at EAC):
Levothyroxine HICL seq Num = 002849
Brimonidine eye drops GSN = 48333 and 27882
COPAYS
Fee for Service = $1.00 / 3.00
PAC copays = $2.50 / 7.50
NH = NO copays
State Funded Foster copay = $1.00 / 3.00 (no exceptions)
MCO/ HMO copay = $1.00 / 3.00 (for Carve-our drugs)
Copay exceptions ($0 copay) regardless of plan assignment:
Patient <21 years old (as determined by the eligibility file)
Patient is pregnant (as determined by submitting pharmacist entering ‘4’ in Prior Auth Type
Code field
Drug is a family planning drug
LTC claims, with the exception of groups S16, S17, and S18
Group S12 and drug is family planning
PDL – 3 day emergency supply
Page: 27
MAXIMUM DOLLAR AMOUNTS
The system will allow a max cost per prescription of $2500.00 including compounds.
The system will deny claims that exceed the maximum dollar limit of $2500.00 with error 78
(Cost Exceeds Max) and the message text “Contact ACS at 1-800-932-3918 to request override”.
The ACS Prior Authorization (PA) Call Center Pharmacist may approve prior authorization
requests for dollar limit overrides after validating the quantity submitted.
Note: When reviewing submitted claims over $2,500.00, ACS PA Call Center Pharmacist will
consider the following minimal criteria:
Proper dispensing units are being submitted, as per the ACS System editing criteria;
Proper days supply being submitted as per number of units dispensed;
Proper FDA dosing guidelines being followed; and
Quantity limitations that already exist as system edits.
The reviewer will use professional judgment and the above minimal criteria to preauthorize a
claim. Claims not in compliance with profession judgment and minimal criteria will be denied.
PRIOR AUTHORIZATION
There are four methods a provider can receive a Prior Authorization for Maryland (OOEP)
Medicaid recipients:
ACS Technical Call Center
Maryland Medicaid Staff
CAMP office
SmartPA
To help the provider determine which method they need to use to obtain a Prior Authorization
the following messages will be sent back on a claim response:
PA denials handled by ACS will return the following message text in the
response: “Prior Authorization Required, Call ACS at 1-800-932-3918
(24/7/365)”.
PA denials handled by the State will return the following message text in the
response: ”Prior Authorization Required, Call MD/ OOEP at (410) 767-1755, MF, 8:30 am – 4:30 pm”.
PA denials handled by the State's CAMP Office will return the following message
text in the response: “Prior Authorization Required, call CAMP Office, (410)
706-3431”.
Below is a list of drugs that require Prior Authorization and which office handles the Prior
Authorization request:
Page: 28
The Maryland Pharmacy Program staff:
Days Supply
Growth Hormones
Synagis (Palivizumab)
Female Hormones for a male and vice versa
Nutritional supplements (see MD PA form for clinical criteria)
Recipient Lock-In
Price (long-term PAs only)
Oxycontin Quantity (during business hours)
Antihemophilic Drugs (claim pended in X2 and evaluated manually by State)
Duragesic Patch Quantity (during business hours)
Topical Vitamin A Derivatives
Opiate Agonists for Hospice and Hospice/LTC
Antiemetic
Serostim
Botox
Orfadin
Revlimid
Revatio
Brand Medically Necessary
The ACS PA Call Center:
Quantity (Note Oxycontin, Duragesic Patch exceptions)
CNS Stimulants
Actiq
Anti-Migraine
Anti-Psychotics (quantity limits)
Oxycontin, Duragesic Patch Qty for after hours/weekends
Maximum dollar limit per claim = $2,500
Maryland Pharmacy Programs Camp Office:
Depo Provera
Lupron Depot
ACS Technical Call Center:
PDL - Non-Preferred drugs
Early Refill & Days Supply
Age Restrictions
Max Quantity overrides
SmartPA
Page: 29
SmartPA is an automated, rules engine, driven system that uses both the medical and pharmacy
information to either grant a Prior Authorization or deny based on the rules for that particular
drug being dispensed. If criteria are met upon claims submission, no call for PA will be required.
The system will automatically generate a Prior Authorization and the claim will pay. When a
claim is denied by SmartPA, the exception message will state which criteria was not met in order
for the PA to be issued. Below is a list of drugs / categories that will be handled by SmartPA:
CNS Stimulants
Actiq
Anti-Migraine
Atypical Antipsychotics
Serostim
Botox
Synagis
Growth Hormones
Antiemetics
Topical Vitamin A
Orfadin
Revlamid
Revatio
Nutritional Supplements
Oxycodone
MENTAL HEALTH DRUGS
ACS will process claims for the Mental Health Carve-out drugs. Claims submitted for non
Mental Health Carve-out drugs using the Medicaid PCN and Group ID will deny with NCPDP
reject code 65 (Patient Not Covered). These claims must be sent to the MCO for processing.
Claims for Mental Health Carve-out drugs MUST be sent to the following:
BIN:
610084
Processor Control #:
Maryland Medicaid DRMDPROD
Group #:
Maryland Medicaid MDMEDICAID
Mental Health Formulary
All Mental Health claims will be processed through the MD/ MA POS system
The following table includes mental health drugs that are carved out of the Managed Care
Organization (MCO) pharmacy benefit.
All drugs from American Society of Health-System Pharmacists (AHFS) therapeutic classes
included in this table, including specific drugs that may not be listed in this table, are carved out
of the MCO pharmacy benefit and are payable as fee-for-service through Maryland Medical
Assistance with the following exceptions.
The following seven drugs, which may be used for some mental health indications, are not
payable fee-for-service (unless otherwise noted) and are the responsibility of the Health Choice
MCO’s for their enrollees, regardless of the Prescriber.
Page: 30
Leuprolide acetate+
Clonidine
Guanfacine
Naltrexone
Liothyronine
Medroxyprogesterone+
Disulfiram
+
When used to treat males for behavioral problems, will be paid fee-for-service, but will require
pre-authorization (PA).
There are also six drugs included in the table below that have been bolded and marked with an
“*”. These drugs are also exceptions to the carve-out and must be covered by the MCO’s.
Please note: All brand drugs, which are available as multi-source generics, require prior approval
and completion of a Maryland Medwatch Form unless otherwise noted.
Therapeutic Class
Antiparkinsonian Agents
AHFS Class No. 120804
Miscellaneous Anticonvulsants
AHFS Class No. 281292
Antidepressants
AHFS Class No. 281604
Drug
benztropine
biperiden
procyclidine
trihexyphenidyl
carbamazepine*
gabapentin*
Gabitril
Keppra
Lamictal*
Lyrica
Tegretol XR (PA)
Trileptal
Topamax*
valproate/divalproex
Zonegran
amitriptyline
amoxapine
bupropion
bupropion SR
citalopram
clomipramine
Cymbalta
desipramine
doxepin
Effexor XR
Emsam
fluoxetine
fluvoxamine
Page: 31
imipramine
Lexapro
Maprotiline
Marplan
mirtazapine
mirtazapine Soltab
Nardil
nefazodone (PA)
nortriptyline
Parnate
paroxetine
Paxil CR
Pexeva
protriptyline
Prozac Weekly (PA)
Sarafem (PA)
sertraline (PA)
Surmontil
Symbyax (PA)
trazodone
Wellbutrin XL
Venlafaxine
Antipsychotic Agents
AHFS Class No. 281608
Abilify
chlorpromazine
clozapine
FazaClo
fluphenazine
Geodon
haloperidol
loxapine
Moban
Orap
perphenazine
Risperdal
Risperdal M-Tab
Seroquel
Symbyax
thioridazine
thiothixene
trifluoperazine
Zyprexa
Zyprexa Zydis
Page: 32
Anorexigenic Agents and
Respiratory and Cerebral
Stimulants
AHFS Class No. 282000
Anxiolytics, Sedatives and
Hypnotics – Benzodiazepines
AHFS Class No. 282408
Benzodiazepines
AHFS Class No. 281208
Miscellaneous Anxiolytics,
Sedatives and Hypnotics
AHFS Class No. 282492
Antimanic Agents
Adderall XR (over age 12 PA required)
amphetamine (over age 12 PA required)
Concerta
Desoxyn (PA)
dextroamphetamine (over age 12 PA required)
Focalin
Focalin XR
Metadate CD
methamphetamine (over age 12 PA required)
methylphenidate
pemoline (PA)
Provigil (PA)
Ritalin LA (PA)
Strattera (Step therapy required age 17 and
under)
alprazolam
chlordiazepoxide
clorazepate
Diastat
diazepam
Doral (PA)
estazolam
flurazepam
lorazepam
midazolam*
oxazepam
Restoril 7.5mg (PA)
Restoril 22.5mg (PA)
temazepam
triazolam
Clonazepam
Ambien
Ambien CR
buspirone
chloral hydrate
droperidol*
hydroxyzine
Lunesta (PA)
Meprobamate
Rozerem
Sonata
Lithium
Page: 33
AHFS Class No. 282800
PA = Prior authorization required
MH Drug Restrictions
The following Mental Health drugs will have additional restrictions or conditions associated with
adjudication. See the table below for details:
1. Depo-Provera
2. Lupron Depot
Drug
Recipient
Sex
Disposition
Payer
Mental Health
N/A
FFS
Non-MH
N/A
DepoProvera,
150mg
F
Continue processing, all
edits apply
Continue processing, all
edits apply
Continue processing (PA
not required)
DepoProvera,
150mg
DepoProvera,
400mg
DepoProvera,
400mg
Lupron
Depot, 7.5mg
M
DENY, “PA Required,
Call 410-706-3431”
FFS
F
Continue processing (PA
not required), all edits
apply
DENY, “PA Required,
Call 410-706-3431”
FFS
FFS
Lupron
Depot, 7.5mg
Lupron
Depot,
22.5mg
Lupron
Depot,
22.5mg
Lupron
M
Continue processing (PA
not required), all edits
apply
DENY, “PA Required,
Call 410-706-3431”
Continue processing (PA
not required), all edits
apply
DENY, “PA Required,
Call 410-706-3431”
Continue processing (PA
FFS
Recipient Status
Fee for Service
M
F
F
M
F
Page: 34
FFS
FFS
FFS
FFS
FFS
FFS
Drug
Recipient Status
Depot, all
other
strengths
Lupron
Depot, all
other
strengths
Clozaril
Recipient
Sex
Disposition
Payer
not required), all edits
apply
M
Continue processing (PA
not required), all edits
apply
FFS
N/A
Continue processing (PA
not required), all edits
apply
FFS
Recipient Status
Drug
Recipient
Sex
Disposition
Payer
MCO
Mental Health
N/A
Continue processing, all
edits apply
FFS
Non-MH
DepoProvera,
150mg
N/A
F
DENY, “Bill MCO”
DENY, “Bill MCO”
MCO
MCO
DepoProvera,
150mg
M
DENY, “PA Required,
Call 410-706-3431”
FFS
DepoProvera,
400mg
F
DENY, “PA Required,
Call 410-706-3431”
FFS
DepoProvera,
400mg
M
DENY, “PA Required,
Call 410-706-3431”
FFS
Lupron
Depot, 7.5mg
Lupron
Depot, 7.5mg
Lupron
Depot,
22.5mg
F
DENY, “Bill MCO”
MCO
M
DENY, “PA Required,
Call 410-706-3431”
DENY, “Bill MCO”
FFS
F
Page: 35
MCO
Drug
Recipient
Sex
Disposition
Lupron
Depot,
22.5mg
Lupron
Depot, all
other
strengths
Lupron
Depot, all
other
strengths
Clozaril
M
DENY, “PA Required,
Call 410-706-3431”
FFS
F
DENY, “Bill MCO”
MCO
M
DENY, “Bill MCO”
MCO
Recipient Status
Payer
FFS
AGE LIMITATIONS:
Maryland Medicaid will enforce the following Age Restrictions:
Non-legend chewable tablets of any ferrous salt when combined with vitamin C, multivitamins,
multivitamins and minerals, or other minerals in the formulation:

Covered for age <12 years

Claims for age >/= 12 will deny (not covered)
Otherwise, NCPDP 60 and message text: "Product/Service Not Covered for Patient Age” &/or
NCPDP 76 and message text: Plan Limitations Exceeded – Call DHMH at 1-410-767-1755"
Topical Vitamin A Derivatives, HIC3 = L9B; and Route = Topical (e.g., Retin-A)

Covered for age < 60 years.· PA required >/= 60
Otherwise, NCPDP 60 and message text: "Product/Service Not Covered for Patient Age - Call
DHMH at 1-410-767-1755", MD will handle PA requests.
LTC / HOSPICE CLAIM BILLING
The system will determine Hospice-Only claims by the following conditions:

Claim contains Patient Location code = ‘11’ (NCPDP field 307-C7)

Client Specific Reporting field on Recipient Eligibility file = "HI"

The Date of Service is within an active coverage span on the Recipient Eligibility file

Facility ID (NCPDP field # 336-8C) is on list of institutions below
Note: The system will deny Hospice claims that do not have both a Patient Location code = ‘11’
and a Client Specific Reporting field on Recipient Eligibility file = "HI.
The system will determine LTC claims by the following conditions:
Page: 36

Claim contains Patient Location code = ‘04’ (NCPDP field 307-C7)

Facility ID (NCPDP field # 336-8C) is on list of institutions below

Pharmacy Provider ID is on the list of LTC providers below
Note: Existing "NH" provider numbers = LTC providers / institutions
The system will determine LTC/Hospice claims by the following distinct conditions:

Client SPECIFIC REPORTING field = "HI" on the recipient's enrollment record with
a date span that includes DOS, AND

PATIENT LOCATION (NCPDP field # 307-C7) = "11", AND

FACILITY ID (NCPDP field # 336-8C) any value on the list of institutions below,
AND

Designated LTC providers in the SERVICE PROVIDER ID (NCPDP field # 201-B1)
LTC PHARMACIES
2103517
2119154
2106385
2117489
2120943
3977165
2122834
802620
2115500
3972709
3972999
2119887
2122086
2102402
2111766
2110889
2110980
2121680
3976137
2126692
2126096
2121856
2121957
4834758
2116615
2123963
802620
2115500
2118835
3973876
3972709
2117251
2119887
2119899
2103517
2120690
2113380
2122492
2125183
2122086
2102402
2111766
2110889
2110980
2121680
3976137
2126692
2126096
4834758
2122579
719952
2123331
719952
2115601
2121957
615534
2122579
2111641
2121856
HOSPICE INSTITUTION IDs
NH0010000
NH0020000
NH0030000
NH0040000
NH0050000
NH0060000
NH0070000
NH0090000
NH0690000
NH0700000
NH0790000
NH0840000
NH0920000
NH0930000
NH1020000
NH1030000
NH4350000
NH4430000
NH4450000
NH4470000
NH4530000
NH4550000
NH4560000
NH4580000
NH6670000
NH6690000
NH7010000
NH7030000
NH7070000
NH7080000
NH7260000
NH7290000
Page: 37
NH9390000
NH9400000
NH9410000
NH9430000
NH9440000
NH9450000
NH9460000
NH9470000
113500700
794021000
115035900
800201100
553265500
111700900
069325100
536345400
NH0100000
NH0110000
NH0150000
NH0160000
NH0170000
NH0180000
NH0190000
NH0200000
NH0210000
NH0220000
NH0230000
NH0240000
NH0250000
NH0270000
NH0300000
NH0330000
NH0350000
NH0360000
NH0400000
NH0410000
NH0430000
NH0460000
NH0470000
NH0480000
NH0510000
NH0520000
NH0530000
NH0540000
NH0550000
NH0570000
NH0590000
NH0600000
NH0610000
NH0630000
NH0640000
NH0650000
NH0660000
NH1090000
NH1100000
NH1120000
NH1300000
NH1510000
NH1530000
NH1630000
NH1760000
NH1780000
NH2030000
NH2070000
NH2080000
NH2090000
NH2260000
NH2280000
NH2310000
NH2510000
NH2520000
NH2530000
NH2770000
NH2820000
NH2830000
NH3020000
NH3040000
NH3080000
NH3090000
NH3260000
NH3270000
NH3280000
NH3540000
NH3560000
NH3760000
NH4010000
NH4020000
NH4260000
NH4290000
NH4340000
NH4590000
NH4600000
NH4620000
NH4640000
NH4650000
NH4670000
NH4680000
NH4690000
NH5040000
NH5070000
NH5110000
NH5120000
NH5150000
NH5190000
NH5200000
NH5210000
NH5220000
NH5230000
NH5250000
NH5270000
NH5280000
NH5290000
NH5530000
NH5760000
NH5780000
NH6010000
NH6030000
NH6260000
NH6290000
NH6300000
NH6510000
NH6530000
NH6550000
NH6560000
NH6610000
NH6650000
NH6660000
NH7500000
NH7510000
NH7520000
NH7580000
NH7620000
NH7650000
NH7660000
NH7700000
NH7710000
NH7720000
NH7740000
NH7770000
NH7930000
NH8010000
NH8050000
NH8090000
NH8120000
NH8150000
NH8220000
NH8230000
NH8240000
NH8250000
NH8300000
NH8360000
NH9020000
NH9190000
NH9240000
NH9250000
NH9260000
NH9290000
NH9310000
NH9330000
NH9340000
NH9350000
NH9360000
NH9370000
NH9380000
NH9480000
NH9500000
NH9510000
NH9520000
NH9530000
NH9540000
NH9550000
NH9560000
NH9570000
NH9580000
NH9590000
NH9600000
NH9610000
NH9620000
NH9630000
NH9640000
NH9650000
NH9660000
NH9670000
NH9680000
NH9690000
NH9700000
NH9710000
NH9720000
NH6640000
432235500
189505200
104500800
536295400
212765200
794012200
043271700
553225600
347001600
251002200
754845100
536255500
039395900
600902600
529904700
391950100
520008300
229910100
365162201
NH0720000
NH9730000
NH9320000
NH9740000
NH2020000
NH9750000
NH5240000
NH9760000
EMERGENCY FILL
The system will allow emergency fills when claims contain a ‘3’ in the Level of Service field
(emergency).

Pharmacy Program recipients will be allowed two 72-hour emergency fills per Rx (no
Page: 38
dispensing fee on second emergency refill) for non-PDL drugs except for those
medications listed in the table below. These medications are not limited to a 72-hour
supply.

Nursing Home recipients will be allowed a 30 days supply of non-PDL drugs
72 Emergency Supply Drug Exceptions
Non-preferred (unit dose) drugs exempt from the 72 hour emergency supply limits
(not limited to 72 hour supply)
Eye drops
Ear drops
Nasal administered drugs
Injectables
Ointments, creams and gels
Antibiotics
Antivirals (Tamiflu, Relenza) during flu season Oct. 1 through Apri1 1
Inhalers
PRICING
Reimbursement for Maryland Medicaid claims will follow the structure listed below:
1) Legend Drugs, Schedule V Cough Preps, Enteric Coated Aspirin, Oral Ferrous Sulfate Prods
Payment is lesser of:
U/C -or- Allowable Cost + Dispensing Fee
Allowable Cost lesser of:
1. IDC,
2. EAC (lesser of): WAC+8%· Direct+8%· · AWP - 12%,
3. FUL
2) Chewable Ferrous Sulfate with Multivitamins
Payment is lesser of:
U/C -or- Allowable Cost + 50% -or- Allowable Cost + Dispensing Fee
Allowable Cost is lesser of:
1. IDC
2. EAC (lesser of): WAC+8% -or- Direct+8% -or- AWP - 12%
Page: 39
3. FUL
3) Condoms
Payment is lesser of:
U/C -or- Allowable Cost + 50%
Allowable Cost:
EAC (lesser of): WAC+8% -or- Direct+8% -or- AWP – 12%
4) Home IV Claims – See subsequent section titled “Compounded Home Infusion (Home IV)
Claims”
5) Medical Supplies and Durable Medical Equip (Needles and Syringes)
Payment is lesser of:
U/C -or- Allowable Cost + Dispensing Fee
Allowable Cost: AWP
6) DAW 1 and 6 Claims
Payment is lesser of:
U/C -or- Allowable Cost + Dispensing Fee
Allowable Cost:
EAC (lesser of): · WAC+8% -or- Direct+8% -or- AWP – 12%
7) Other OTC Drugs (Insulin and Nutritional Supplements)
Payment is lesser of:
U/C -or- Allowable Cost + 50% -or- Allowable Cost + Dispensing Fee
Allowable Cost: AWP
DISPENSING FEES:

Brand not on PDL: $2.69

PDL and generic: $3.69

LTC Dispensing Fee:
Brand name drug not on PDL - $3.69
Generic drug or brand name drug on PDL $4.69
* Limit of 1 dispensing fee/month /NDC for NH patient: (can be overridden by PA type code
= 5).

Hospice Dispensing Fee:
Brand name drug not on PDL - $2.69
Generic drug or brand name drug on PDL - $3.69

LTC/Hospice Dispensing Fee
Brand name drug not on PDL - $3.69
Generic drug or brand name drug on PDL - $4.69

Partial Fills:
½ dispensing fee at initial fill
½ dispensing fee at completion fill
Copay paid on initial fill.
Page: 40
RETURN TO STOCK (FOR PRESCRIPTIONS TO RECIPIENTS RESIDING IN NURSING
HOMES
Full Returns:
A claim will be recognized as a return to stock if position one of NCPDP field 462-EV (Prior
Authorization Number Submitted) is equal to 1 The pharmacy enters code above and re-bills
(B3) the claim with a quantity equal to the quantity that was originally submitted. The claim will
pay with only a dispensing fee.
Partial Returns:
The pharmacy must change the quantity to the quantity that was used, and re-bill the claim (B3).
There is no need to enter a value in the Prior Authorization field. Payment will include the
quantity used plus the dispensing fee.
DRUG COVERAGE
ACS will ensure that all drugs in Therapeutic Classes 01-99 are covered, except where
exclusions are noted in this section below.
The following rules will be enforced for OTC Drugs:


Generally not covered,
Covered OTC drugs must be rebateable. Non-rebateable drugs will deny, NCPDP 70, ‘NDC
Not Covered’.
OTC Coverage Exceptions
OTC Coverage Exceptions (all other OTCs will deny with NCPDP 70 – NDC not covered)
TC = 86
Infant Formulas
OTC Coverage Exceptions (all Schedule V Cough Preps
other OTCs will deny with
NCPDP 70 – NDC not covered)
TC = 86
Condoms
Max qty = 12
GSN = 004381
Enteric Coated Aspirin 325mg
DCC = I
Insulins
TC = 68
Protein Lysates
HIC3 = C6D
Drisdol
HIC3 = C1W, C5F, C5G, C5U, Nutritional Supplements
M4B
GSN = 031631
Ferrous sulfate drops
(125mg/ml)
GSN = 001639
Ferrous sulfate elixir
(220mg/5ml)
GSN = 001642
Ferrous sulfate syrup
(90mg/5ml)
GSN = 011832, 001645,
Ferrous sulfate tablets, 300mg
Page: 41
001646, 017378
or 325mg
HIC3 = C3B; or HSN =
001025, 001029, 006485,
001024, 001095, 001086; and
Dosage Form = TC; and
OTC
DCC = M, N, O, P, Q, R
HIC3 = G9A
HSN = 008966
HSN = 006605, 026243
Chewable tablets of any ferrous
salt when combined with
vitamin C, multivits, multivits +
minerals, or other minerals in
the formulation
Hypodermic needles / syringes
OTC Contraceptives
Pen needles
Alavert Allergy Sinus, Allergy
Relief D-12 &24 Hour, Claritin
D 12 &24Hr, loratidine D 24
hour
Alavert, Allergy Relief, Claritin
10 Reditabs, Tavist ND, and
loratidine tabs
Plan B Contraceptive
HSN = 007605
HSN = 07318
Max age = 11 years (cover
through year 11)
Min qty = 60 tablets
Max days supply = 100
From 1/2005 updates
From 1/2005 updates
for female recipients 18 years
or older
The following rules apply to DME/DMS :



Needles and syringes are covered through POS.
All other DME/ DMS (durable medical equipment/ disposable medical supplies) should be
billed on a HCFA 1500 form and forwarded to the DME/ DMS Unit.
Questions should be addressed to the Program Specialist at DME/ DMS at (410) 767-1739.
The following are exceptions to the rules for DME/DMS:


Needles & Syringes, Drug Category = M, N, O, P, Q, R
Pen Needles, HSN = 008966
LTC Drug Coverage Exceptions include:
Page: 42


OTC (including needles, syringes, and nutritional supplements) are not covered except for
insulin and Schedule V cough preps.
All normally covered medications in unit dose form
Hospice Drug Coverage exclusions include:


AHFS = 28:08.08
This will be denied with edit 75, PA required and the message: “Bill Hospice – Call State
with any questions”.
LTC/Hospice:



Covers all unit dose items
Coverage exclusions: OTC (including needle, syringes, & nutritional supplements
Coverage exclusions: AHFS = 28:08.08. will be denied with edit 75, PA required and the
message: “Bill Hospice – Call State with any questions”. State staff will handle override
approvals.
Unit Dose:
The system will deny unit dose drugs with edit 70 (drug not covered) with the exception of drugs
listed below. Message text to providers: “Unit Dose Package”.
Unit Dose Drug Exceptions
Unit Dose Drugs Exceptions for Retail Claims (all other U/D will deny with NCPDP 70 – NDC not
covered)/ “Unit Dose Package Size”
HSN = 000739; and UD
Ferrous Sulfate (single
ingredient products only)
Prenatal Vitamins w/Iron
HSN = 018809, 023540,
020559, 023539, 023763,
020193, 018378, 023068,
018377, 018379, 018822,
018816, 021013, 006033,
018805, 018829, 001011,
001010, 022684, 022687,
022686, 022685, 022711,
021399, 021451, 022710,
025978; and UD
HSN = 010933 ; and UD
Stromectol
Page: 43
GSN = 040910, 040911,
047126; and UD
GSN = 047326
GSN = 011964, 011963; and
UD
HSN = 001578; and UD
GSN = 008838; and UD
GSN = 031055, 031056; and
UD
GSN = 049296, 040887; and
UD
GSN = 047453, 047454,
047636; and UD
GSN = 001171; and UD
GSN = 000591, 000592; and
UD
GSN = 000586; and UD
GSN = 031099; and UD
GSN = 045215, 045216; and
UD
GSN = 049443; and UD
GSN = 009326, 009327; and
UD
GSN = 048463; and UD
GSN = 045266; and UD
GSN = 041562, 041563; and
UD
GSN = 022232, 046525,
046526; and UD
GSN = 015551; and UD
HSN = 000057; and UD
GSN = 018370; and UD
Route = ophthalmic; and UD
GSN 048698 and UD
GSN 048699 and UD
GSN 005039 and UD
GSN 047324 and UD
GSN 023545 and UD
GSN 050660 and UD
GSN 049741 and UD
GSN 011688 and UD
GSN 049871, 041878, 041849
and UD
Micardis 20mg, 40mg & 80mg
Micardis HCT 40/12.5mg
Sandimmune 25mg & 100mg
Chloral Hydrate
Etoposide
Pepcid RPD
Prevacid Liquid
Remeron Sol-Tab
Water for Inhalation
Mucomyst
Sodium Chloride
Aldara
Androgel
PrimaCare
Vancocin HCL
Zomig ZMT
Methotrexate Dose Pak
Zofran ODT
Pulmicort
Deleted GSN 046565
Ceenu
Ipratropium Bromide
Bactroban Nasal
Eye Drops
Albuterol 0.63mg/3ml
Albuterol 1.25mg/3ml
Albuterol 0.83mg/ml
Micardis HCT80/12.5
Mesnex 400 mg
Zelnorm 2mg
Zelnorm 6mg
Cromolyn 2 ml inhalation
Xopenex (Levalbuterol)
Inhalation Soln products
Page: 44
GSN 000859 and UD
GSN 000689 and UD
GSN 000667 and UD
GSN 000659 and UD
GSN 000673 and UD
GSN 000657 and UD
GSN 038271 and UD
GSN 001574 and UD
GSN 040911 and UD
GSN 023882 and UD
GSN 023881 and UD
GSN 52877
GSN 52876
GSN 58828
GSN 58829
GSN 04444
Levocarnitine 330mg
Iron polysac.
Complex/cyanocobalamin/FA
Fe fumarate/Ascorbic
acid/VitB12 intrinsic factor/FA
Fe fumarate/Ascorbic
acid/cyanocobalamin/FA
Fe sulfate/Ascorbic acid/FA
Fe fumarate/Ascorbic
acid/cyanocobalamin/Stomac
concentrate
Trinsicon
Iberet-folic 500
Telmisartan (Micardis) 80mg
Cyclosporine (Neoral) 25mg
Cyclosporine (Neoral) 100mg
Chromagen FA
Chromagen Forte
Chromagen Forte Capsules
Chromagen FA Capsules
Mesalamine 4Gm/60ml Rect S
Package Size:
The system will ensure that products commonly billed with incorrect quantity (i.e.: Ophthalmics,
prefilled injectable syringes, etc.) are submitted in multiples of correct package size, otherwise
claims will be denied for missing/invalid quantity.
Family Planning
The following are covered under family planning:
Drug Category = C, T - Contraceptives, Oral & Topical
TC = 63 - Systemic Contraceptives
Gender
The following gender specific coverage will be enforced and deny with edit 70, Female only:
Drug Category C - contraceptives, oral
HIC3: X1B - Diaphragms/Cervical Cap
Drug Category = W, except Depo-Provera: GSN = 017584, 026098, 003268, 003270,
Contraceptives, Systemic, non-oral
COMPOUNDED HOME INFUSION (HOME IV) CLAIMS:
TPN
Submit as one claim under one prescription number. Do not use Submission Clarification Code
= 99.
Page: 45
Use compound code 2 for multi-ingredient functionality.
Enter NDC and quantity of each ingredient, including the large volume diluents (sterile water for
injection).
Quantity and days supply should be per batch sent. Use proper units. NOTE: Units for TPNs
are all expressed in “mls”.
Lipids (HIC3=M4B) can be included on the compound or billed separately depending on the
manner prescribed (1:3 TPN formula or 1:2 TPN formula). If the lipids are dispensed
separately from the TPN admixture, submit the lipid claim as a non-compound claim using
compound code 0 or 1. Claim will adjudicate on-line with a pharmacy dispensing fee. If the
lipids are prescribed as part of the TPN formula, then bill the lipids as part of the TPN compound
claim in the multi-ingredient segment.
Claim will pay on-line with one regular pharmacy dispensing fee for the drug portion of the IV
compound.
Provider will bill for the IV compounding fee and supplies under DMS/DME HCPC codes.
Submit completed Pharmacy Invoice and Record of Home IV Therapy and DME/DMS
Dispensed form along with a copy of the TPN order for State to review.
(NOTE: for Fee-for-Service Recipients enrolled in PAC and Medicaid recipients residing in
Nursing Homes without supply coverage under DME/DMS, the TPN claim is manually priced
and includes reimbursement of each drug ingredient in the TPN, a dispensing fee ($7.25 per day
of therapy) and supplies (at a flat rate) used in compounding. Both drug and supply portions are
paid under pharmacy Services. To allow manual pricing, the provider must submit '99' in the
Submission Clarification Code field (NCPDP field #420D.) and must still enter each ingredient
of the TPN formula with its corresponding quantity in the multi-ingredient segment. This will
allow Program staff to price each ingredient listed in the Line Item Section of the ACS system.
For all recipients, including fee-for-service MA, PAC, and Nursing Home recipients, providers
may bill for each drug additive (MVI, Vitamin K, Pepcid, etc.) separately as a non-compound
claim using the non-compound code 2 under Pharmacy Services. Each of these claims will
adjudicate on-line with a pharmacy dispensing fee.
Hydration Therapy
Submit as one claim under one prescription number.
Use compound code 2 for multi-ingredient functionality. Do not use Submission Clarification
Code = 99
Enter NDC and quantity of each ingredient (i.e. sodium bicarbonate, magnesium sulfate, etc).
Use proper units. NOTE: Units for hydration therapy are all expressed in “mls”.
May bill for the large volume diluent (i.e. Dextrose 5% in Sodium chloride 0.45%).
Note: Hydration Therapy and TPN are the only therapies for which providers may bill the
diluents under Pharmacy Services.
Quantity and days supply should be per batch sent.
Claim will pay on-line with one pharmacy dispensing fee.
Page: 46
Submit completed Pharmacy Invoice and Record of Home IV Therapy and DME/DMS
Dispensed form along with a copy of the IV order for post-payment review by the State.
Bill for compounding fees, supplies under DMS/DME codes using the specific HCPC codes.
(NOTE: for Fee-for-Service Recipients enrolled in PAC and Medicaid recipients residing in
Nursing Homes without supply coverage under DME/DMS, the hydration therapy claim is
manually priced and includes reimbursement of each drug ingredient in the hydration therapy
compound, an IV compounding dispensing fee ($7.25 per day of therapy) and supplies (at a flat
rate) used in compounding. Both drug and supply portions are paid under pharmacy Services.
To allow manual pricing, the provider must submit '99' in the Submission Clarification Code
field (NCPDP field #420D.) and must still enter each ingredient of the hydration therapy formula
with its corresponding quantity in the multi-ingredient segment. This will allow Program staff to
price each ingredient listed in the Line Item Section of the ACS system.
Submit completed Pharmacy Invoice and Record of Home IV Therapy and DME/DMS
Dispensed form along with a copy of the hydration therapy order for State to review and release
payment.)
Non-TPN, Non-Hydration Therapy
(I.e. Anti-infective, anti-fungal, antiviral therapy, chemotherapy, cardiac drugs, iron chelating
agents, etc.)
Use compound code = 1 to bill for cost of active drug only- Do not bill for any Diluents. Use
single drug NDC with corresponding quantity and days supply per batch sent. Use proper units.
NOTE: Unit is “each” for each vial in the powder form (and not “each” for each gram) and “ml”
for liquid vials in the unreconstituted form.
Pays on-line for the single active drug ingredient only with a pharmacy dispensing fee.
Do not use Submission Clarification Code = 99.
Bill for IV compounding fees, diluents and supplies using DMS/DME HCPC codes.
Submit completed Pharmacy Invoice and Record of Home IV Therapy and DME/DMS
Dispensed form along with a copy of the IV order for State to conduct post-payment review.
(NOTE: for Fee-for-Service Recipients enrolled in PAC and Medicaid recipients residing in
Nursing Homes, reimbursement for dispensing fee ($7.25 per day of therapy), and supplies
(which include reimbursement for the diluents) used in compounding will be included in the
calculated reimbursement rate and paid under pharmacy services.
Use Submission Clarification Code = 99 so it can be manually priced by the State to include fee
and supplies/diluents at flat rate. Submit completed Pharmacy Invoice and Record of Home IV
Therapy and DME/DMS Dispensed form along with a copy of the IV order for State to review
and release for payment.)
Non-Compounded Premix Systems
(i.e. anti-infectives or commercial hydration therapies, premixed TPN, etc.)
Use compound code = 1
Do not use Submission Clarification Code = 99
Page: 47
Bill for NDC and the quantity of the premixed product. Units for the premix systems are all
expressed in “ml”. Quantity and days supply should be per batch sent.
Pays on-line with a pharmacy dispensing fee. For ex. a 7 day supply of vancomycin 1g in 200ml
Dextrose 5% in Water prescribed qd (daily) should be billed with quantity of 1400 (200ml x 7).
Bill for NDC of the diluent bag only if applicable to the two-component premix system such as
the Advantage system).
Each claim pays on-line with a pharmacy dispensing fee.
Submit completed Pharmacy Invoice and Record of Home IV Therapy and DME/DMS
Dispensed form along with a copy of the IV order for State to review.
Clotting Factors and High Cost Drugs Such as IV Enzyme Replacement Therapies
(HIC3 = MOE and MOF and other IV enzyme replacement therapies)
IV claims for clotting factors and other extremely expensive IV replacement therapies are set to
deny for hand-pricing by the State.
Submit on-line using non-compound code 0 or 1. No need to submit with submission
clarification code 99.
Units billed for clotting factors dispensed in various potencies may be combined and billed using
the NDC of one of the vial potency for the same product.
Do not combine the units of enzyme replacement therapies. For ex. claims for Cerezyme in the
200 units and 400 units potencies must be submitted as separate claims and priced as individual
claims for each strength.
Claim will automatically deny with message to submit to State for review and hand-pricing.
Fill out and submit Clotting Factor and High-Cost Drug Standard Invoice along with a copy of
the prescriber's order, a copy of the actual purchase invoice showing cost paid for the clotting
factor, proof of delivery (signed delivery ticket), Pharmacist Clotting Factor Dispensing Record,
and the Voluntary Recipient Kept Factor Infusion Log.
Page: 48
DRUGS DENIED WITH 99 RULES
Therapeutic
Classification Description
Drugs to treat hereditary
HIC3=D7D
tyrosinemia
HIC3=M0E
Antihemophilic factors
HIC3=M0F
Factor IX preparations
HIC3=M0G
Antiporphyria factors
Antineoplastic
HIC3=V1M
immunomodulator agents
Enzyme replacements-Misc
HIC3=Z1D
(ubiquitous enzymes)
Drugs for TX of Gaucher
HIC3=Z1G
Disease
HIC3=Z2H
HIC3=Z1Hincluded in
Z1D
HIC3=Z1Iincluded in
Z1D
HIC3=Z1Jincluded in
Z1D
HIC3=Z1Kincluded in
Z1D
HIC3=Z1L
Products
nitisinone (Orfadin) oral capsules
IV injections
IV injections
panhematin (Panhematin) IV injections
lenalidomide (Revlimid) oral capsules
Fabrazyme, Ceredase, Cerezyme,
Aldurazyme, Adagen- all injections
Systemic enzyme inhibitors
miglustat (Zavesca) oral capsules
alpha-1 proteinase inhibitors (Prolastin inj.,
Aralast inj., Zemaira- all inj.)
Metabolic disease enzyme
replacement
agalsidase beta (Fabrazyme) injection
Metabolic dis.enzyme replacMisc.Gaucher d/s
alglucerase (Ceredase) inj.; imiglucerase
(Cerezyme)- all injections
Metab.dis. enzyme replacMucopolysaccharide
galsulfase (Naglazyme); idursulfase
(Elaprase); laronidase (Aldurazyme)-inj
Meta.dis.enz. replac-severe
combined immune def
Metabolic disease enzyme
replacement-Misc.
pegademase bovine (Adagen) injection
alglucosidase alpha (Myozyme) injection
Page: 49
MEDICARE D
The following rules will be implemented for MED D:

Maryland Medicaid will not be processing COB claims for part D eligible patients

Denied claims for Part D covered products will return a NCPDP 41 – Submit Bill to Other
Processor or Primary Payer

See table below for a list of Medicare Part D Excluded Drugs that are covered by Maryland
Medicaid
Medicare D Excluded Drugs Covered by MD Medicaid
Description
Medical Supplies
Code Level
TC
Agents used for anorexia,
weight loss or weight gain
Agents used to promote
fertility
Agents used for symptomatic
relief of cough/cold
Rx vitamins and minerals,
except prenatal vitamins and
fluoride products
DCC
Code Values
00
Exceptions:
Part D Must Cover
GSN = 009797
HSN = 004348
HSN = 008966
DCC = Q, R
F
DCC
B
TC
OTC
Rx Required
Field
Barbiturates
Benzodiazepines:
Alprazolam
Chlordiazepoxide
TC
16
17
80
81
82(Except HIC3=C6F)
83
84
85
N = OTC Drugs
Exceptions:
Part D Must Cover
HSN = 011115 & OTC
HSN = 007605 & OTC & Generic
46
HSN
HSN
HSN
HSN
HSN
HSN
HSN
HSN
001617
001611
001610
001612
001615
001618
004846
001616
Clorazepate
Diazepam
Halazepam
Lorazepam
Oxazepam
TC
Page: 50
Prazepam
Estazolam
Flurazepam
Midazolam
Quazepam
Temazepam
Triazolam
Clonazepam
Medical Supplies
HSN
HSN
HSN
HSN
HSN
HSN
HSN
HSN
TC
Agents used for anorexia,
weight loss or weight gain
Agents used to promote
fertility
DCC
001613
006036
001593
001619
001595
001592
001594
001894
00
Exceptions:
Part D Must Cover
GSN = 009797
HSN = 004348
HSN = 008966
DCC = Q, R
F
DCC
B
Page: 51
SECTION VIII
BREAST AND CERVICAL CANCER DIAGNOSIS AND TREADTMENT (BCCDT) PROGRAM
SPECIFICS
MULTI-LINE COMPOUND CLAIM SUBMISSION
BCCDT will accept multi-line Compound claims. If providers submit a compound claim with a single
ingredient the claim will be denied.
The system will accept up to 40 line items (individual ingredients) in each compound claim. The
system will allow providers to use Submission Clarification code 8 (process compound for approved
ingredients) to override denials for compound ingredients that are not covered.
DUPLICATE CLAIM PROCESSING
The system will use the following standard methodology to determine Duplicate paid claims:
Response Status: D (retransmission NCPDP Duplicate Response)
Match on: Pharmacy ID (NCPDP field # 201-B1), RX # (NCPDP field #402-D2),
Patient ID (NCPDP field #302-C2), NDC (NCPDP field #407-D7), DOS (NCPDP field
#401-D1) and New/Refill Code (NCPDP field #601-57)
Error 83: Duplicate RX
Match on: Pharmacy ID (NCPDP field # 201-B1), RX # (NCPDP field #402-D2),
Patient ID (NCPDP field #302-C2), GSN (Not on claim; FDB) and DOS (NCPDP field
#401-D1)
Error: 83: Different Pharmacy Search
Match on: RX # (NCPDP field #402-D2), Patient ID (NCPDP field #302-C2), GSN
(Not on claim; FDB) and DOS (NCPDP field #401-D
Error 83: Duplicate Fill
Match on: Patient ID (NCPDP field #302-C2), GSN (Not on claim; FDB) and DOS
(NCPDP field #401-D1)
DISPENSING LIMITS:
Days Supply:
There is a per claim days supply maximum of 34 days. Quantity dispensed should be commensurate to
the days supply.
Exceptions:
Maintenance drugs allow 102 days supply
REFILLS
A maximum of 11 refills for Non-Controlled Covered Drugs.
Refills are not allowed on non-controlled drugs to be filled 360 days or more from the date prescribed.
A maximum of 5 refills for Schedules III, IV and V controlled covered drugs.
Refills are not allowed on controlled drug to be filled 180 days or more from the date prescribed.
The system will not allow refills for Schedule II controlled covered drugs
PRICING
ACS will ensure the claims reimburse at the following pricing:
Page: 52
Lesser of:
-U&C
- Allowable Cost + dispensing fee
Allowable Cost:
Lesser of:
1. IDC
2. EAC (lesser of): WAC+8%· Direct+8%· AWP - 12%
3. FUL
COPAYS:
There are no copays for BCCDT recipients
DISPENSING FEE:
BCCDT has the following dispensing fee structure:

BRAND products = $2.69

Generic Products = $3.69

Partial Fill dispensing fee will be paid ½ at the initial fill and ½ at the completion fill
PRIOR AUTHORIZATION
Prior Authorization requests will be handled either by the BCCDT office or at the ACS Technical Call
Center. Below is a list prior authorizations that are handled by each entity:
ACS Technical Call Center:
The ACS Call Center will handle the following prior authorization requests on behalf of
MD BCCDT:
Maximum dollar limit > $2500.00
Early Refill
Brand Medically Necessary - DAW 1, with exceptions
Day Supply for approved situations
PA denials handled by ACS will return the following message text in the response: “Prior
Authorization Required, Call ACS at 1-800-932-3918 (24/7/365)”.
BCCDT Office:
The MD BCCDT staff will handle the following prior authorization requests:

Early Refill - For requests outside established criteria

PA/Medical Certification - authorization based on diagnosis

DME/DMS for HCFA 1500 billing - exception: needles, syringes that are paid through POS
PA denials handled by MD BCCDT will return the following message text in the response: “Prior
Authorization Required, call MD BCCDT (410) 767-6787, M-F, 8:30 am – 4:30 pm”.
DRUG COVERAGE
Drug Coverage is defined by the BCCDT program and its parameters. BCCDT covers drugs that are
related to breast or cervical cancer diagnosis or treatment or complications of treatment. Below is a
Page: 53
grid of covered drugs for all groups active on the Date of Service (DOS) with BCCDT some of these
drugs may require prior authorization based on diagnosis and/or medical documentation:
Drug Code
H3A
H3D
H3E
H6J
S2B
W1W
W1X
W1Y
W1Z
W1K
W1D
W2F
H2E
W1A
W1Q
H7E
H7C
H2S
W1C
W4E
H2U
HSN 010249
HSN 001653
HSN 018385
HSN 002860
HSN 003893
HSN 002889
HSN 001847
HSN 020803
GSN 011832, 001645, 001646,
017378
HSN 002867
HSN 012351
HSN 001975
HSN 002877
HSN 002148
HSN 004129
HSN 002874
Drug Name
Analgesics, Narcotics
Analgesics, Salicylates
Analgesics/Antipyretics, NonSalicylates
Anti-emetics
Comments
Oral forms only covered
Oral forms only covered
Exclude HSN 002005 –
Scopolamine
Anti-Inflammatory Agents
Oral forms only covered
Cephalosporins – 1st gen
Oral forms only covered
nd
Cephalosporins – 2 gen
Oral forms only covered
rd
Cephalosporins – 3 gen
Oral forms only covered
Cephalosporins – 4th gen
Oral forms only covered
Lincosamides
Oral forms only covered
Macrolides
Oral forms only covered
Nitrofuran Derivatives
Oral forms only covered
Non-Barbiturates, Sedative-Hypnotic Oral forms only covered
Penicillins
Oral forms only covered
Quinolones
Oral forms only covered
Serot-2 Amtag/Reuptake Inhib
Oral forms only covered
(SARIS)
Serot-Norepineph Reup-Inhib
Oral forms only covered
(SNRIS)
Serotonin Spec Reuptake Inhib
Oral forms only covered
(SSRI)
Tetracyclines
Oral forms only covered
Trichomonacides
Oral forms only covered
Tricy Antidepr & Rel NSRUI
Oral forms only covered
Anastrozole
Bupropion HCL
Exclude GSN 031439
Capecitabine
Cortisone Acetate
Cyclophosphamide
Dexamethasone
Deflunisal
Exemestane
Ferrous Sulfate
OTC TO COVER
Hydrocortisone
Letrozole
Meclizine HCL
Methylprednisolone
Metoclopramide HCL
Nystatin
Prednisolone
Page: 54
HSN 002879
HSN 012014
HSN 011632
HSN 018801
HSN 33401
HSN 02045
HSN 01608
HSN 11506
HSN 21157
F1A
TC 48
D6D
Z2A
TC 30
TC 16
TC 15
TC 76
P5A
TC 58
TC 74
TC 79
Q6I
Q6W
Q6P
Q6V
Q6S
TC 71
D6S
H7J
M9P
C1D
H6H
TC 55
Q5P
Q4F
TC 72
TC 73
HSN 004047
HSN 007708
HSN 009005
HSN 022142
GSN 007062
HSN 015176
Prednisone
Promethazine HCL
Toremifene Citrate
Trastuzumab
Biafine Emulsion
Dicyclomine
Hydroxyzine
Mirtazepine
Zyvox
Androgenic Agents
Anticonvulsants
Anti-diarrheal Agents
Antihistamines
Antineoplastic Agents
Antitussives – Expectorants
Bronchodilators
Cardiovascular Preparations, Other
Corticosteroids, Inhaled
Diabetic Therapy
Digitalis Preparations
Diuretics
Eye Antibiotic – Coticoid
Combination
Eye Antibiotics
Eye Antiinflammatory Agent
Eye Antiviral
Eye Sulfonamide
Hypotensives, Others
Laxatives & Cathartics
MAOIS – Non-Selective &
Irreversible
Platelet Aggregation Inhibitors
Potassium Replacement
Skeletal Muscle Relaxants
Thyroid Preparations
Topical Antiinflammatory
(corticosteroids)
Vaginal Antifungals
Vasodilators, Coronary
Vasodilators, Peripheral
Bacitracin
Cadexomer Iodine
Fosfomycin Tromethamine
HC Acetate/Lidocaine HCL
HC Acetate/Pramoxine HCL
Hydrocortisone/Pramoxine HCL
Page: 55
Rectal forms only covered
GSN 040262
GSN 043256
GSN 003407
GSN 003411
GSN 003412
GSN 007407
GSN 007409
HSN 016196
HSN 003385
HSN 007527
HSN 003363
HSN 004107
GSN 009477
GSN 009478
HSN 004284
HSN 004285
HSN 004270
HSN 020355
HSN 004283
W3B
P4B
P4L
D4K
N1B
M9K
N1C
M9L
Q5F
Q4W
Q4S
HSN 003904
HSN 010798
HSN 004570
HSN 010778
HSN 007845
HSN 010166
HSN 025963
HSN 002285
HSN 010280
HSN 003916
HSN 006578
HSN 023523
HSN 021114
HSN 021102
HSN 003923
Lidocaine
Lidocaine
Lidocaine HCL
Lidocaine HCL
Lidocaine HCL
Lidocaine HCL
Lidocaine HCL
Lidocaine/Prilocaine
Mupirocin
Mupirocin Calcium
Neomy Sulf/Bacitra/Polymyxin B
Phenazopy HCL/Hyoscy/Butabarb
Phenazopyridine HCL
Phenazopyridine HCL
Sodium CL 0.45PC Irrig. Soln
Sodium CL Irrig Soln
Sodium Hypochlorite
Temozolomide
Water for Irrigation, Sterile
Antifungal Agents
Bone Form, Stim Agents Parathy
Bone Ossification Suppression
Agent
Gastric Acid Secretion Reducers
Hemantinics, Other
Heparin Preparations
Leukocyte (Wbc) Stimulants
Oral Anticoagulants, Coumarin Type
Topical Antifungals
Vaginal Antibiotics
Vaginal Sulfonamides
Carboplatin
Gemcitabine HCL
Ifosfamide
Irinotecan HCL
Melphalan
Paclitaxel, Semi-Synthetic
Bevacizumab
Biafine Cream
Docetaxel
Doxorubicin HCL
Epirubicin
Fulvestrant
Goserelin Acetate
Leuprolide Acetate
Megestrol Acetate
Page: 56
HSN 003905
HSN 003926
HSN 003912
HSN 003913
HSN 009614
Q4K
HSN 003902
HSN 003907
HSN 004101
HSN 004102
HSN 004094
G1A
HIC3 = C5U
HIC3 = C5F
HIC3 = C1W
Methotrexate Sodium
Tamoxifen Citrate
Vinblastine
Vincristine Sulfate
Vinorelbine Tartrate
Vaginal Estrogen Preparations
Cisplatin
Fluorouracil
Methanamine Hippurate
Methenamine Mandelate
MTH/ME
BLUE/BA/SALICY/ATP/HYOS
Estrogenic Agents
Nutritional Therapy, Med Cond
Special Electrolytes & Misc.
Nutrients
Dietary Supplements
Electrolyte Maintenance
HIC3 = C5G
Food Oils
HIC3 = M4B
TC = 68
IV Fat Emulsions
Protein Lysates
HSN 004182, 004183
HSN 009007
HSN 010117
HSN 013221
H3N
Acyclovir, Zovirax
famcyclovir
valacyclovir
foscarnet
Narcotic/NSAID
Oral forms only
Includes products for
disease-specific nutritional
therapy
Includes Ensure-type
products
Includes electrolyte
solutions
Includes corn, safflower
oils
Includes amino acid
products
No PA required
Claims for Gastric Acid Secretion Reducers (D4K) will pay without a PA if the patient is in plans
BCCDT1, BCCDT2 or BCCDT4 -and- the patient medication history finds a paid claim within last 34
days for H6J or HSN 002874, 002879, 002889, 002860, and 02867.
ACS will ensure that claims for drug code C1D (Potassium Replacement) are payable if the patient has
a paid claim for a drug in TC = 79 (Diuretics) within the last 34 days.
Max Quantity by Drug 120
Max Qty: Oxycontin – 120/fill Quantity Maximum (960 mg max total per day) – NCPDP 76 – Plan
Limitations Exceeded – Call BCCDT at (410) 767-6787
GSN = 024505, 024506,
025702, 024504, 045129
Max Quantity by Drug –Duragesic
Max Qty: Duragesic Patches – 20/fill Qty Maximum – NCPDP 76 – Plan Limitations Exceeded –
Call BCCDT at (410) 767-6787
Page: 57
HSN = 006438
Duragesic Patches (all strengths)
Max Quantity by Drug – Max qty = 4000
Max Qty: 4000 – NCPDP 76 – Plan Limitations Exceeded
GSN 003062
Sod Sulf/Sod/NaHCO#/KCL/Pegs
GSN 019656
Sod Chloride/NaHCO3/Pegs
Max Quantity by Drug – Max qty = 4050
Max Qty: 4050 - NCPDP 76 – Plan Limitations Exceeded
GSN 024953
Sod Sulf/Sod/NaHCO3/KCL/Pegs
Max Quantity by Drug – Max qty = 120 / 34 days
Max Qty: Actiq - NCPDP 76 – Plan Limitations Exceeded
HSN 01747
Actiq MCG Lozenge
Max Quantity by Drug – Antiemetics
Max Qty: Antiemetic 10 tabs per month Qty Maximum – NCPDP 76 – Plan Limitations Exceeded –
Call BCCDT at (410) 767-6787 (Qty is a combined qty limit of 10 tabs per month of all GSNs listed
below.)
GSN=34749
GSN=34750
GSN=43230
Anzemet 50mg tabs
Anzemet 100mg tabs
Zofran 24mg tabs
Max Qty: Antiemetic 15 tabs per month Qty Maximum – NCPDP 76 – Plan Limitations Exceeded –
Call BCCDT at (410) 767-6787 (Qty is a combined qty limit of 15 tabs per month of all GSNs listed
below.)
GSN = 21592
Kytril 1.0mg tabs
GSN= 51911
Emend 80 mg caps
GSN=51912
Emend 125mg caps
GSN=51913
Emend 125-80mg caps Trifold
Pack
Max Qty: Zofran 30 tabs per month Qty Maximum – NCPDP 76 – Plan Limitations Exceeded –
Call BCCDT at (410) 767-6787 (Qty is a combined qty limit of 30 tabs per month of all GSNs listed
below.)
GSN=16392 – Own Category
Zofran 4mg tabs
GSN=16393
Zofran 8mg tabs
GSN=41562
Zofran ODT 4mg
GSN=41563
Zofran ODT 8mg tabs
Max Qty: Antiemetic 75 ml per month Qty Maximum – NCPDP 76 – Plan Limitations Exceeded –
Call BCCDT at (410) 767-6787
Page: 58
GSN = 28107
Zofran 4mg/ml solution
Max Qty: Antiemetic 150 ml per month Qty Maximum – NCPDP 76 – Plan Limitations Exceeded
– Call BCCDT at (410) 767-6787
GSN = 21592
Kytril 1.0mg/5ml solution
Max Days 102
Max Days 102 - NCPDP 76- Plan Limitations Exceeded (includes Maintenance Medications)
For PA, call BCCDT at 410-767-6787
DEA = 2
All Schedule II Narcotics
GSN = 004964, 044980
Leuprolide 3-month kit
DCC = R
Insulin Syringes
AHFS = 24:04
Cardiac Drugs
AHFS = 24:08
Hypotensive agents
Central Alpha-Agonists
AHFS = 24:08.16
AHFS = 24:08.20
Direct Vasodilators
AHFS = 24:08.32
Peripheral Adrenergic
Inhibitors
AHFS = 24:08.92
Misc. Hypotensive Agents
AHFS = 24:12.08
Vasodilating Agents
HIC3 = C1D
AHFS 40:12 (Replacement
Solutions)
Listed products only
Potassium supplements
only
AHFS = 40:28
Diuretics
AHFS = 68:20.08
Insulins
AHFS = 68:20.20
Sulfonylureas
AHFS = 68:36.04
Thyroid Agents
HSN = 001879, 001878,
001877
AHFS 28:12.12
(Hydantoins)
Listed products only
Phenytoin
Phenytoin Sodium
 HSN = 000739; and
Route = oral
AHFS 20:04.04 (Iron
preparations)
Listed products only
Oral products in which
ferrous sulfate is the only
active ingredient
Note: OTC is not a requirement
for these chewable Fe products
(per regs)
AHFS = 24:20
Alpha-Adrenergic Blocking
Agents
AHFS = 24:24
Beta-Adrenergic Blocking
Page: 59
Agents
AHFS = 24:28
Calcium-Channel Blocking
Agents
AHFS = 24:32
Renin-Angiotensin System
Inhibitors
AHFS = 24:32.04
Angiotensin-Converting
Enzyme Inhibitors
AHFS = 24:32.08
Angiotensin II Receptor
Antagonists
HSN 003926
Tamoxifen
HSN 010249
Anastrozole (Arimidex)
OTC DRUG COVERAGE
OTC drugs are generally not covered by BCCDT but there are exceptions and they are in the grid
below:
OTC Exception List – All OTCs to deny w/ NCPDP 70 – Drug Not Covered w/the
exception of the products listed below
Drug Code
HIC3 = C5U
HIC3 = C5F
Drug Name
Nutritional Therapy, Med Cond
Special Electrolytes & Misc.
Nutrients
Dietary Supplements
HIC3 = C1W
Electrolyte Maintenance
HIC3 = C5G
Food Oils
HIC3 = M4B
GSN 011832, 001645, 001646,
017378
IV Fat Emulsions
Ferrous Sulfate
Comments
Includes products for
disease-specific nutritional
therapy
Includes Ensure-type
products
Includes electrolyte
solutions
Includes corn, safflower
oils
OTC TO COVER
MEDICARE B
BCCDT will cost avoid for Medicare B covered drugs
The system will deny COB claims for Medicare B recipients if the Other Coverage Code is not equal
to ‘2’ with edit 41 (bill other insurance) and the message text: “Bill Medicare B“.
The following is a list of drugs covered by Medicare B:
Drug Code
GSN = 008838
Code Level
Oral Chemotherapy
VePesid (Etoposide)
Page: 60
Code Values
GSN = 008770, 008771
GSN = 008773
GSN = 036872, 045266,
035928, 036874, 047823,
047824
HSN = 018385
Cytoxan (Cyclophosphamide)
Alkeran (Melphalan)
Methotrexate
Xeloda (Capecitabine)
Qualified Medicare Beneficiary (QMB) Recipients
The system will pay coinsurance for QMB recipients if claims contain another coverage code of 3 or 4
for Med-B covered drugs only.
ACS will ensure that QMB recipients have pharmacy coverage except for drugs covered by Medicare
B such as Xeloda- then BCCDT pays only denied claims. Pharmacies then must bill Medicare and then
Medicaid and BCCDT will be the payer of last resort for coinsurance.
The system will reject QMB claims where the Other Coverage Code is not equal to ‘3-4’; the response
will contain reject code edit 70 (Drug Not Covered) and the message text “BCCDT Only Reimburses
Non-Covered Medicare B covered drugs"
MEDICARE D
BCCDT will cost avoid for Medicare D recipients. Providers are required to ensure COB claims for
Medicare D to contain “77777” in the Other Payer ID (NCPDP field 340-7C). The Other Payer ID is
not required for non-Medicare D carriers.
Drugs not covered by Medicare D that may be covered by BCCDT. Some require prior authorization.
TC
Medical Supplies
DCC
A
gents used for
anorexia, weight
loss or weight gain
Agents used for
symptomatic relief
of cough/cold
Rx vitamins and
minerals, except
prenatal vitamins
and fluoride
products
00
Exceptions:
Part D Must Cover
GSN = 009797
HSN = 004348
HSN = 008966
DCC = Q, R
F
TC
16
17
TC
80
81
82(Except HIC3=C6F)
83
84
85
Page: 61
OTC
Benzodiazepines:
Alprazolam
Chlordiazepoxide
Clorazepate
Diazepam
Halazepam
Lorazepam
Oxazepam
Prazepa
m
Estazolam
Flurazepam
Midazolam
Quazepam
Temazepam
Triazolam
Clonazepam
Rx Required Field
N = OTC Drugs
Exceptions:
Part D Must Cover
HSN = 011115 & OTC
HSN = 007605 & OTC
& Generic
HSN
HSN
HSN
HSN
HSN
HSN
HSN
HSN
HSN
001617
001611
001610
001612
001615
001618
004846
001616
001613
HSN
HSN
HSN
HSN
HSN
HSN
HSN
006036
001593
001619
001595
001592
001594
001894
Page: 62
COPAY Only Claim Submission
BCCDT will allow for the submission of copay only claims but the following rules must be followed
in order for the claim to be reimbursed:
There is a $60.00 maximum on all copay only claims. Claims submitted for amounts greater than the
maximum will have to be approved by BCCDT.
BCCDT will pay co-payments for PAC recipients if claims contain an "8" in NCPDP field 308-C8,
Other Coverage Code.
The system will reject PAC claims where the Other Coverage Code is not equal to ‘8’ (Copay Only)
with reject code edit 70 (Drug Not Covered) and the message text “BCCDT Only Reimburses Copayments – Please bill PAC
The following fields must be populated when submitting a copay only claim:
Other Coverage Code (308-C8) = 8
Other Amount Claimed Submitted Count = 1
Other Amount Claimed Submitted Qualifier = 99
Other Amount Claimed Submitted = copay amount and must equal the amount in Gross
Amount Due
Gross Amount Due = copay amount and must equal the amount in the Other Amount
Claimed Submitted
**No COB Segment is submitted with a Copay only claim.
GENERIC MANDATORY
BCCDT has a generic mandatory program in place. The system will deny brand drugs when a generic
is available with edit 22 (M/I Dispense As Written/DAW code) when submitted as Brand Medically
Necessary (DAW = 1).
The system will accept the following Dispense as Written (DAW) values (NCPDP field
408-D8):
0 - default, no product selection
1 - Physician request
5 - Brand used as generic
PRODUR EDITS:
BCCDT will deny for Therapeutic Duplication (TD) and Early Refill (ER) only. Alert messages will
be returned for other ProDUR problem types.
ProDUR edits that deny may be overridden by the pharmacy provider at POS using the interactive
NCPDP DUR override codes for selected conflict types.
To request an Early Refill override, contact AFFILIATED COMPUTER SERVICES, INC.: 1-800932-3918.
Page: 63
Days supply information is critical to the edit functions of the ProDUR system. Submitting incorrect
days supply information in the days supply field can cause false ProDUR messages or claim denial for
that particular claim or for drug claims that are submitted in the future.
Technical Call Center:
Affiliated Computer Services’ Technical Call Center is available 24 hours per day, seven days per
week.
The telephone number is: 1-800-932-3918
Alert message information is available from the Call Center after the message appears. If you need
assistance with any alert or denial messages, it is important to contact the Call Center about Affiliated
Computer Services’ ProDUR messages at the time of dispensing. The Call Center can provide claims
information on all error messages which are sent by the ProDUR system. This information includes:
NDCs and drug names of the affected drugs, dates of service, whether the calling pharmacy is the
dispensing pharmacy of the conflicting drug, and days supply.
The Technical Call Center is not intended to be used as a clinical consulting service and cannot replace
or supplement the professional judgment of the dispensing pharmacist. AFFILIATED COMPUTER
SERVICES, INC has used reasonable care to accurately compile ProDUR information. Because this
information is unique; it is intended for pharmacists to use at their own discretion in the drug therapy
management of their patients.
Affiliated Computer Services’ ProDUR is an integral part of the BCCDT Program’s claims
adjudication process. ProDUR includes: reviewing claims for therapeutic appropriateness before the
medication is dispensed, reviewing the available medical history, focusing on those patients at the
highest severity of risk for harmful outcome, and intervening and/or counseling when appropriate.
Page: 64
SECTION IX
MARYLAND AIDS DRUG ASSISTANCE PROGRAM (MADAP) SPECIFICS
The specific Maryland AIDS Drugs Assistance Program information is listed in this section. The basic
information is covered in the beginning of this manual in the ALL section. In this section you will find
some repetitive information but new, special rules as well.
GENERIC MANDATORY
The system will deny brand drugs when a generic is available and the DAW code = 1 (Physician
request) with edit 22 (M/I DAW code) and the message “PA required – Brand Medically Necessary”.
ACS will ensure that the only valid DAW codes will be 0, 1, and 5:
0 - default, no product selection
1 - Physician request
5 - Brand used as generic
DATE RX WRITTEN AND DATE OF SERVICE
The system will enforce the following rules regarding the amount of time allowed between Date RX
Written and Date of Service:
If DEA = 2 (CII) – 5 (CV), then 30 days
If DEA = 0, then 120 days
Edit only applies to original prescriptions
PRICING
The following reimbursement structure is used by the MADAP program:
1) Legend Drugs
Payment is lesser of:
U/C -or- Allowable Cost + Dispensing Fee
Allowable Cost lesser of:
1. IDC,
2. EAC (lesser of): WAC+8%· Direct+8%· · AWP - 12%,
3. FUL
2) Medical Supplies (Needles and Syringes)
Payment is lesser of:
U/C -or- Allowable Cost + Dispensing Fee
Allowable Cost: AWP
3) DAW 1 Claims
Payment is lesser of:
U/C -or- Allowable Cost + Dispensing Fee
Allowable Cost:
EAC (lesser of): · WAC+8% -or- Direct+8% -or- AWP – 12%
4) OTC Drugs (Insulin)
Payment is lesser of:
Page: 65
U/C -or- Allowable Cost + 50% -or- Allowable Cost + Dispensing Fee
Allowable Cost: AWP
COPAYS
ACS will ensure that MADAP claims do not have copays
Dispensing Fee
Brand Products = $3.69
Generic Products = $4.69
Partial fills = ½ + ½ dispensing fee.
Drug Coverage
All medications on MADAP's formulary are covered and that list is below for reference.
Generic
Brand name
abacavir
Ziagen
abacavir-lamivudine
abacavir-zidovudinelamivudine
Epzicom
acyclovir
Trizivir
Zovirax,
Acyclovir
HRSA
Restrict* code
Anti-Ret Group
Anti-retroviral
1
NRTI
N
Anti-retroviral
2
NRTI
N
Anti-retroviral
3
NRTI
N
0
albuterol
amitriptyline
hydrochloride
Proventil
0
Elavil
0
amlodipine
(generic only)
0
Amoxil, Trimox,
Wymox, Biomox 0
Drug
CD AppDT
d04376 49
2/1/1999
d05354 118 8/1/2004
d04727 79
Antiviral
N
Bronchial
Dilator
N
Antidepressan
t
N
Antihypertens
ive
N
d00001 03
1/1/1992
Antibiotics
N
d00088 101 12/1/2003
d00749 107 8/1/2004
d00146 81
d00689 134 2/28/2006
amoxicillin
amoxicillin-clavulanate
potassium
Augmentin
amphotericin B
Fungisone
amphotericin B
cholesteryl sulfate
Amphotec
0
0
Antibiotics
Antifungal
N
N
d00089 95
d00077 04
0
N
d04100 106 5/3/2004
amprenavir
Agenerase
1
N
d04428 58
7/14/2000
atazanivir sulfate
Reyataz
1
N
d04882 90
12/1/2003
atenolol
(generic only)
0
N
d00004 129 2/28/2006
atorvastatin
atovaquone
Lipitor
Mepron,
0
0
Antifungal
Protease
Inhibitor
Protease
Inhibitor
Antihypertens
ive
Antilipemic
Agent
PCP
N
N
d04105 69
d01120 21
Page: 66
12/1/2003
1/1/1992
5/5/2000
6/15/1993
Malarone
Zithromax
azithromycin
buprenorphine
sublingual
Suboxone
buprenorphine/naloxon
e sublingual
Subutex
0
bupropion
Wellbutrin
0
captopril
carbamazepine
(generic only)
Tegretol, & XR
0
cephalexin
Keflex, Keftab
0
chlorothiazide
cidofovir
ciprofloxacin
citalopram
hydrobromide
clarithromycin
chlorothiazide
Vistide
Cipro, Ciloxan
0
0
0
Celexa
Biaxin
0
0
clindamycin
Cleocin
0
clonidine
(generic only)
Lotrimin,
Mycelex
0
Prophylaxis
Mycobacterial N
Opioid
Dependence N
Opioid
Dependence N
Antidepressan
t
N
Antihypertens
ive
N
anticonvulsant N
N
Antibiotics
N
Antihypertens
ive
N
Antiviral
N
Antibiotics
N
Antidepressan
t
N
Mycobacterial N
Toxoplasmosi
s
N
Antihypertens
ive
N
0
Antifungal
N
d01236 05
Antifungal
PCP
Prophylaxis
Protease
Inhibitor
N
d03561 83
N
d00098 25
N
d05825 148 7/12/2006
clotrimazole
clotrimazolebetamethasone
0
0
Lotrisone Cream 0
dapsone
Dapsone
0
darunavir
daunorubicin citrate
liposome
Prezista
1
DaunoXome
0
delavirdine
Rescriptor
1
didanosine
Videx, ddl
1
diltiazem
diphenoxylate-atropine
divalproex, valproic
acid
(generic only)
0
Lomotil, Di-Atro 0
Depakote,
Depakene
0
doxazosin
doxycycline
(generic only)
Doryx,
0
0
Neoplasm
N
Anti-retroviral
NNRTI
N
Anti-retroviral
NRTI
N
Antihypertens
ive
N
Antidiarrheal N
Antimanic/An
ticonvulsant N
Antihypertens
ive
N
Antibiotics
N
Page: 67
d00091 29
7/14/2000
d04819 155 1/25/2007
156
d00840
1/25/2007
d00181 73
5/5/2000
d00006 126 2/28/2006
d00058 154 10/26/06
d00096 103 12/1/2003
d00190 145 2/28/2003
d04028 35 7/14/2000
d00011 65 7/14/2000
d04332 82
d00097 22
6/15/1993
d00043 39
7/14/2000
d00044 137 2/28/2006
1/1/1992
11/1/1994
d04239 50
2/1/1999
d04119 34
7/14/2000
d00078 06
1/1/1992
d00045 132 2/28/2006
d03506 51 2/1/1999
d03833 77
5/5/2000
d00726 136 2/28/2006
d00037 96 12/1/2003
Vibramycin,
Periostat
efavirenz
Sustiva
efavirenz/emtricitab/ten
ofovir
Atripla
1
emtricitabine
Emtriva
emtricitabine-tenofovir
DF
Truvada
1
enfuvirtide
epoetin alpha
erythromycin
escitalopram oxalate
ethambutol
ethinyl estradiolethynodiol
ethinyl estradiolnorgestimate
famciclovir
3
2
Fuzeon
1
Procrit, Epogen 0
E-Base, Ery-Tab,
E-Mycin, Eryc
0
Anti-retroviral
NNRTI
N
Anti-retroviral
NNRTI
N
Anti-retroviral
NRTI
N
Anti-retroviral
NRTI
N
Fusion
Inhibitor
Y
Cytokines-e Y
d04355 43
7/14/2000
d05825 150 7/12/2006
d04884 108 8/1/2004
d05352 117 8/1/2004
d04853 89
d00223 47
12/1/2003
2/1/1999
Lexapro
Myambutol
0
0
Antibiotics
N
Antidepressan
t
N
Mycobacterial N
Zovia 1/50
0
Contraceptive N
d03388 141 2/28/2006
Sprintec 28
Famvir
0
0
Contraceptive N
Antiviral
N
Antilipemic
Agent
N
Cytokines
Y
Antifungal
N
Antidepressan
t
N
Antipsychotic N
Antiviral
N
Protease
Inhibitor
N
Antiviral
N
Anticonvulsan
t
N
Antiviral
N
Antilipemic
Agent
N
Unkn
N
Antidiabetic N
Antipsychotic N
Antihypertens
ive
N
Antihypertens N
d03781 139 2/28/2006
d03775 52 2/1/1999
fenofibrate micronized Tricor
filgrastim
Neupogen
fluconazole
Diflucan
0
0
0
fluoxetine
fluphenazine
fomivirsen
0
0
0
Prozac
Prolixin
Vitravene
fosamprenavir calcium Lexiva
foscarnet
Foscavir
0
0
gabapentin
ganciclovir
Neurontin
Cytovene
0
0
gemfibrozil
glimepiride
glipizide
haloperidol
(generic only)
Amaryl
Glucotrol
Haldol
0
0
0
0
hydralazine
hydrochlorothiazide
(generic only)
0
hydrochlorothiazi 0
Page: 68
d00046 102 12/1/2003
d04812 109 8/1/2004
d00068 07 1/1/1992
d04286 91
d00512 48
d00071 08
12/1/2003
2/1/1999
1/1/1992
d00236 71
d00237 64
d04343 53
5/5/2000
5/5/2000
2/1/1999
d04901 110 8/1/2004
d00065 09 5/1/1992
d03182 66
d00066 10
7/14/2000
5/1/1992
d00245
d03864
d00246
d00027
3/1/2003
7/27/2006
12/1/2003
5/5/2000
86
151
92
76
d00132 138 2/28/2006
d00253 146 2/28/2006
de
hydroxyurea
hydroxyzine
Droxia
Atarax
1
0
imiquimod
Aldara Cream
0
indapamide
indapamide
0
indinavir
insulin glargine
insulin lispro
insulin NPH
interferon alpha-2A
interferon alpha-2B
isoniazid
isoniazid-rifampin
itraconazole
ketoconazole
Crixivan
Lantus
Humalog
Humulin N
Roferon-A
Intron-A
Nydrazid, INH
Rifamate
Sporanox
Nizoral
1
0
0
0
0
0
0
0
0
0
lamivudine
lamotrigine
Epivir, 3TC
Lamictal
1
0
leucovorin
Leucovorin
0
levetiracetam
Keppra
levonorgestrel 0.75 mg Plan B
0
0
lisinopril
0
lithium carbonate
loperamide
(generic only)
Lithium
Carbonate
Imodium
lopinavir-ritonavir
Kaletra
2
maraviroc
medroxyprogesterone
megestrol acetate
metformin HCL
metoclopramide
selzentry
(generic only)
Megace
Glucophage
Reglan
0
0
0
0
0
metoprolol
metronidazole
(generic only)
Flagyl, Metryl,
0
0
0
0
ive
Anti-retroviral
NRTI
N
Antianxiety N
Immune
Response
Modifier
N
Antihypertens
ive
N
Protease
Inhibitor
N
Antidiabetic N
Antidiabetic N
Antidiabetic N
Neoplasm
N
Neoplasm
N
Mycobacterial N
Mycobacterial N
Antifungal
N
Antifungal
N
Anti-retroviral
NRTI
N
Unkn
N
PCP
Prophylaxis N
Anticonvulsan
t
N
Contraceptive N
Antihypertens
ive
N
Antimanic
Antidiarrheal
Protease
Inhibitor
CCR-5
coreceptor
antagonist
Contraceptive
Wasting
Antidiabetic
Unkn
Antihypertens
ive
Antibiotics
Page: 69
d01373 36
d00907 75
7/14/2000
5/5/2000
d04125 44
7/14/2000
d00260 147 2/28/2006
d03985
d04538
d04373
d04370
d01369
d01369
d00101
d03508
d00102
d00103
26
124
121
123
11
104
12
105
62
13
7/14/2000
2/28/2006
2/28/2006
2/28/2006
5/1/1992
6/1/1992
5/1/1992
6/1/1992
7/14/2000
5/1/1992
d03858 27 7/14/2000
d03809 152 7/27/2006
d00275 14
5/1/1992
d04499 111 8/1/2004
d03242 144 2/28/2006
d00732 127 2/28/2006
N
N
d00061 112 8/1/2004
d01025 54 2/1/1999
N
d04717 78
Y
N
N
N
N
9/04/2007
d00284 143 2/28/2006
d01348 20 6/15/1993
d03807 94 12/1/2003
d00298 153 7/27/2006
N
N
d00134 130 2/28/2006
d03208 97 12/1/2003
miconazole
mirtazapine
Protostat
Monistat
0
0
nandrolone
Remeron
injection &
patches
nelfinavir
Viracept
1
nevirapine
Viramune
1
nifedipine
norethindrone
(generic only)
Errin
0
0
nortriptyline
nystatin
octreotide
olanzapine
oxandrolone
oxymetholone
paromomycin
Pamelor, Aventyl
Mycostatin
Sandostatin
Zyprexa
Oxandrin
Anadrol-50
Humatin
0
0
0
0
0
0
0
paroxetine
peginterferon alfa 2a
peginterferon alfa 2b
Paxil
Pegasys
Peg-Intron
Pentam,
NebuPent
Trilafon
0
0
0
Polytrim
0
pentamidine
perphenazine
polymyxin Btrimethoprim sulfate
0
0
0
pravastatin
Pravachol
primaquine phosphate Primaquine
prochlorperazine
Compazine
0
0
0
propranolol
pyrazinamide
0
0
pyrimethamine
quetiapine
(generic only)
Rifater
Daraprim,
Fansidar
Seroquel
Raltegravir
regular insulin
ribavirin
rifabutin
Isentress
Humulin R
Rebetol, Copegus
Mycobutin
0
0
0
0
0
0
Antifungal
N
Antidepressan
t
N
d00155 55
Wasting
N
Protease
Inhibitor
N
Anti-retroviral
NNRTI
N
Antihypertens
ive
N
Contraceptive N
Antidepressan
t
N
Antifungal
N
Antidiarrheal N
Antipsychotic N
Wasting
Y
Wasting
N
Antibiotics
N
Antidepressan
t
N
HepCVirus Y
HepCVirus Y
PCP
Prophylaxis N
Antipsychotic N
d00568 42
7/14/2000
d04118 32
7/14/2000
d04029 30
7/14/2000
Antibiotics
N
Antilipemic
Agent
N
Antibiotics
N
Antiemetic
N
Antihypertens
ive
N
Mycobacterial N
Toxoplasmosi
s
N
Antipsychotic N
Integrase
inhibitor
N
Antidiabetic N
HepCVirus Y
Mycobacterial N
d03529 115 8/1/2004
Page: 70
2/1/1999
d04025 113 8/1/2004
d00051 135 2/28/2006
d00555 142 2/28/2006
d00144
d01233
d00370
d04050
d00566
d04295
d01104
40
59
56
63
46
61
67
7/14/2000
7/14/2000
2/1/1999
5/5/2000
7/14/2000
7/14/2000
7/14/2000
d03157 70
d04821 93
d04746 87
5/5/2000
12/1/2003
3/1/2003
d00030 02 1/1/1992
d00855 114 8/1/2004
d00348 68
d00351 98
d00355 60
5/5/2000
12/1/2003
7/14/2000
d00032 131 2/28/2006
d00117 15 5/1/1992
d00364 16 5/1/1992
d04220 120 2/28/2006
10/15/200
7
d04374 122 2/28/2006
d00085 88 3/1/2003
d01097 23 6/15/1993
rifampin
risperidone
Rifadin,
Rimactane
Risperdal
0
0
ritonavir
Norvir
1
rosuvastatin
Crestor
0
saguinavir
Fortovase, SQV
1
sertraline
Zoloft
0
spironolactone
(generic only)
0
stavudine
Zerit, d4T
1
sulfadiazine
tenofovir disoproxil
fumarate
testosterone
transdermal
thalidomide
Sulfadiazine
0
tipranavir
Aptivus
1
Bactrim, Septra,
Septra DS
0
Desyrel, Desyrel
Dividose
0
Viread
1
Androderm,
Androgel, Testim 0
Thalomid
0
Mycobacterial N
Antipsychotic N
Protease
Inhibitor
N
Antilipemic
Agent
N
Protease
Inhibitor
N
Antidepressan
t
N
Antihypertens
ive
N
Anti-retroviral
NRTI
N
Toxoplasmosi
s
N
Anti-retroviral
NRTI
N
d00047 17
d03180 74
5/1/1992
5/5/2000
d03984 28
7/14/2000
d04851 149 4/27/2006
d03860 37
7/14/2000
d00880 72
5/5/2000
d00373 128 2/28/2006
d03773 24
11/1/1994
d00118 38
7/14/2000
d04774 85
1/1/2002
d00558 41
d04331 57
7/14/2000
2/1/1999
(generic only)
Proloprim,
Trimpex
0
Wasting
N
Wasting
N
Protease
Inhibitor
N
PCP
Prophylaxis N
Antidepressan
t
N
Antihypertens
ive
N
0
Antibiotics
N
d00123 100 12/1/2003
Tri-Sprintec 28
Valtrex
0
0
Contraceptive N
Antiviral
N
d03781 140 2/28/2006
d03838 45 7/14/2000
Valcyte
0
d04755 84
venlafaxine HCL
Effexor XR
0
verapamil
(generic only)
0
zalcitabine
Hivid, ddC
1
Antiviral
N
Antidepressan
t
N
Antihypertens
ive
N
Anti-retroviral
NRTI
N
Anti-retroviral
NRTI
N
Anti-retroviral N
TMP-SMX
trazadone HCL
triamterene
trimethoprim
triphasic ethestradiolnorgestimate
valacyclovir
valganciclovir
hydrochloride
zidovudine
Retrovir, AZT
zidovudine-lamivudine Combivir
1
2
Page: 71
d05538 119 9/27/2005
d00124 18
5/1/1992
d00395 80
d00396 125 2/28/2006
d03181 116 8/1/2004
d00048 133 2/28/2006
d00127 19
1/1/1993
d00034 01
d04219 33
1/1/1992
7/14/2000
Carbamazepine
Tegretol, & XR
NRTI
anticonvulsant N
N
d00058 154 10/26/06
* Y Indicates Prior Authorization Required
NOTE: Peginterferon alfa (including 2b and 2a) and ribavirin covered in combination, and only for
treatment of HCV infection in HIV co-infected clients.
The following is a list of covered injectables:
Covered Injectable Products
HSN 006071
HSN 006072
HSN 007802
HSN 009792
HSN 004869
HSN 004182
HSN 010893
HSN 004128
HSN 010219
HSN 012800
HSN 006334
HSN 011506
HSN 004045
HSN 004704
HSN 010804
HSN 004013
HSN 025044
HSN 004553
HSN 006070
HSN 001624
HSN 001626
HSN 013221
HSN 001660
HSN 001661
HSN 001608
HSN 001063
HSN 004157
HSN 001413
HSN 002826
HSN 024035
HSN 021367
HSN 009599
HSN 001628
HSN 004040
Ciprofloxacin (Cipro i.v.)
Ciprofloxacin (Cipro i.v.)
Fluconazole (Diflucan)
Fluconazole (Diflucan)
Fluconazole (Diflucan)
Acyclovir (Zovirax)
Ampho B C-S (Amphotec)
Amphotericin-B (Fungisone)
Amphotericin-B Lipid Complex (Abelcet)
Amphotericin-B Liposome (Ambisome)
Azithromycin (Zithromax)
Cidofovir (Vistide)
Clindamycin (Cleocin)
Clindamycin (Cleocin)
Daunorubicin Citrate Liposomal (DaunoXorne)
Doxycyline (Vibramycin)
Enfuvirtide (Fuzeon)
Epoetin Alpha (Epogen, Procrit)
Filgrastim (Neupogen)
Fluphenazine (Prolixin, generics)
Fluphenazine (Prolixin, generics)
Foscarnet (Foscavir)
Haloperidol (Haldol)
Haloperidol (Haldol)
Hydroxizine (Atarax, Vistaril)
Leucovorin (Wellcovorin, generics)
Metronidazole (Flagyl)
Nandrolone (Nadrolone)
Octreotide (Sandostatin)
Peginterferon alfa 2a (Pegasys)
Peginterferon alfa 2b (Peg-Intron)
Pentamidine (Pentam, NebuPent
Prochloperazine (Compazine)
Rifampin (Rifadin, Rimactane)
Page: 72
HSN 001400
HSN 001401
Testosterone injection (Depo-Testosterone)
Testosterone injection (Delatestryl)
Maintenance Drug List
The MADAP maintenance drug list = antiretroviral therapies (NNRTIs, NRTIs, PIs, Fusion Inhibitors).
Prior Authorization
There are three places providers can obtain a prior authorization for the MADAP program: ACS,
MADAP and SmartPA. Below will outline which entity gives the Prior Authorization for which
category of drug.
PA Drug List
Drug
Performed by
HSN 025044
Enfuvirtie (Fuzeon)
MADAP
HSN 004553
Epoetin Alpha (Epogen, Procrit)
SmartPA
HSN 006070
Filgrastim (Neupogen)
SmartPA
HSN 001412
Oxandrolone (Oxandrin)
SmartPA
HSN 024035
Peginterferon alfa 2a (Pegasys)
MADAP
HSN 021367
Peginterferon alfa 2b (Peg-Intron)
MADAP
HSN 004184
Ribavirin (Rebetol, Copegus)
MADAP
HSN 034927
Maraviroc (Selzentry)
MADAP
The ACS Technical Call Center will handle the following prior authorization requests for
MADAP:
EarlyRefill
Quantity
Price per claim limit ≥$2500.00
The ACS PA Call Center will handle the following prior authorization requests for MADAP:
Epoetin Alpha (Epogen, Procrit)
Filgrastim (Neupogen)
Oxandrolone (Oxandrin)
The MADAP staff will handle all other prior authorization requests.
SmartPA
Page: 73
SmartPA is a rules engine driven program that will search existing claim and medical history to
evaluate whether or not the recipient has met the set criteria to receive the drug being billed. If the
recipient meets criteria then the system generates a Prior Authorization and the claim is paid. If the
recipient does not meet criteria, the claim is denied with a SmartPA specific edit advising which
criteria was not met.
The following categories are submitted to SmartPA for evaluation:
Epoetin Alpha (Epogen, Procrit)
Filgrastim (Neupogen)
Oxandrolone (Oxandrin)
Copay Only Claim Billing Guidelines
MADAP will allow providers to bill for a copay only claim. In order for the claim to be processed
correctly, the following guidelines must be followed.
The system will require claims for COB copay only billing to adhere to the following NCPDP
parameters:
NO COB SEGMENT SUBMITTED
OCC = 8
Other Amount Claimed Qualifier = 99
Other Amount Claimed = Amount of copay
Gross Amount Due = Equal Other Amount Claimed/Amount of copay
Other Amount Claimed Submitted must be the entire patient copay as charged by the
pharmacy
Page: 74
SECTION X
MARYLAND KIDNEY DISEASE PROGRAM (KDP) SPECIFICS
This section will outline program specific information that is not covered in the beginning of this
manual.
Generic Mandatory and Dispense as Written Code Usage
KDP has a generic mandatory program in place that must be followed. When providers submit a claim
for a drug that has a generic equivalent and there is no active PA on file or appropriate DAW code, the
claim will deny with an NCPDP Reject code ‘22’ – M/I DAW Code.
KDP accepts the following DAW codes:
ACS will ensure that the only valid DAW codes will be 0, 1, 5 and 6:
0 - default, no product selection
1 - Physician request
5 - Brand used as generic
6 – Client Override
KDP allows the use of DAW 6 for medications determined by KDP as follows (pay at EAC):
Duragesic NDCs: 50458003305, 50458003405, 50458003505, 50458003605, 50458003705
Rebetol NDCs: 00085119403, 00085132704, 00085135105, 00085138507
Flonase NDCs: 00173045301
LTC
The KDP system has no LTC recipients and will reject claims submitted with LTC identifiers (NCPDP
field 307-C7, Patient Location = 3 – Nursing Home or 4-Long Term/Extended Care) with NCPDP edit
70 and message text: “LTC Claims Not Allowed for Reimbursement”.
MINIMUM / MAXIMUM QUANTITIES
The KDP program enforces the following Minimum / Maximum quantity limits:
A maximum quantity limit of 350 for the following Immunosuppressive Oral tablets/capsules will be
enforced.
Azathioprine
Cyclosporine
Mycophenolate Mofetil (Cellcept)
Sirolimus (Rapamume)
Tacrolimus (Prograf)
HSN = 004523, 004524, 010086, 010012, 020519, 008974; and Route = Oral
There is a max quantity limit of 350 for Immunosuppressants, Oral tablets/capsules.
The max quantity limit for Oxycontin (GSN = 024505, 024506, 025702, 024504, 045129) is 120.
Page: 75
Note: This is a per fill quantity limit, not an accumulation limit.
MINIMUM QUANTITY
There is a minimum quantity limit of 100 tablets for Ferrous sulfate 325mg tablets (GSN = 001645,
001646, 017378).
A minimum quantity limit of 480 ml for Ferrous sulfate elixir (220mg/5ml), GSN = 001639) will be
applied.
KDP will enforce a minimum quantity limit of 60 tablets for non-legend chewable tablets of any
ferrous salt when combined with vitamin C, multivitamins, multivitamins and minerals, or other
minerals in the formulation (HIC3 = C3B; and Dosage form = TC).
DATE OF RX WRITTEN AND DATE OF SERVICE
The system will enforce the following rules regarding the amount of time allowed between Date RX
Written and Date of Service:
No greater than 10 days.
Claims greater than this 10 day limit will deny for NCPDP Error Code M4 (Prescription
Number/Time Limit Exceeded).
Edit only applies to original prescriptions.
UNIT DOSE
The system will deny claims for unit dose medications with the exception of drugs listed below with
error 70 (drug not covered) and message text: “Unit Dose Package Size”.
Unit Dose Drugs Exceptions for Retail Claims (all other U/D will deny with NCPDP 70 – NDC not
covered)/ “Unit Dose Package Size”
HSN = 000739; and UD
Ferrous Sulfate (single
ingredient products only)
GSN = 040910, 040911,
Micardis 20mg, 40mg & 80mg
047126; and UD
GSN = 011964, 011963,
Cyclosporine 25mg & 100mg
Includes Gengraf
023881, 023882; and UD
caps
GSN = 031055, 031056; and
Pepcid RPD
UD
GSN = 049296, 040887; and
Prevacid Liquid
UD
GSN = 009326, 009327; and
Vancocin HCL
UD
GSN = 018370; and UD
Bactroban Nasal
PRICING
ACS will ensure the claims reimburse at the following pricing:
Legend Drugs, Schedule V Cough Preps, Enteric Coated Aspirin, Oral Ferrous Sulfate
Prods
Payment is lesser of:
U/C -or- Allowable Cost + Dispensing Fee
Page: 76
Allowable Cost is lesser of:
1. IDC,
2. EAC (lesser of): WAC+8%· Direct+8%· Distributors + 8%· AWP 12%,
3. FUL
Chewable Ferrous Sulfate with Multivitamins
Payment is lesser of:
U/C -or- Allowable Cost + 50% -or- Allowable Cost + Dispensing Fee
Allowable Cost is lesser of:
1. IDC
2. EAC (lesser of): WAC+8% -or- Direct+8% -or- Distributors + 8% or- AWP - 12%
3. FUL
DAW 1 and 6 Claims
Payment is lesser of:
U/C -or- Allowable Cost + Dispensing Fee
Allowable Cost:
EAC (lesser of): · WAC+8% -or- Direct+8% -or- Distributors + 8% -orAWP – 12%
Other OTC Drugs (Insulin and Nutritional Supplements)
Payment is lesser of:
U/C -or- Allowable Cost + 50% -or- Allowable Cost + Dispensing Fee
Allowable Cost: AWP
Medical Supplies and Durable Medical Equip (Needles and Syringes)
Payment is lesser of:
U/C -or- Allowable Cost + Dispensing Fee
Allowable Cost: AWP
ACS will ensure that KDP claims do not have copays.
ACS will ensure that claims will reimburse with the following
dispensing fee:
DISPENSING FEE
Brand Products = $2.69
Generic Products = $3.69
Partial fills – ½ + ½ dispensing fee.
Page: 77
COPAY
KDP recipients do not have a copay.
PRIOR AUTHORIZATIONS
The ACS Technical Call Center will handle the following prior authorization requests for KDP:
Early Refill
Quantity
Price per claim limit ≥ $2500.00
The KDP staff will handle the following prior authorization requests:
Early Refills for requests outside established criteria
Nutritional supplements for specific NDCs
DME/DMS for HCFA 1500 billing - Exception: needles, syringes, blood glucose test strips
Providers can reach the KDP prior authorization staff at 410-767-5000 or 5002, M-F, 8:00 am – 4:30
pm.
Page: 78
SECTION XI
EDITS
ON-LINE CLAIMS PROCESSING MESSAGES:
Following an on-line claim submission by a pharmacy, the system will return a message to indicate the
outcome of processing. If the claim passes all edits, a “Paid” message will be returned with Maryland
Medicaid’s allowed amount for the paid claim. A claim that fails an edit and is rejected (denied) will
also return a message. Following is a list of the program’s error codes with their corresponding
NCPDP reject codes.
As shown below, the NCPDP error code is returned with the NCPDP message. Additionally,
supplemental messages are sometimes returned in the additional message field of the claim that may be
helpful in resolving the specific error. Where applicable, the NCPDP field that should be checked is
referenced. Check the Solutions box if you are experiencing difficulties. For further assistance contact
AFFILIATED COMPUTER SERVICES, INC. at:
1- 800-932-3918
(Nationwide Toll Free Number)
POINT OF SALE REJECT CODES AND MESSAGES
~ All edits may not apply to this program ~
Reject Code
5.1
Reject
Code
NCPDP Error Description
Exception
Code
Client
or Base
Edit
Internal (long) message
for Help Desk
MD
BCCDT
KDP
MA
01
M/I Bin
4001
B
The BIN Number is missing or does not match one of the
valid values (ie: 610084)
D
D
D
D
02
M/I Version Number
4002
B
The Version Number is missing (spaces) or it does not
match one of the valid values specified for the field
D
D
D
D
02
M/I Version Number
4003
B
The Version Number is not one of the versions that the
customer accepts for processing.
D
D
D
D
03
M/I Transaction Code
4004
B
The Transaction Code is missing (zeros) or it does not match
one of the valid values specified for the field in Version 3.2.
D
D
D
D
03
M/I Transaction Code
4005
B
D
D
D
D
03
M/I Transaction Code
4006
B
The Transaction Code is missing (spaces) or it does not
match one of the valid values specified for the field in
Version 5.1.
The Transaction Code is not one of the transaction codes in
Version 3.2 or 5.1 that the customer accepts for processing.
D
D
D
D
04
M/I Processor Control Number
4007
B
M/I Processor Control #
DRnnTEST = Test
DRnnPROD = Production
DRnnACCP = Acceptance
D
D
D
D
05
M/I Pharmacy Number
4009
B
The pharmacy provider id does not exist on the provider
master table.
D
D
D
D
05
M/I Pharmacy Number
4370
B
B
B
B
B
06
07
M/I Group ID
M/I Cardholder ID
4751
4011
B
B
The pharmacy id on the replacement or credit request does
not match the pharmacy provider number on the claim that
is being replaced or credited.
M/I Group Id always required
The member id is missing (Zero).
D
D
D
D
D
D
D
D
Page: 79
07
M/I Cardholder ID
4010
B
The member id is missing or equal spaces.
D
D
D
D
08
09
09
M/I Person Code
M/I Birthdate
M/I Birthdate
4752
4012
4013
B
B
B
M/I Person Code
B
D
D
B
D
B
B
D
B
B
D
B
09
1C
M/I Birthdate
M/I Smoker/Non-Smoker Code
4424
4918
B
B
The Date Of Birth does not match participant file DOB.
M/I Smoker/Non-Smoker Code
B
B
B
B
B
B
B
B
1E
M/I Prescriber Location Code
4919
B
M/I Prescriber Location Code
B
B
B
B
10
M/I Patient Gender Code
4753
B
Sex code is missing or invaild
B
B
B
B
11
M/I Patient Relationship Code
4754
B
M/I Patient Relationship Code
B
B
B
B
12
M/I Patient Location Code
4016
B
B
B
B
B
13
M/I Other Coverage Code
4019
B
The claim Welfare Customer Location (Patient Location) is
missing or does not match one of the valid values specified
for the field
The Other Coverage Code is missing or it does not match
one of the valid values specified for the field.
D
D
D
D
14
M/I Eligibility Override Code
4022
B
The Eligibility Clarification Code (drug prescription
override code) is missing (zero) or it does not match one of
the valid values specified for the field.
B
B
B
B
15
M/I Date of Service
4023
B
M/I days supply
D
D
D
D
15
M/I Date of Service
4859
B
Date dispensed is missnig or invalid
D
D
D
D
15
M/I Date of Service
4800
B
Date disp. earlier than prscrbd
D
D
D
D
15
M/I Date of Service
4801
B
Date disp. after billing date
D
D
D
D
16
M/I Prescription/Service Reference
Number
4025
B
M/I Rx number. If prescription number is missing (zeros) or
not numeric - then post the error.
D
D
D
D
17
M/I Fill Number
4028
B
D
D
D
D
17
M/I Fill Number
4027
B
The Prescription Refill Number (Fill Number) is not
numeric.
IP Refill Indicator (Fill Number) is equal to zeros
OR
(IP Refill Indicator (Fill Number) is greater than zeros
AND
IP Provider Number equals History Provider Number
AND
IP Prescription Number equals History Prescription Number
AND
IP GSN equals History GSN
AND
IP Date Prescribed equals History Date Prescribed)
D
D
D
D
19
M/I Days Supply
4030
X
D
D
D
D
19
M/I Days Supply
4852
B
The Submitted Days Supply Amount (Days Supply) is
zeroes.
Edit will check for both MISSING and INVALID conditions
D
D
D
D
The Date Of Birth is missing (zeros).
The Date of Birth is greater than the current date or the Date
of Birth is not a valid date.
Page: 80
19
M/I Days Supply
4385
B
The Claim’s Submitted Days Supply Amount (Days Supply)
> Plan Header Days Supply Limit (or Maintenance Days
Supply Limit for Maintenance Drugs)
AND
A Custom Plan Benefit Limit record exists for this Customer
- Plan - and Benefit Limit Type
AND
(The Custom Plan Accumulation Code = ‘No Edit’
OR
The Custom Plan’s Days Submitted Number = Default Days
Supply Number (999)
D
D
D
D
19
M/I Days Supply
4386
B
The Claim’s Submitted Days Supply Amount (Days Supply)
> Plan Header Days Supply Limit (or Maintenance Days
Supply Limit for Maintenance Drugs)
AND
A Custom Plan Benefit Limit record exists for this Customer
- Plan - and Benefit Limit Type
AND
The Custom Plan Accumulation Code = ‘Edit Acute Only’
AND
The Custom Plan’s Maintenance Dose < Default Daily Dose
(9999.999)
AND
The Claim’s calculated Daily Dose > Custom Plan’s
Maintenance Dose
AND
The Claim’s Submitted Days Supply Amount (Days Supply)
> Custom Plan’s Days Submitted Number
D
D
D
D
19
M/I Days Supply
4387
B
The Claim’s Submitted Days Supply Amount (Days Supply)
> Plan Header Days Supply Limit (or Maintenance Days
Supply Limit for Maintenance Drugs)
AND
A Custom Plan Benefit Limit record exists for this Customer
- Plan - and Benefit Limit Type
AND
The Custom Plan Accumulation Code = ‘Edit All Drugs’
AND
The Claim’s Submitted Days Supply Amount (Days Supply)
> Custom Plan’s Days Submitted Number
D
D
D
D
19
M/I Days Supply
4388
B
The Plan’s Max Units Limit < “Unlimited Units (9999.999)”
AND
The Claim’s Drug Submitted Quantity > Plan’s Max Units
Limit
AND
No Custom Plan Benefit Limit record exists for this
Customer - Plan - and Benefit Limit Type
D
D
D
D
19
M/I Days Supply
4389
B
The Plan’s Max Units Limit < “Unlimited Units (9999.999)”
AND
The Claim’s Drug Submitted Quantity > Plan’s Max Units
Limit
AND
A Custom Plan Benefit Limit record exists for this Customer
- Plan - and Benefit Limit Type
AND
The Custom Plan Max Units Accumulation Code = ‘No
Edit’
AND
The Custom Plan’s Units Limit Number < Default Max
Units (9999.999)
D
D
D
D
Page: 81
19
M/I Days Supply
4390
B
19
M/I Days Supply
4391
B
19
M/I Days Supply
4392
C
19
M/I Days Supply
4400
B
19
M/I Days Supply
4401
B
The Custom Plan Max Units Accumulation Code = ‘Edit
Acute Only’
AND
The Custom Plan’s Maintenance Dose < Default Daily Dose
(9999.999)
AND
The Claim’s calculated Daily Dose > Custom Plan’s
Maintenance Dose
AND
The Claim’s Drug Submitted Quantity > Plan’s Max Units
Limit
The Custom Plan Max Units Accumulation Code = ‘Edit All
Drugs’
AND
The Claim’s Drug Submitted Quantity > Custom Plan’s Max
Units Limit
The Claim’s Drug DEA Code = ‘2’ (Schedule 2 - Most
Abused)
AND
(The Drug’s Category Code = ‘Z’ (Attention Deficit
Disorder)
AND
The Claim’s Submitted Days Supply Amount (Days Supply)
> 60 Days)
OR
(The Drug’s Category Code not = ‘Z’ (Attention Deficit
Disorder)
AND
The Claim’s Submitted Days Supply Amount (Days Supply)
> 30 Days)
A Custom Plan Benefit Limit record exists for this
Customer, Plan, and Benefit Limit Type
AND
The Claim’s Submitted Days Supply Amount (Days Supply)
> Plan Header Days Supply Limit (or Maintenance Days
Supply Limit for Maintenance Drugs)
AND
The Custom Plan’s Days Submitted Number = Default Days
Supply Number (999)
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
A Custom Plan Benefit Limit record exists for this
Customer, Plan, and Benefit Limit Type
AND
The Claim’s Submitted Days Supply Amount (Days Supply)
> Plan Header Days Supply Limit (or Maintenance Days
Supply Limit for Maintenance Drugs)
AND
The Custom Plan’s Days Submitted Number not = Default
Days Supply Number (999)
AND
The Claim’s Submitted Days Supply Amount (Days Supply)
> The Custom Plan’s Days Submitted Number
AND
The Drug’s Therapeutic Class is not in an “Exempt” hardcoded table
AND
The Drug’s Category Code is not = ‘C’ (Oral
Contraceptives)
AND
The Claim’s Drug DEA Code = ‘0’ or ‘1’ (Schedule 0 – No
DEA Control, Schedule 1 - Research)
D
D
D
D
Page: 82
19
M/I Days Supply
4403
B
A Custom Plan Benefit Limit record does not exist for this
Customer - Plan - and Benefit Limit Type
AND
The Claim’s Submitted Days Supply Amount (Days Supply)
> Plan Header Days Supply Limit (or Maintenance Days
Supply Limit for Maintenance Drugs)
D
D
D
D
2C
M/I Pregnancy Indicator
4031
B
Missing/Invalid Pregnancy Indicator 5.1 only
The pregnancy indicator is missing (spaces) or it does not
match one of the valid values specified for the field.
B
B
B
B
2E
M/I Primary Care Provider ID
Qualifier
4032
B
B
B
B
B
20
M/I Compound Code
4033
B
Missing/Invalid Primary Care Provider ID Qualifier 5.1 only
The Primary Care Provider ID is submitted on the Prescriber
Segment
AND The Primary Care Provider ID Qualifier is missing or
it does not match one of the valid values specified for the
field.
Edit posted if not 0 - 1 - 2
D
D
D
D
Client Specific (IN): Note: if value 2 (compound) - will be
rejected by edit M5 (requires manual claim)
21
M/I Product/Service ID
4645
B
Post edit when a line item on a 5.1 claim is a dummy drug.
A dummy drug will have "CONSULTEC" as the
manufactors name.
D
D
D
D
21
M/I Product/Service ID
4034
B
The National Drug Code (NDC) is missing - non-numeric or all zeros.
D
D
D
D
21
M/I Product/Service ID
4803
B
NDC invalid format
D
D
D
D
21
M/I Product/Service ID
4450
B
The Product/Service ID Qualifier indicates the
Product/Service ID is an NDC
AND
The NDC is missing or non-numeric.
D
D
D
D
22
M/I Dispensed As Written Code
4622
B
Edit to deny claims that request a DAW code that is not
valid for the plan, ie: a claim was paid with a DAW of '2',
but '2' is not a valid DAW code per the given plan.
D
D
D
D
22
M/I Dispensed As Written Code
4037
B
D
D
D
D
23
M/I Ingredient Cost Submitted
4038
B
The Dispense As Written DAW/Product Selection Code
does not match one of the valid values specified for the
field.
The submitted ingredient amount/Ingredient Cost Submitted
is missing (zero).
D
D
D
D
25
M/I Prescriber Identification
4973
B
Prescriber on Review (Suspend)
B
B
B
B
25
M/I Prescriber Identification
4979
B
Prescriber writing prescription for schedule II drug must
have a valid DEA# on file
B
B
B
B
25
M/I Prescriber Identification
4975
B
Prescriber on Review (Deny)
B
B
B
B
25
M/I Prescriber Identification
4042
B
The Prescriber ID Qualifier is equal to DEA and the first
two positions of the Prescriber Provider Id are not
alphanumeric
OR
The Prescriber ID Qualifier is equal to DEA and the last
seven positions of the Prescriber Provider Id do not pass the
check sum validation routine.
D
D
D
D
26
M/I Unit Of Measure
4876
B
The Unit of Measure code is not equal to the valid values
D
D
D
D
27
28
Future Use
M/I Date RX Written
4877
4043
B
B
The Date Prescription Written is missing or invalid
B
D
B
D
B
D
B
D
Page: 83
28
M/I Date RX Written
4044
B
Client Specific (IN): The claim Date Prescribed is less than
the date the participant eligibility on the participant member
table began minus 30 days
OR
The claim Date Prescribed is greater than the date the
participant eligibility on the participant member table ended.
D
D
D
D
28
M/I Date RX Written
4045
B/C
D
D
D
D
28
M/I Date RX Written
4860
B
The drug is a Schedule II drug and the number of days since
the date prescribed is more than 30 days prior to the first
date of service
Date prescribed is invalid
D
D
D
D
28
M/I Date RX Written
4046
B
The date prescription written is greater than the date of
service.
D
D
D
D
29
M/I # Refills Authorized
4047
B
The drug is a schedule two drug and the number of refills
authorized is greater zero.
D
D
D
D
29
M/I # Refills Authorized
4425
C
The drug is a schedule zero and the number of refills
authorized is greater than 11.
D
D
D
D
29
M/I # Refills Authorized
4426
C
The drug is a schedule 3, 4 or 5 and the number of refills
authorized is greater than 5.
D
D
D
D
3A
M/I Request Type
4048
B
D
D
D
D
3B
M/I Request Period Date-Begin
4049
B
Missing/Invalid Request Type – 5.1 Only
The 5.1 transaction code equal P1-P4 and the request type
on the PA transaction is missing or not equal to one of the
valid values specified.
Missing Request Period Date-Begin – 5.1 Only
The Request Period Date-Begin is missing (zeros).
B
B
B
B
3C
M/I Request Period Date-End
4050
B
Missing Request Period Date-End – 5.1 Only
The Request Period Date-End is missing (zeros)
B
B
B
B
3D
M/I Basis Of Request
4051
B
Missing/Invalid Basis Of Request – 5.1 Only
The Basis Of Request is missing (spaces) or it does not
match one of the valid values specified for the field.
B
B
B
B
3E
M/I Authorized Representative First
Name
4052
B
M/I Authorized Representative First Name
B
B
B
B
3F
M/I Authorized Representative Last
Name
4053
B
M/I Authorized Representative Last Name
B
B
B
B
3G
M/I Authorized Representative Street
Address
4920
B
M/I Authorized Representative Street Address
B
B
B
B
3H
M/I Authorized Representative City
Address
4921
B
M/I Authorized Representative City Address
B
B
B
B
3J
M/I Authorized Representative
State/Province Address
4922
B
M/I Authorized Representative State/Province Address
B
B
B
B
3K
M/I Authorized Representative
Zip/Postal Zone
4923
B
M/I Authorized Representative Zip/Postal Zone
B
B
B
B
3M
Prescriber Phone Number
4054
B
Prescriber Phone Number
B
B
B
B
3N
M/I Prior Authorized Number
Assigned
4055
B
Missing Prior Authorization Number Assigned – 5.1 Only
The Prior Authorization Number Assigned is missing
(zeros).
B
B
B
B
3P
M/I Authorization Number
4056
B
Missing Authorization Number – 5.1 Only
The Authorization Number is missing (spaces).
B
B
B
B
Page: 84
3R
Prior Authorization Not Required
4924
B
Prior Authorization Not Required
B
B
B
B
3S
M/I Prior Authorization Supporting
Documentation
4057
B
M/I Prior Authorization Supporting Documentation
B
B
B
B
3T
Active Prior Authorization Exists
Resubmit At Expiration Of Prior
Authorization
4058
B
Active Prior Authorization Exists Resubmit At Expiration
Of Prior Authorization
B
B
B
B
3W
Prior Authorization In Process
4059
B
Prior Authorization In Process – 5.1 Only
An inquiry was made on a Prior Authorization that was in
“Pending” Status.
B
B
B
B
3X
Authorization Number Not Found
4060
B
Authorization Number Not Found – 5.1 Only
An inquiry or a reversal was made on a Prior Authorization
that could not be found.
B
B
B
B
3Y
Prior Authorization Denied
4061
B
Prior Authorization Denied – 5.1 Only
An inquiry was made on a Prior Authorization that was in
“Pending” Status.
B
B
B
B
30
M/I PA Med Cert #
4068
B
D
D
D
D
32
M/I Level of Service
4756
B
THE CLAIM IS VERSION 3.2 AND THE PRIOR
AUTHORIZATION TYPE CODE(DRUG CERT CODE) IS
NOT A VALID VALUE.
Client Specific Edit (IN)
Post edit if not valid value:
00=Not Specified
01=Patient Consultation
02=Home Delivery
03=Emergency
04=24 Hour Service
05=Patient Consultation About Generic Product Selection
D
D
D
D
32
M/I Level of Service
4961
C
Edit posted for: 1) illegal alliens; 2) non-aliens - override
restricted card (lockin) and 3) non-aliens - emergency fills:
level of srvc = 03 (emergency) and day supply is < 5
D
D
D
D
33
M/I RX Origin Code
4757
B
RX origin code missing or not a valid value
B
B
B
B
34
M/I Submission Clarification Code
4070
B
Invalid Submission Clarification Code
B
B
B
B
The Submission Clarification Code(drug RX override code)
is not equal to valid values
35
M/I Primary Care Provider ID
4071
B
The Primary Care Provider ID is missing (spaces).
B
B
B
B
35
M/I Primary Care Provider ID
4072
B
The primary care provider qualifier is equal to DEA
AND
(The first two positions of primary care provider id is not
alphabetic uppercase
OR
The last seven positions of the primary care provider id do
not pass the check sum validation routine).
OR
The primary care provider qualifier is equal to Medicaid or
UPIN or NCPDP or State License
AND
The primary care provider id is missing.
B
B
B
B
38
M/I Basis of Cost
4759
B
Basis of Cost is missing or invalid
B
B
B
B
Page: 85
39
M/I Diagnosis Code
4760
B
Diagnosis Code is missing or invalid
B
B
B
B
4C
M/I Coordination Of Benefits/Other
Payments Count
4074
B
Missing/Invalid Coordination Of Benefits/Other Payments
Count – 5.1 Only
A COB segment is present and the Coordination Of
Benefits/Other Payments Count is missing (zeros).
D
D
D
D
4E
M/I Primary Care Provider Last
Name
4925
B
M/I Primary Care Provider Last Name
B
B
B
B
40
Pharmacy not contracted with plan on
date of service
4862
C
Pharmacy not contracted with plan on date of service Checks if the pharmacy is on file and if the date range for
the plan includes the date of service on the claim; if not then post the error
D
D
D
D
Edit will post for non-590 providers submitting 590 claims
Note: This is a generic edit that posts for non-INCAID or
non-590 providers; accordingly
40
Pharmacy not contracted with plan on
date of service
4756
B
prov. inelig. to bill for DOS
D
D
D
D
40
Pharmacy not contracted with plan on
date of service
4075
B
The Date Of Service does not fall within the date range on
the provider network table that the provider was eligible to
provide services.
OR
The Date Of Service does fall within the date range on the
provider network table that the provider was eligible to
provide services for the plan but the network was not valid
for the Customer and Group on the Date Of Service
D
D
D
D
40
Pharmacy not contracted with plan on
date of service
4806
X
Pharmacy not contracted with plan on date of service
D
D
D
D
41
Submit bill to other processor or
primary payer
4077
B
Edit will post if the participant has TPL And TPL amount
less is than 5% of submitted ingredient cost And Other
insurance indicator = 2 - 3 or 4
B
B
B
B
41
Submit bill to other processor or
primary payer
4863
C
member covered by private ins
D
D
D
D
41
Submit bill to other processor or
primary payer
4427
NE
Nebraska Client Specific edit:
Patient has other coverage and the only policy is a cancer
policy (policy coverage code 43) and the claim is for a
cancer drug (one of the following 16 specific therapeutic
classes): L5J, Q5N, V1A, V1B, V1C, V1D, V1E, V1F, V1J,
V1K, V1N, V1O, V1Q, V1R, Z2E, Z2G.
BugTracker #4427
B
B
B
B
41
Submit bill to other processor or
primary payer
4433
MA
Client Specific (MA): The coverage type is not “17” and the
other insurance indicator is “0 -1 -3 -4” and the other
amount paid is zero.
B
B
B
B
41
Submit bill to other processor or
primary payer
4962
B
If claim indicates no other coverage but datebase indicates
COB coverage, then post edit (1-30-04 Revised description:)
D
D
D
D
41
Submit bill to other processor
4460
MD
Primary paid amount is less than 20% of allowable charge".
B
D
D
B
42
43
44
45
Future Use
Future Use
Future Use
Future Use
4880
4881
4882
4883
Page: 86
46
47
48
49
5C
Future Use
Future Use
Future Use
Future Use
M/I Other Payer Coverage Type
4884
4885
4886
4887
4078
B
5E
M/I Other Payer Reject Count
4079
B
50
Non-Matched Pharmacy Number
4440
50
Non-Matched Pharmacy Number
51
The Other Payer Coverage Type (COB Heirarchy) is
missing (spaces) or it does not match one of the valid values
specified for the field.
A COB segment is present and the Other Payer Reject Count
is missing.
D
D
D
D
D
D
D
D
B
An adjustment request record has a Servicing Pharmacy
(ALT ID) equal to spaces.
B
B
B
B
4442
B
B
B
B
B
Non-Matched Group Id
4689
B
An adjustment request record has targeted a history record
for adjustment - but the billing provider number on the
adjustment request record does not match the billing
provider number on the history record
IF DURING THE 1ST OR 2ND PASS OF THE
ADJUDICATION PROCESS, THE GROUP-ID WAS
CHANGED IN THE CLAIM TYPE ASSIGNMENT
PROGRAM AS A RESULT OF THE PRIORITY
RANKING SYSTEM, THEREFORE, THE GROUP-ID
BEING USED NO LONGER EQUALS THE GROUP-ID
SUBMITTED IN THE ORIGINAL CLAIM.
B
B
B
B
51
Non-Matched Group Id
4083
B
ACS Required
Date of Svc not in range of the plan on the
D
D
D
D
51
Non-Matched Group Id
4082
B
B - Group Record not on file
D
D
D
D
51
Non-Matched Group Id
4085
B
C - Mail Order claim: Mail order pricing id not on the group
file.
B
B
B
B
52
Non-Matched Cardholder Id
4086
B
Non-matched member id. member not found on eligibility
file.
D
D
D
D
52
Non-Matched Cardholder Id
4369
B
D
D
D
D
53
Non-Matched Person Code
4088
B
The Participant ID on the replacement or credit request does
not match the Participant ID on the claim that is being
replaced or credited.
The member number was not found on the participant
member table.
B
B
B
B
54
Non-Matched Product/Service ID
Number
4685
B
Date of Service is prior to the NDDF Added Date.
B
B
B
B
54
Non-Matched Product/Service ID
Number
4089
B
Non-matched NDC (not on drug file)
D
D
D
D
55
Non-Matched Product Package Size
4761
B
Non-Matched Product Package Size
B
B
B
B
55
UNBREAKABLE PACKAGE
4451
B
CLAIM UNITS MUST BE MULTIPLE OF PACKAGE
SIZE.
B
B
B
B
56
Non-Matched Prescriber
Identification
4090
B
Physician # does not match physician # on Lockin
Note: updated 12/12/06 to read "RECIPIENT LOCKED
INTO DIFFERENT PHYSICIAN "
D
D
D
D
56
Non-Matched Prescriber
Identification
4977
C
Physician Lic# not on file
B
B
B
B
56
Non-Matched Prescriber
Identification
4421
B
Prescriber ID not found on provider enrollment eligibility
table. Prescriber ID not valid for this client
B
B
B
B
58
Non-Matched Primary Prescriber
4763
B
Non Matched Primary Prescriber
B
B
B
B
Page: 87
A - 1st
group file
59
Non-Matched Clinic Identification
4764
B
Non-matched Clinic id
B
B
B
B
6C
M/I Other Payer ID Qualifier
4926
B
**No description for exception code
D
D
D
D
6E
M/I Other Payer Reject Code
4091
B
The other payer reject count is greater than zero and the
other payer reject code is missing (spaces).
D
D
D
D
60
Drug Not Covered For Patient Age
4092
B
Post if minimum age on custom record and patient is below
that age and no pa exists.
11/26 EOB edit moved from edit 88
D
D
D
D
60
Drug Not Covered For Patient Age
4093
C
The IP participant age is less than the Minimum Age or
greater than the maximum age on the Custom Plan Table
AND
Prior authorization indicator does NOT equal “Covered”
AND
The Age Edit Status on the Custom Plan table does NOT
equal “Prior Authorization”
D
D
D
D
61
Drug Not Covered For Patient
Gender
4094
B
D
D
D
D
62
Patient/Card Holder ID name
Mismatch
4765
B
Drug not covered for patient gender. If the drug is specified
for a particular gender on the custom record and the patient
is not that gender and no prior authorization on the medical
profile; then post the error.
member name & Number Disagree
B
B
B
B
64
Claim Submitted Does Not Match
Prior Authorization
4096
B
(The Claim PA Number missing
OR
The Claim PA Number does not match the PA number)
AND
The PA Requires a matching PA number on the Claim
B
B
B
B
65
Patient is Not Covered
4985
B
B
B
B
B
65
Patient is Not Covered
4097
B
D
D
D
D
65
Patient is Not Covered
4958
B
EDIT WILL POST IF MEMBER IS NOT COVERED BY
MEDICAID EVEN IF ELIGIBLE UNDER A SPECIFIC
PLAN
Patient not covered – Checks the coverage data on the
eligibility file to see if the claim FDOS is in range. Also
checks the relationship to determine if the member is
covered and checks to see if it is a covered member id. If
not covered for any of these reasons; then post the error.
Patient no longer covered because deceased
B
B
B
B
65
Patient is Not Covered
4810
B
Client Specific (IN): member enrolled w/MCO on DOS
B
B
B
B
65
Patient is Not Covered
4813
C
member has other insurance but no other payor amt or other
payor date submitted on the claim
B
B
B
B
65
Patient is Not Covered
4911
C
Filled before coverage effective – If the claim’s FDOS falls
before the oldest coverage beginning date in the coverage
table (Eligibility file); then the error is posted.
D
D
D
D
65
Patient is Not Covered
4865
Filled after coverage expired
D
D
D
D
65
Patient is Not Covered
4866
B
Filled after coverage terminated
D
D
D
D
65
Patient is Not Covered
4099
C
The date of service on the claim matches a segment on the
participant plan table
AND
The Plan ID is not 001 or 002
AND
The aid category on the COE table does not match the first
two bytes of the COE on the COE table.
B
B
B
B
Page: 88
65
Patient is Not Covered
4101
B
The claim drug coverage code is Family but the Participant
Relationship Code is not Self - Spouse - Child - or Other
OR
(The claim drug coverage code is Individual
AND
The Participant Relationship Code is not Self)
OR
(The claim drug coverage code is Subscriber Spouse
AND
The Participant Relationship Code is not Self or Spouse)
OR
(The claim drug coverage code is Subscriber Child
AND
The Participant Relationship Code is not Self or Child)
OR
(The claim drug coverage code is Other
AND
The Participant Relationship Code is not Self or spouse or
Child or Other)
B
B
B
B
65
Patient is Not Covered
4102
B
The claim member id is not equal to the member id on the
participant’s member table
OR
The claim First Date Of Service is less than the participant
member table eligibility began date
OR
The claim First Date Of Service is greater than the
participant member table eligibility end date.
D
D
D
D
65
Patient is Not Covered
4429
If the participant is production and the claim was marked as
a test claim because it contained a test provider
D
D
D
D
66
Patient Age Exceeds Maximum Age
4103
B
Post if drug has a maximum age specified on a customer
record and the age of the member exceeds this maximum
D
D
D
D
66
Patient Age Exceeds Maximum Age
4105
C
Drug Maximum Age Exceeded
D
D
D
D
The IP Participant Age is equal to or greater than the custom
plan table drug maximum age
AND
The prior authorization Indicator does not equal “Covered”
AND
The Age Edit Status on the Custom Record not = “Prior
Authorization”.
67
Filled Before Coverage Effective
4728
OH/MD
MD (1/17/07) - THIS FIELD IS USED TO SUBMIT THE
COPAY WHEN OTHER COVERAGE CODE = 8.
B
D
B
D
67
Filled Before Coverage Effective
4727
OH/MD
MD (1/17/07) - This field is required when submitting a
copay amount with other coverage code = 8. The qualifier
should be 99 (other)
B
D
B
D
67
Filled Before Coverage Effective
4726
OH/MD
MD (1/17/07) - This field is required when submitting a
copay amount with other coverage code = 8. The count is
typically 1.
B
D
B
D
67
Filled Before Coverage Effective
4722
OH
PENDING INJURY; ALLEGED CLAIM
B
D
B
B
67
Filled Before Coverage Effective
4106
B
Note: edit deleted by Nashville
B
B
B
B
The claim Date Of Service is less than the oldest plan
coverage beginning date.
Page: 89
68
Filled After Coverage Expired
4108
B
The Date Of Service is before the market entry date on the
drug table.
B
B
B
B
69
Filled After Coverage Terminated
4888
B
Filled After Coverage Terminated
B
B
B
B
7C
M/I Other Payer ID
4957
B
Non-Matched Other Payer Id
D
D
D
B
7E
M/I DUR/PPS Code Counter
4110
B
The DUR/PPS Code Counter is missing (zeros).
D
D
D
D
70
NDC Not Covered
4684
B
NDC NOT COVERED - REASON CODES: A =DESI
DRUG B =NO REBATE C = NOT COVERED ON PLAN
FILE D =NO VALID PRICING CATEGORY ON GROUP
FILE FOR DOS E =NO PRICING ON DRUG FILE FOR
DATE OF CLAIM F =NO MAIL-ORDER SERVICE FOR
CLIENT G =MAIL-ORDER FOR MAINTENANCE
DRUGS ONLY I= DEFAULT CODE - NOT COVERED
ON PLAN
D
D
D
D
70
NDC Not Covered
4619
NE
D
D
D
D
70
Product/Service Not Covered
4980
BE / IA
Reason code P - The Labeler portion of the NDC indicates it
is not covered
D
D
D
D
70
Product/Service Not Covered
4116
B
NDC not covered – Reason Codes:
A =DESI Drug
B =No Rebate
C = Not Covered on Plan File
D =No Valid Pricing Category on Group File for DOS
E =No Pricing on Drug File for Date of Claim
F =No Mail-Order Service for Client
G =Mail-Order for Maintenance Drugs Only
I= Default Code – Not Covered on Plan
D
D
D
D
**3.2 edit only - see 4683 for equivalent 5.1 edit**
Deny the claim if the date filled is 366 days past the drug
obsolete date (not term date)
Nashville description:
The Product/Service ID Qualifier indicates that the
Product/Service ID field contains a NDC and the Plan
indicates a Non-Covered Drug
70
Product/Service Not Covered
4853
C
Less than effective Drug
B
B
B
B
70
Product/Service Not Covered
4123
B
Reason Code E: No price on drug file
D
D
D
D
D
D
D
D
70
Product/Service Not Covered
4113
B
The Product/Service ID Qualifier indicates that the
Product/Service ID field contains a NDC and no drug
pricing data for the drug was in effect for the claim Date of
Service.
A =DESI Drug
(Less than effective Drug) - non-reimbursable
Nashville description:
If the Product/Service ID Qualifier indicates a NDC in the
Product/Service ID field
AND
The Plan’s Designer Drug Allowed indicator equals ‘N’
AND
The DESI Drug Override is not equal to ‘Y’
AND
The Drug's DESI Code = '1', '4', or '5'.
Page: 90
70
Product/Service Not Covered
4117
B
No signed rebate agreement (reason code B).
D
D
D
D
D
D
D
D
B
B
B
B
B
B
B
B
D
D
D
D
Nashville description:
HCFA Rebate Criteria Not Met – 3.2 Only (Mass Specific)
The Product/Service ID Qualifier indicates that the
Product/Service ID field contains a NDC
AND
((Drug Rebate data is found for the Claim’s NDC and Date
of Service on the Drug Rebate Table
AND
The Drug Rebate Code for the NDC = “No Rebate” (‘0’)
AND
The NDC is not a “Rebate Exempt” NDC (hard-coded
table – Massachusetts specific))
OR
(Drug Rebate data is not found for the Claim’s NDC and
Date of Service on the Drug Rebate Table))
AND
The Drug’s Class Code not = “OTC” (‘O’)
AND
The Drug’s Therapeutic Class not = “Vaccine” (‘W7B’ thru
‘W7Q’)
AND
The Drug’s GCN not = “Non-Drug Item” (‘94200’)
AND
The Claim’s Drug Compound Code not = “Compound” (‘2’)
70
Product/Service Not Covered
4120
B
D =No Valid Pricing Category on Group File for DOS
Nashville description:
The Product/Service ID Qualifier indicates that the
Product/Service ID field contains a NDC and a valid group
pricing segment was not found on the group pricing table
70
Product/Service Not Covered
4118
B
F =No Mail-Order Service for Client
If the Product/Service ID Qualifier indicates that the
Product/Service ID field contains a NDC
AND
The Claim’s Input Form Code indicates a Mail Order claim
AND
The Customer table Mail Order Program Indicator is not
equal to Mail Order Program
70
Product/Service Not Covered
4119
B
G =Mail-Order for Maintenance Drugs Only
Nashville Description:
If the claim input form code is mail order
AND
The Product/Service ID Qualifier indicates that the
Product/Service ID field contains a NDC
AND
The Customer Mail Order Code equals Maintenance Only
Covered
AND
The Claim Maintenance Drug Indicator is not equal to
Maintenance Drug.
70
Product/Service Not Covered
4115
B
I= Default Code – Not Covered on Plan
The Product/Service ID Qualifier indicates that the
Product/Service ID field contains a NDC and the Plan
benefit limit range table indicates a Non-Covered Drug.
Page: 91
70
Product/Service Not Covered
4111
B
The First Date Of Service on a Claim with a Workers
Compensation Customer ID is less than the date of injury on
the Prior Authorization Header Table.
B
B
B
B
70
Product/Service Not Covered
4114
B
If the Product/Service ID Qualifier indicates that the
Product/Service ID field contains a NDC
AND
The NDC is a Plan Non-Covered Drug from the benefit limit
range table
AND
No previous pricing edits have been set for this claim
AND
The Plan Benefit Limit Override PA is not equal to “I “
(Override Initial RX).
D
D
D
D
70
Product/Service Not Covered
4121
B
If the Product/Service ID Qualifier indicates that the
Product/Service ID field contains a NDC
AND
The Claim Allowed Charge equals $0.00
AND
The Group Pricing DAW code on the group pricing table
equals spaces.
B
B
B
B
70
Product/Service Not Covered
4122
C
If the Product/Service ID Qualifier indicates that the
Product/Service ID field contains a NDC
AND
The drug is a Plan Non-Covered Drug
AND
No previous pricing edits have been set for this claim
AND
The Plan Benefit Limit Override PA is not equal to “I “
(Override Initial RX)
AND
The Plan ID is not equal to ‘101’ thru ‘123’ (Massachusetts
Long Term Care Plan).
B
B
B
B
70
Product/Service Not Covered
4124
B
If the stepcare indicator on the customer and group tables is
equal to ‘Y’
AND
The drug is not covered by the Plan or by a PA
AND
The reject code on the StepCare record is “70”
AND
The number of agents taken is less than the number of
agents required
OR
The amount of time the drugs were taken was less than the
therapy span required.
OR
If the number of agents required is greater than the number
of drugs that were each taken for the correct therapy span
B
D
B
B
71
Prescriber is Not Covered
4770
X
Prescriber is Not Covered
B
B
B
B
72
Primary Prescriber is Not Covered
4771
X
Primary Prescriber is Not Covered
B
B
B
B
73
Refills are Not Covered
4131
B
The Custom Plan Max Number of Refills is not equal to
“Unlimited” (999)
AND
The Plan Benefit Limit Override PA is equal to “N” (No
Override) or “ “ (not set)
AND
The Custom Plan Max Number of Refills is less than Claim
Refill Indicator (Fill Number)
AND
The drug prescription override indicator is not equal to “Y”.
B
B
B
B
Page: 92
73
Refills are Not Covered
4128
B
The Custom Plan Max Number of Refills is not equal to
“Unlimited” (999)
AND
The Plan Benefit Limit Override PA is equal to “N” (No
Override) or “ “ (not set)
AND
The Custom Plan Max Number of Refills is less than Claim
Refill Indicator (Fill Number)
AND
The drug prescription override indicator is not equal to “Y”.
D
D
D
D
73
Refills are Not Covered
4129
B
Number Of Mail Order Refills Exceeded
The provider payment code is mail order
AND
The Claim Refill Indicator (Fill Number) is greater than the
plan number of refill limit
B
B
B
B
73
Refills are Not Covered
4130
B
B
B
B
B
74
Other Carrier Payment Meets or
Exceeds Payable
4772
B
Maximum Number Of Refills Exceeded
If the claim is not mail order
AND
The Claim Refill Indicator is greater than the plan
Authorized Refills
Client Specific (CO) Other carrier payment meets or
exceeds payable – PDCS CO only
B
B
B
B
75
Prior Authorization Required
4711
OH
BILL SUBJECT TO SMARTPA CLINICAL RULES.
SMARTPA RULES ENGINE DOWN.
D
B
B
D
75
Prior Authorization Required
4965
C
Client Specific (IN) 590 claims in excess of $500 require
PA. If there is no PA; the claim should deny for NCPDP
edit 75 and EOB 3002.
B
B
B
B
75
Prior Authorization Required
4133
B
If the DUR amount limit accumulator equals ‘all’
AND
The DUR amount limit total (a calculated field) is greater
than the DUR amount limit from the plan benefits limit table
AND
The DUR amount limit status on the plan’s benefits limit
table equals ‘P’
AND
There is no prior authorization indicated on the claim.
B
B
B
B
75
Prior Authorization Required
4146
B
If the Plan Benefit Limit Override PA equals “I “ (Override
Initial RX)
AND
The Claim Refill Indicator equals 0
AND
The Prior authorization indicator is not equal to (“Prior
Authorized” or “Covered”).
B
B
B
B
75
Prior Authorization Required
4134
B
The Prior Authorization used units plus the claim drug
quantity is greater than the Prior Authorization approved
units amount
D
D
D
D
75
Prior Authorization Required
4821
Client Specific (IN) out of state provider req. PA
B
B
B
B
(OHWORK) BILL SUBJECT TO SMARTPA CLINICAL
RULES. INJURED WORKER DOES NOT HAVE
REQUIRED DIAGNOSIS ON FILE SUPPORTING THE
USE OF THE DRUG.
Page: 93
75
Prior Authorization Required
4822
out of state provider req. PA
B
B
B
B
(OHWORK) BILL SUBJECT TO SMARTPA CLINICAL
RULES. INJURED WORKER DOES NOT HAVE
REQUIRED DIAGNOSIS ON FILE SUPPORTING THE
USE OF THE DRUG.
75
Prior Authorization Required
4914
B
Client Specific (IN) Non-PDL Drug - Prior Authorization
Required (TCP Program)
B
B
B
B
75
Prior Authorization Required
4140
B
D
D
D
D
75
Prior Authorization Required
4141
B
D
D
D
D
75
Prior Authorization Required
4142
B
If the (Custom Plan Max Units Accum is not equal to “N”
(None)
OR
The Custom Plan Max Units is not equal to Work Default
Max Units (99999.999))
AND
The Custom Plan Max Units Accum equals “C” (Acute
Dose Only)
AND
The Custom Plan Maintenance Claim Dose less than Work
Default Dose (9999.999)
AND
The Daily Dose (derived by taking Claim Submitted
Quantity / Claim Days Supply) greater than Custom Plan
Maintenance Claim Dose
AND
The Claim Submitted Quantity is greater than Custom Plan
Max Units
AND
The Custom Plan Max Units Status equals “P” (PA
Required)
AND
The prior authorization indicator is not equal to (“Prior
Authorized” or “Covered”).
If the Custom Plan Max Units Accum equals “A” (All
Doses)
AND
The Claim Submitted Quantity is greater than Custom Plan
Max Units
AND
The Custom Plan Max Units Status equals “P” (PA
Required)
AND
The Prior authorization indicator is not equal to (“Prior
Authorized” or “Covered”).
If the Custom Plan Max Number of Refills is not equal to
“Unlimited” (999)
AND
The Plan Benefit Limit Override PA equals “I” (Override
Initial RX)
AND
The Claim Refill Indicator greater 0
AND
The Custom Plan Max Number of Refills less than (<) The
Claim Refill Indicator
AND
The Prior authorization indicator is not equal to (“Prior
Authorized” or “Covered”).
B
B
B
B
Page: 94
75
Prior Authorization Required
4143
B
The Plan Benefit Limits indicate “Not Covered”
AND
The Claim PA Type Code not = ‘8’ (PA Override)
AND
The Plan Benefit Limit Override PA equals “I” (Override
Initial RX)
AND
The Claim Refill Indicator is equal to 0
AND
The Plan Benefit Limt Med Cert Indicator = ‘Y’ (Override)
AND
The Claim PA Indicator not = “Prior Authorized” or
“Covered”)
AND
(The Claim PA Type Code = ‘2’ (Med Cert)
OR
The Claim RX Override Code = ‘7’ (Medically
Necessary)).
B
B
B
B
75
Prior Authorization Required
4144
B
If the Custom Plan Max Number of Refills is not equal to
“Unlimited” (999)
AND
The Plan Benefit Limit Override PA equals “Y” (Override)
AND
The Custom Plan Max Number of Refills less than Claim
Refill Indicator
AND
The Prior authorization indicator is not equal to (“Prior
Authorized” or “Covered”).
B
B
B
B
75
Prior Authorization Required
4145
B
The Plan Benefit Limit Override PA equals “Y” (Override)
and the Prior authorization indicator is not equal to (“Prior
Authorized” or “Covered”).
D
D
D
D
75
Prior Authorization Required
4145
B
Client is in Nursing Home, please try Medicare part D
B
B
B
B
75
Prior Authorization Required
4145
B
Client is in Nursing Home
B
B
B
B
75
Prior Authorization Required
4148
C
Client Specific Edit (MA): PA Required For Telephone
Prescription Schedule II Drug
(also checks for oxycontin limits exceeded))
If the prescription originated by telephone for a schedule II
drug
AND
It is not an emergency service level
AND
It is not a paper claim
B
B
B
B
75
Prior Authorization Required
4149
B
If the Daily Dose (derived by taking Claim Submitted
Quantity / Claim Days Supply) greater than Custom Plan
Maintenance Claim Dose
AND
The Custom Plan Maintenance Indicator equals “Pay”
AND
The Prior authorization indicator is not equal to (“Prior
Authorized” or “Covered”).
B
B
B
B
75
Prior Authorization Required
4150
B
If the Custom Plan Maximum Daily Dose Units is not equal
to 0
AND
The Daily Dose (derived by taking Claim Submitted
Quantity / Claim Days Supply) greater than Custom Plan
Maximum Daily Dose
AND
Claim dose indicator equals ‘pay’
AND
The Prior authorization indicator is not equal to (“Prior
Authorized” or “Covered”).
D
D
D
D
Page: 95
75
Prior Authorization Required
4151
B
If the Custom Plan Minimum Daily Dose Units is not equal
to 0
AND
The Daily Dose (derived by taking Claim Submitted
Quantity / Claim Days Supply) is less than the Custom Plan
Minimum Daily Dose
AND
The Prior authorization indicator is not equal to (“Prior
Authorized” or “Covered”).
The Claim Participant Age is not less than the Custom Plan
Drug Maximum Age
AND
The Prior authorization indicator is not equal to (“Prior
Authorized” or “Covered”)
AND
The Custom Plan Age Edit Status equals “PA Required”
AND
The Claim’s Prior Authorization Type Code not = “PA
Override” (‘8’).
D
D
D
D
75
Prior Authorization Required
4152
B
D
D
D
D
75
Prior Authorization Required
4153
B
If the Claim Participant Age is not greater than the Custom
Plan Drug Minimum Age
AND
The Prior authorization indicator is not equal to (“Prior
Authorized” or “Covered”)
AND
The Custom Plan Age Edit Status equals “PA Required”
AND
The Claim’s Prior Authorization Type Code not = “PA
Override” (‘8’).
D
D
D
D
75
Prior Authorization Required
4154
B
D
D
D
D
4155
B
The (Custom Plan Days Supplied Accum is not equal to “N”
(None)
AND
The Custom Plan Days Supplied is not equal to Work
Default Days (999))
AND
The Custom Plan Days Supplied Accum equals “C” (Acute
Dose Only)
AND
The Custom Plan Maintenance Claim Dose less than the
Work Default Dose (9999.999)
AND
The Daily Dose (derived by taking Claim Submitted
Quantity / Claim Days Supply) is greater than the Custom
Plan Maintenance Claim Dose
AND
The Claim Submitted Days is greater than Custom Plan
Days Supplied
AND
The Custom Plan Days Supplied Status equals “P” (PA
Required)
AND
The Prior authorization indicator is not equal to (“Prior
Authorized” or “Covered”).
If the Custom Plan Days Supplied Accum equals “A” (All
Doses)
AND
The Claim Submitted Days is greater than the Custom Plan
Days Supplied
AND
The Custom Plan Days Supplied Status equals “P” (PA
Required)
AND
The Prior authorization indicator is not equal to (“Prior
Authorized” or “Covered”).
75
Prior Authorization Required
D
D
D
D
Page: 96
75
Prior Authorization Required
4156
B
An entry on the Custom Record exists
AND
The DUR Units Accumulator Code on the Custom Record is
not equal to “N”
AND
The DUR Units Amount on the Custom Record is greater
than +0.000 and less than +99999.999
AND
((The DUR Units Accumulator Code on the Custom Record
equals “C” (Acute))
AND
(IP Daily Dose is greater than the Maintenance Claim Dose
on the Custom Record)
AND
(DUR Units Total is greater than the DUR Units Amount on
the Custom Record)
AND
(DUR Units Status on the Custom Record equals “P”)
AND
(Prior authorization indicator is not equal to “C” (Covered)
and not equal to “A” (Prior Authorization))
OR
((DUR Units Accumulator Code on the Custom Record
equals “A” (All))
AND
(DUR Units Total is greater than the DUR Units Amount on
the Custom Record)
AND
(DUR Units Status on the Custom Record equals “P”)
AND
(Prior authorization indicator not equal to “C” (Covered)
and not equal to “A” (Prior Authorization)))
Page: 97
D
D
D
D
75
Prior Authorization Required
4157
B
An entry exists on the Custom Record
AND
DUR Days Supply Accumulator Code on the Custom
Record is not equal to “N”
AND
DUR Days Supply Amount on the Custom Record is greater
than +0 and less than +999
AND
((DUR Days Supply Accumulator Code on the Custom
Record equals “C” (Acute))
AND
(IP Daily Dose is greater than the Maintenance Claim Dose
on the Custom Record)
AND
(DUR Days Supply Total is greater than the DUR Days
Supply Amount on the Custom Record)
AND
(DUR Days Supply Status on the Custom Record equals
“P”)
AND
(Prior authorization indicator is not equal to “C” (Covered)
and not equal to “A” (Prior Authorization)))
OR
((DUR Days Supply Accumulator Code on the Custom
Record equals “A” (All))
AND
(DUR Days Supply Total is greater than the DUR Days
Supply Amount on the Custom Record )
AND
(DUR Days Supply Status on the Custom Record equals
“P”)
AND
(Prior authorization indicator is not equal to “C” (Covered)
and not equal to “A” (Prior Authorization)))
Page: 98
D
D
D
D
75
Prior Authorization Required
4158
B
An entry exists on the Custom Record
AND
DUR Max RX Accumulator Code on the Custom Record is
not equal to “N”
AND
DUR Max RX Amount on the Custom Record is greater
than +0 and less than +999
AND
((DUR Max RX Accumulator Code on the Custom Record
equals “C” (Acute))
AND
(IP Daily Dose is greater than the Maintenance Claim Dose
on the Custom Record)
AND
(DUR Max RX Total is greater than the DUR Max RX
Amount on the Custom Record)
AND
(DUR Max RX Status on the Custom Record equals “P”)
AND
(Prior authorization indicator is not equal to “C” (Covered)
and not equal to “A” (Prior Authorization)))
OR
((DUR Max RX Accumulator Code on the Custom Record
equals “A” (All))
AND
(DUR Max RX Total is greater than the DUR Max RX
Amount on the Custom Record)
AND
(DUR Max RX Status on the Custom Record equal to “P”)
AND
(Prior authorization indicator is not equal to “C” (Covered)
and not equal to “A” (Prior Authorization)))
D
D
D
D
75
Prior Authorization Required
4159
C
Exceeds Min or Max Age Limit
The Participant Age is equal to or greater than the
Maximum Age or less than the Minimum Age allowed
D
D
D
D
D
D
D
D
Original Mass Edit Text:
Exceeds Min or Max Age Limit
The Customer ID is equal to Massachusetts and a Custom
Record Exists for the Customer ID
AND (The IP Participant Age is equal to or greater than the
Maximum Age on the Custom Record)
OR (IP Participant Age is less than the Minimum Age on the
Custom Record)
AND The Prior authorization indicator not equal to
“Covered”
AND The Age Edit Status on the Custom Record equals
“Prior Authorization”.
75
Prior Authorization Required
4381
B
Formulary exists for the Plan and Drug Code
AND
Plan Detail Formulary Type Code = ‘C’ (Closed)
AND
Formulary Coverage Indicator not = ‘N’ (Not Covered)
AND
Claim’s Prior Authorization Indicator = ‘ ‘ (No PA) - ‘P’
(Use Plan) - or ‘R’ (PA doesn’t match claim)
AND
Claim’s DAW Code not = ‘1’ (Physician)
Page: 99
75
Prior Authorization Required
4447
B
75
Prior Authorization Required
4448
C
The In process Billing Provider ID not equal History Billing
Provider ID
AND
First date of service on the current claim must be after the
first date of service on the history claim.
AND
First date of service on the current claim must be before the
date calculated to be the history claim’s first date of service
plus days supplied less the grace period.
AND
The claim dates of service overlap
AND
(History Route Code equals IP Route Code
OR
(IP Route Code equals (A or B or C or H or L or S or T or 1
or 2 or 3 or 7)
AND
History Rout Code equals (A or B or C or H or L or S or T
or 1 or 2 or 3 or 7))
AND
The History NDC found on Drug Record
AND NOT
(History Generic Code equals IP Generic Code
OR
History NDC equals IP NDC
OR
IP Generic Code equals “01697” AND History Generic
Code equals “02521”
OR
History NDC equals IP NDC
OR
IP Generic Code equals “01698” AND History Generic
Code equals “02529”
OR
History NDC equals IP NDC
OR
IP Generic Code equals “92989” AND History Generic
Code equals “08453”
OR
IP Generic Code equals “04348” AND History Generic
Code equals “08450”
OR
IP Generic Code equals “92999” AND History Generic
Code equals “08452”)
AND
The route codes must be the same or they must both be
systemic route
(History Route Code equals IP Route Code
OR
(IP Route Code equals (A or B or C or H or L or S or T or 1
or 2 or 3 or 7)
AND
History Rout Code equals (A or B or C or H or L or S or T
or 1 or 2 or 3 or 7)))
AND
Specific therapeutic class must be the same. Any
Therapeutic Class Code Specific on the Drug Record from
the IP NDC is equal to any Therapeutic Class Code specific
on the Drug Record from the History NDC.
Drug to Drug Interaction
Page: 100
B
B
B
B
B
B
B
B
75
Prior Authorization Required
4449
B
If Medical Profile Override Indicator set to NO
and
(History FDOS is greater than IP FDOS
OR
After processing through all of history claims)
AND
The Dose Form on the Drug Record from the IP NDC must
equal ‘Each’ or ‘Milliliter’
AND
Calculated Daily Dose must be more than the Maximum
Daily Dose on the Drug Record
B
B
B
B
75
Prior Authorization Required
4125
B
StepCare
If the customer participates in StepCare
AND
The drug is not covered by the Plan or by a PA
AND
The reject code on the StepCare record is “75”
AND
The number of agents taken is less than the number of
agents required
OR
The amount of time the drugs were taken was less than the
therapy span required.
OR
If the number of agents required is greater than the number
of drugs that were each taken for the correct therapy span
B
D
B
B
76
Plan Limitations Exceeded
4675
FL
Claim subject to SmartPA Clinical Rules. Patient has
another medication in history which indicates duplication of
therapy.
B
B
B
B
B
B
B
B
B
B
B
B
(OHWORK) BILL SUBJECT TO SMARTPA CLINICAL
RULES. INJURED WORKER DOES NOT HAVE
REQUIRED DIAGNOSIS ON FILE SUPPORTING THE
USE OF THE DRUG.
76
Plan Limitations Exceeded
4674
FL
Claim subject to SmartPA Clinical Rules. Dose not
optimized.
(OHWORK) PA EFFECTIVE SPAN = 180DAYS
76
Plan Limitations Exceeded
4673
FL
Claim subject to SmartPA Clinical Rules. Claim exceeds
SmartPA quantity limits/maximum daily dosage.
(OHWORK) PA EFFECTIVE SPAN = 180DAYS
76
Plan Limitations Exceeded
4823
B
Plan Limitations Exceeded - Prior Authorization Required
From Health Care Excel 800-457-4518
(oxycontin limits)
B
B
B
B
76
Plan Limitations Exceeded
4970
C
Client Specific (IN) Step Care - Greater than 90 days in 180
days of Ranitidine or Nizatidine > 150 mg/day; Famotidine
> 20mg/day; Cimetidine > 400mg/day PA required from
Health Care Excel 800-457-4518
B
B
B
B
76
Plan Limitations Exceeded
4968
B
Non-PDL Drug - Supply Limited (TCP Program)
B
B
B
B
Page: 101
76
Plan Limitations Exceeded
4552
B
Base edit for condition: greater than 34 days supply for nonmaintenance drug
B
B
B
B
76
Plan Limitations Exceeded
4913
C
B
B
B
B
76
Plan Limitations Exceeded
4831
B
D
D
D
D
76
Plan Limitations Exceeded
4832
B
Client Specific (IN) CSR 43 - greater than 34 days supply
for non-maint. Drug Prior Authorization required from
Health Care Excel 800-457-4518
Plan Limits Exceeded - see below reason codes:
B =Custom Rec; All Doses - Max $ Limit Exceeded for
Spec Dur
C =Custom Rec; Acute Dose - Max $ Limit Exceeded for
Spec Duration
D
D
D
D
76
Plan Limitations Exceeded
4165
B
D =Custom Rec; All Doses - Submitted Units > Max Units
for Spec Claim
D
D
D
D
Submitted Quantity Exceeds Custom Plan Limits
The Custom Plan Max Units Accum equals “A” (All Doses)
AND
The Claim Submitted Quantity is greater than Custom Plan
Max Units
AND
The Custom Plan Max Units Status equals “D” (Deny)
AND
Prior authorization indicator is not equal to (“Prior
Authorized” or “Covered”).
76
Plan Limitations Exceeded
4867
B
E =Custom Rec; Acute Dose - Submitted Units > Max Units
for Spec Claim
D
D
D
D
76
Plan Limitations Exceeded
4168
B
F =Custom Rec; All Doses - Submitted days > Max Days
Supp for Spec Claim
D
D
D
D
D
D
D
D
DUR Days Supplied Limits Exceeded
An entry exists on the Custom Record
AND DUR Days Supply Accumulator Code on the Custom
Record is not equal to “N”
AND DUR Days Supply Amount on the Custom Record is
greater than +0 and less than +999
AND ((DUR Days Supply Accumulator Code on the
Custom Record equals “C” (Acute))
AND (IP Daily Dose is greater than the Maintenance Claim
Dose on the Custom Record)
AND (DUR Days Supply Total is greater than the DUR
Days Supply Amount on the Custom Record)
AND (DUR Days Supply Status on the Custom Record
equals “D”)
AND (Prior authorization indicator is not equal to “C”
(Covered) and not equal to “A” (Prior Authorization)))
OR ((DUR Days Supply Accumulator Code on the Custom
Record equals “A” (All))
AND (DUR Days Supply Total is greater than the DUR
Days Supply Amount on the Custom Record)
AND (DUR Says Supply Status on the Custom Record
equals “D”)
AND (Prior authorization indicator is not equal to “C”
(Covered) and not equal to “A” (Prior Authorization)))
76
Plan Limitations Exceeded
4163
B
G =Custom Rec; Acute Dose - Submitted days > Max Days
Sup for Spec claim
Exceeds Custom Plan Days Supplied Limits
The Custom Plan Days Supplied Accum equals “A” (All
Doses)
AND
The Claim Submitted Days greater than Custom Plan Days
Supplied
AND
The Custom Plan Days Supplied Status equals “D” (Deny)
AND
The Prior authorization indicator is not equal to (“Prior
Authorized” or “Covered”).
Page: 102
76
Plan Limitations Exceeded
4160
B
H =Custom Rec; Daily Dose > Maintenance Claim Dose
D
D
D
D
D
D
D
D
Not Covered By Custom Plan
The Daily Dose equals the Custom Plan Maintenance Claim
Dose
AND
The Custom Plan Maintenance Indicator is not equal to
“Pay”
AND
The Custom Plan Maintenance Claim Dose Indicator equals
“Deny, no PA”
AND
The Prior authorization indicator is not equal to (“Prior
Authorized” or “Covered”).
76
Plan Limitations Exceeded
4169
B
I =Custom Rec; All Doses - Max Num of Scripts exceeded
for Spec Dur
An entry exists on the Custom Record
AND
DUR Max RX Accumulator Code on the Custom Record is
not equal to “N”
AND
DUR Max RX Amount on the Custom Record is greater
than +0 and less than +999
AND
((DUR Max RX Accumulator Code on the Custom Record
equals “C” (Acute))
AND
(IP Daily Dose is greater than the Maintenance Claim Dose
on the Custom Record)
AND
(DUR Max RX Total is greater than the DUR Max RX
Amount on the Custom Record)
AND
(DUR Max RX Status on the Custom Record equals “D”)
AND
(Prior authorization indicator is not equal to “C” (Covered)
and not equal to “A” (Prior Authorization)))
OR
((DUR Max RX Accumulator Code on the Custom Record
equals “A” (All))
AND
(DUR Max RX Total is greater than the DUR Max RX
Amount on the Custom Record)
AND
(DUR Max RX Status on the Custom Record equals “D”)
AND
(Prior authorization indicator is not equal to “C” (Covered)
and not equal to “A” (Prior Authorization)))
76
Plan Limitations Exceeded
4868
B
J =Custom Rec; Acute Dose - Max num Scripts exceeded
for Spec Dur
D
D
D
D
76
Plan Limitations Exceeded
4869
B
K =Custom Rec; All Doses - Submitted Days > Max Days
Supp for Spec Duration
D
D
D
D
76
Plan Limitations Exceeded
4870
B
L =Custom Rec: Acute Dose - Submitted Days > Max Days
Supp for Spec Duration
D
D
D
D
Page: 103
76
76
Plan Limitations Exceeded
Plan Limitations Exceeded
4171
4172
B
B
M =Custom Rec; All Doses - Submitted Units > Max Units
for Spec Dur
The DUR amount limit accumulator equals ‘A’ (all)
AND
The DUR amount limit total is greater than the DUR amount
limit from the plan benefits limit table
AND
The DUR amount limit status on the plan’s benefits limit
table equals ‘D’
AND
There is no prior authorization
N =Custom Rec; Acute Dose - Submitted Units > Max Units
for Spec Dur
D
D
D
D
D
D
D
D
D
D
D
D
DUR Daily Dosage Limit Exceeded
The DUR amount limit accumulator on the plan benefits
limits database equals ‘C’ (acute)
AND
The daily dose is greater than the maintenance claim dose on
the plan’s benefits limit table
AND
The DUR amount limit total is greater than the DUR amount
limit from the plan benefits limit table
AND
The DUR amount limit status on the plan’s benefits limit
table equals ‘D’
AND
There is no prior authorization
76
Plan Limitations Exceeded
4166
B
O =Plan file Max Scripts exceeded for a Specific Duration
The Number of Scripts on the Plan Record is greater than
zero and less than 999.
AND
The Script Limit Total is greater than the Number of Scripts
on the Plan Record.
AND
Prior authorization indicator is not equal to “1” or “3”
AND
The Prescription Limit Exempt Indicator on the Custom
Record is not equal to “Y”.
76
Plan Limitations Exceeded
4833
B
P= Patient Exceeds Monthly Refill Limit
D
D
D
D
76
Plan Limitations Exceeded
4161
B
The Number of Scripts on the Plan Record is greater than
zero and less than 999.
AND
The Script Limit Total is greater than the Number of Scripts
on the Plan Record.
AND
Prior authorization indicator is not equal to“1” or “3”
AND
The Prescription Limit Exempt Indicator on the Custom
Record is not equal to “Y”
D
D
D
D
Page: 104
76
Plan Limitations Exceeded
4162
B
76
Plan Limitations Exceeded
4164
B
(The Custom Plan Days Supplied Accum is not equal to “N”
(None)
OR
The Custom Plan Days Supplied is not equal to Work
Default Days (999))
AND
The Custom Plan Days Supplied Accum equals “C” (Acute
Dose Only)
AND
The Custom Plan Maintenance Claim Dose less than Work
Default Dose (9999.999)
AND
The Daily Dose is greater than Custom Plan Maintenance
Claim Dose
AND
The Claim Submitted Days is greater than Custom Plan
Days Supplied
AND
The Custom Plan Days Supplied Status equals “D” (Deny)
AND
The Prior authorization indicator is not equal to (“Prior
Authorized” or “Covered”).
(The Custom Plan Max Units Accum is not equal to “N”
(None)
AND
The Custom Plan Max Units is not equal to Work Default
Max Units (99999.999))
AND
The Custom Plan Max Units Accum equals “C” (Acute
Dose Only)
AND
The Custom Plan Maintenance Claim Dose less than Work
Default Dose (9999.999)
AND
The Daily Dose is greater than Custom Plan Maintenance
Claim Dose
AND
The Claim Submitted Quantity is greater than Custom Plan
Max Units
AND
The Custom Plan Max Units Status equals “D” (Deny)
AND
The Prior authorization indicator is not equal to (“Prior
Authorized” or “Covered”).
Page: 105
D
D
D
D
D
D
D
D
76
Plan Limitations Exceeded
4167
B
An entry exists on the Custom Record
AND
DUR Units Accumulator Code on the Custom Record is
not equal to “N”
AND
DUR Units Amount on the Custom Record is greater than
+0.000 and less than +99999.999
AND
((DUR Units Accumulator Code on the Custom Record
equals “C” (Acute))
AND
(IP Daily Dose is greater than the Maintenance Claim Dose
on the Custom Record)
AND
(DUR Units Total is greater than the DUR Units Amount on
the Custom Record)
AND
(DUR Units Status on the Custom Record equals “D”)
AND
(Medical Profile Override Indicator is not equal 1 and not
equal 3)
AND
(Prior authorization indicator is not equal “C” (Covered) and
not equal “A” (Prior Authorization))
OR
((DUR Units Accumulator Code on the Custom Record
equals “A” (All))
AND
(DUR Units Total is greater than the DUR Units Amount on
the Custom Record)
AND
(DUR Units Status on the Custom Record equals “D”)
AND
(Prior authorization indicator is not equal to “C” (Covered)
and not equal to “A” (Prior Authorization)))
D
D
D
D
76
Plan Limitations Exceeded
4170
C
History Accumulator Greater Than 60 Days
B
B
B
B
B
D
B
B
IP Generic Code Number one of the following: 01697,
01698, 04348, 12867, 12868, 13025, 40120, 64269, 92989,
92999, 94639
AND
IP first date of service is greater than the current date minus
181 days
AND
Massachusetts History Accumulator is greater than +60
AND
The Prior authorization indicatory is not equal to “Covered”
and not equal to “Prior Authorization”
76
Plan Limitations Exceeded
4126
B
StepCare
If the stepcare indicator on the customer and group tables is
equal to ‘Y’
AND
The drug is not covered by the Plan or by a PA
AND
The reject code on the StepCare record is “76”
AND
The number of agents taken is less than the number of
agents required
OR
The amount of time the drugs were taken was less than the
therapy span required.
OR
If the number of agents required is greater than the number
of drugs that were each taken for the correct therapy span
Page: 106
77
Discontinued Product/Service ID
Number
4173
B
Discontinued NDC number - HCFA
D
D
D
D
The Claim Date Of Service is greater than the HCFA Drug
Termination Date on the Drug Table.
78
Cost Exceeds Maximum
4174
B
The allowed ingredient charge on a non-compound claim is
greater than $99,999.99
D
D
D
D
78
Cost Exceeds Maximum
4175
B
The Claim total Reimbursement Amount is Greater than the
Group Maximum Compound Drug Amount.
D
D
D
D
78
Cost Exceeds Maximum
4176
B
This edit is posted if the submitted sales tax for providers
located in New Mexico, Louisiana, or Illinois exceeds 20%.
If the submitted sales tax and the total claim charge is equal,
the edit will not be posted.
This edit will also zero out the submitted sales tax if the
provider is from any state other than the three listed above.
These states do not charge sales tax on prescriptions.
D
D
D
D
79
Refill Too Soon
4063
B
FILLED AFTER-EXCEEDS 15 DAYS EARLY OVER 180
PERIOD-PA REQUIRED. CALL ACS AT 866-556-9320VALID REFILL TOO SOON CRITERIA:DOSAGE
CHANGE OR LOST RX 1 TIME PER YEAR
B
B
B
B
79
Refill Too Soon
4177
B
In Process Member Number equals History Member
Number
AND
The history claim’s participant ID equals In Process claim’s
Participant ID
AND
The history claim’s status code equals “to be paid” or “paid”
AND
The history claim’s transaction type code equals “Original”
or “Debit of Adjustment”
AND
The history claim’s document type code equals
“Adjustment” or “Fee for Service (FFS)”
AND
The history claim’s TCN is not equal to In Process claim’s
replaced TCN
AND NOT
((In Process Prescription Denial Override equals (“Vacation
Supply” or “Lost Prescription” or “Therapy Change” or
“Starter Dose” or “Medically Necessary”))
OR
(In Process Prior Authorization Type Indicator equals
“Medical Certify”)
OR
(Medical Profile Override Indicator equals (2 or 3)))
AND
Total Days Supplied greater than Days Elapsed
AND
The Custom Record’s Refill Exempt Indicator is not equal to
“Y”.
B
B
B
B
8C
8E
M/I Facility ID
M/I DUR/PPS Level Of Effort
4927
4928
B
B
M/I Facility ID
M/I DUR/PPS Level Of Effort
B
B
B
B
B
B
B
B
8E
M/I DUR/PPS Level Of Effort
4178
B
A DUR/PPS segment is present and the DUR/PPS Level Of
Effort does not match one of the valid values specified for
the field
B
B
B
B
Page: 107
81
Claim Too Old
4735
OH
AGED SUSPENDED BILL
B
B
B
B
81
Claim Too Old
4577
MS
Client Specific Edit (MS): Timely Filing Date is less than
the First Date of Service
B
B
B
B
81
Claim Too Old
4184
B
If claim is older than the filing limit established on the group
file; then the error is posted.
D
D
D
D
81
Claim Too Old
4180
C
The Claim is not an Adjustment via POS
AND
The claim Other Insurance Indicator is Secondary Insurance
Claim (2 -3 -4)
AND
The claim COB PayerId Date is numeric and greater than
zeros
AND
The claim Date Of Adjudication (Current Date) is greater
than the claim COB Payerid Date plus 90 days and less than
the claim COB Payerid Date plus 549 days.
B
B
B
B
81
Claim Too Old
4181
C
B
B
B
B
81
Claim Too Old
4182
C
The Claim is not an Adjustment via POS
AND
The claim Other Coverage Code is Secondary Insurance
Claim (2 -3 -4)
AND
The claim COB Payerid Date is numeric and greater than
zeros
AND
The claim Date Of Adjudication (Current Date) is greater
than the claim COB Payerid Date plus 548 days.
The Claim is not an Adjustment via POS
AND
The claim Other Insurance Indicator is not Secondary
Insurance Claim (2 -3 -4)
AND
The claim Date Of Adjudication (Current Date) is greater
than the claim First Date Of Service plus 90 days and less
than the claim First Date Of Service plus 366 days.
B
B
B
B
81
Claim Too Old
4183
C
The Claim is not an Adjustment via POS
AND
The claim Other Insurance Indicator is not Secondary
Insurance Claim (2 -3 -4)
AND
The claim Date Of Adjudication (Current Date) is greater
than the claim First Date Of Service plus 365 days.
B
B
B
B
82
Claim is Post Dated
4871
B
Claim post dated
D
D
D
D
82
Claim is Post Dated
4802
B
Date billed after adjudication date
D
D
D
D
82
Claim is Post Dated
4420
B
Batch date less than first date of service
D
D
D
D
Page: 108
83
Duplicate Paid/Captured Claim
4854
B
83
Duplicate Paid/Captured Claim
4186
B
Dup Check: Searches history. If a claim with the same
FDOS and 1st 5 characters of the GCN’s are equal; then dup
check continues. If prior authorization is required; or the
prescribing physician DEA numbers are equal; or the prior
auth med cert code indicates medical certification; or the
denial override is set to medically necessary; then dup check
is ended; otherwise; it checks to see if a custom record exists
with the dup check indicator set to “Y”; if not; if the
provider numbers are equal; error “Exact Duplicate (83)” is
posted; else “Possible Duplicate (83)” is posted. I f all 5
characters of the GCN are equal - checks to see if it is
94200; if so; if the therapeutic classes are different; or the
drug category code = reusable/disposable syringes; or {the
generic product indicator = non-drug item; and the drug
class = over-the-counter and the 1st 9 chars. of the NDC are
equal}; then dup check is terminated. If these conditions are
not met; then the same process as for a 4-character GCN
match continues at the point of determining if a custom
record exists.
Duplicate across providers
The history claim’s participant ID equals In Process claim’s
Participant ID
AND
The history claim’s first date of service (FDOS) equals In
Process claim’s FDOS
AND
The history claim’s member number equals In Process
claim’s member number
AND
The history claim’s Generic Code equals In Process claim’s
Generic Code
AND
The history claim’s status code equals “to be paid” or “paid”
AND
The history claim’s transaction type code equals “Original”
or “Debit of Adjustment”
AND
The history claim’s document type code equals
“Adjustment” or “Fee for Service (FFS)”
AND
The history claim’s TCN is not equal to In Process claim’s
replaced TCN
AND
The custom plan record’s “DUP-CHECK-EXEMPT-IND”
is not equal to “Y.”
AND NOT
(If in process claim is a medical supply claim (Generic
Code equals 94200)
AND
((The history claim’s therapeutic class code spec is not
equal to In Process claim’s therapeutic class code spec)
OR
(The Drug Record’s drug category code is equals “Reuse
Syringe Insulin” (Q) or “Dispose Syringe Insulin” (R))
OR
(In Process claim’s Generic Product Indicator equals NonDrug Item
AND
History Claim’s Generic Product Indicator equals Non-Drug
Item
AND
The Drug Record’s Drug Class equals “Over the counter”
AND
The History claim’s NDC is not equal to In Process NDC )))
Page: 109
D
D
D
D
D
D
D
D
83
Duplicate Paid/Captured Claim
4185
B
Exact Duplicate
The history claim’s Pharmacy Provider equals In Process
claim’s Pharmacy Provider
AND
The history claim’s participant ID equals In Process claim’s
Participant ID
AND
The history claim’s first date of service (FDOS) equals In
Process claim’s FDOS
AND
The history claim’s member number equals In Process
claim’s member number
AND
The history claim’s Generic Code equals In Process claim’s
Generic Code
AND
The history claim’s status code equals “to be paid” or “paid”
AND
The history claim’s transaction type code equals “Original”
or “Debit of Adjustment”
AND
The history claim’s document type code equals
“Adjustment” or “Fee for Service (FFS)”
AND
The history claim’s TCN is not equal to In Process claim’s
replaced TCN
AND
The custom plan record’s “DUP-CHECK-EXEMPT-IND”
is not equal to “Y.”
D
D
D
D
B
B
B
B
D
D
D
D
AND NOT
(If in process claim is a medical supply claim (Generic Code
equals 94200)
AND
((The history claim’s therapeutic class code spec is not
equal to In Process claim’s therapeutic class code spec)
OR
(The Drug Record’s drug category code is equals “Reuse
Syringe Insulin” (Q) or “Dispose Syringe Insulin” (R))
OR
(In Process claim’s Generic Product Indicator equals NonDrug Item
AND
History Claim’s Generic Product Indicator equals Non-Drug
Item
AND
The Drug Record’s Drug Class equals “Over the counter”
AND
The History claim’s NDC is not equal to In Process NDC )))
Affected Invoice Types:
Pharmacy
84
Claim Has Not Been Paid/Captured
4834
B
84
Claim Has Not Been Paid/Captured
4192
B
Claims Edit Exhibit
Claim has not been paid/captured – if matching history
claim was a credit or incumbent or mail-order; the error is
posted to the claim (financial EOB)
The original claim that is attempting to be adjusted/credited
was not found or is a credit.
Page: 110
84
Claim Has Not Been Paid/Captured
4193
B
The original claim that is attempting to be credited is a mail
order claim
D
D
D
D
84
Claim Has Not Been Paid/Captured
4374
B
A credit claim cannot be adjusted. The replacement claim of
an adjustment can be voided or replaced - but the credit
claim of an adjustment can never be voided or replaced.
This edit can post to provider submitted credit requests provider submitted replacement claims - online entered
credit requests - and online entered replacement requests.
D
D
D
D
85
Claim Not Processed
4188
B
Claim not processed – reject code not found on reject
control table or too many reject codes are posted to claim or
related history entries exceeded for claim or participant
D
D
D
D
85
Claim Not Processed
4187
B
The maximum number of entries for the related history table
have been met or exceeded.
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
The Member Number on the claim or adjustment being
processed is currently being updated by another user or
system process. (This situation should rarely occur. Simply
trying to process again normally results in this exception not
occurring again).
Formulary Type Code for the Plan not = ‘N’ (No Formulary)
AND
No Formulary is found on the Drug Formulary Table
B
B
B
B
B
B
B
B
Program: S780C / S780 Add-to-RLTD-Hist
85
Claim Not Processed
4960
B
Set if attempting to roll off old history and WS-010-NOROLL-OFF
85
Claim Not Processed
4363
B
85
Claim Not Processed
4364
B
85
Claim Not Processed
4375
B
85
Claim Not Processed
4379
B
85
Claim Not Processed
4404
B
85
Claim Not Processed
4414
B
The pharmacy’s physical address information could not be
found.
D
D
D
D
85
Claim Not Processed
4415
B
If the loaded exception count is 0.
B
B
B
B
85
Claim Not Processed
4445
B
Claims is system generated
AND
(Transaction Type is Void
OR
Transaction Type is Debit of Adjustment)
AND
Cycle number equal zero
AND
Batch number is less that system generated batch number
D
D
D
D
86
Submit Manual Reversal
4775
B
B
B
B
B
87
Reversal Not Processed
4835
B
D
D
D
D
Program: PDDC8622 / S560 Roll-Off-Hist-Section
This edit will post if the header-level override exception
location code does not have a matching code on the
Reference text location database
This exception can be posted to the claim if a logic error such as a missing replaced TCN number for a credit
transaction - or a credit with a claim status of to-be-denied occurs.
In some instances - it can be used to denote unexpected SQL
codes from DB2 calls - where it might also be used in
conjunction with the DB2 error exit routine - which
terminates claim processing.
Certain logic error situations dictate that the claim header
status be set to suspend at the time of posting this edit.
This exception can be used to suspend the claim if a logic
error - such as a subscript out of bounds - occurs
Reversal not processed - If the matching history claim was
found and was already credited; or was to-be-credited; or the
original claim was denied; then the error is posted.
Page: 111
87
Reversal Not Processed
4836
B
POS Reversal claim > 60 days
B
B
B
B
87
Reversal Not Processed
4837
B
no POS reversal in fin. cycle
B
B
B
B
87
Reversal Not Processed
4189
B
The original claim that is attempting to be adjusted/credited
has already been credited.
D
D
D
D
87
Reversal Not Processed
4190
B
The original claim that is attempting to be adjusted/credited
is in the process of being credited.
D
D
D
D
87
Reversal Not Processed
4191
B
The original claim that is attempting to be adjusted/credited
was denied.
D
D
D
D
87
Reversal Not Processed
4376
B
The adustment reason code entered on the request is missing
or invalid (not numeric or not on valid values table). See the
Data Dictionary for a list of valid values.
D
D
D
D
87
Reversal Not Processed
4439
B
An adjustment request record has targeted a history record
for adjustment - but the history record has been suspended
D
D
D
D
87
Reversal Not Processed
4441
B
An adjustment request record has targeted a history record
for adjustment - but the history record has been voided
D
D
D
D
87
Reversal Not Processed
4443
B
An adjustment request record has targeted a history record
for adjustment - but the keyed replaced number (TCN) on
the adjustment request record that identifies the history
record is equal to zeros.
D
D
D
D
88
DUR Reject Error
4974
B
Error will post when the current refill is filled later than
(Previous fill's date of service + (1.25 * its days supply)).
B
B
B
B
88
DUR Reject Error
4205
B
Accompanied by DUR conflict code: ER Early Refills
required Prior Authorization from Health Care Excel 800457-4518
D
D
D
D
Edit 88 from the DUR Program has been posted and the
conflict code exists on the DUR Filter Record
AND
Generic code or Therapeutic Class Code Specific (From the
history or IP claim, depending on the 88 exception that was
posted) is on the DUR Filter Record
AND
The Adjudication Indicator on the DUR Filter Record is
equal to “Pay”
AND
If the history claim is being processed for DUR
AND
(History Participant Age is less than the Minimum Age on
the DUR Filter Record
OR
History Participant Age is greater than the Max Age on the
DUR Filter Record
OR
History Day Supplied is greater than Days Supplied on the
DUR Filter Record
OR
IP Submitted Quantity / IP Days Supplied is greater than
Max Daily Dose Units on the DUR Filter Record
Page: 112
88
DUR Reject Error
4202
B
Accompanied by DUR conflict code: HD
P
P
P
P
P
P
P
P
History FDOS is greater than IP FDOS OR
After processing through all of history claims)
AND
The Dose Form on the Drug Record from the IP NDC must
equal ‘Each’ or ‘Milliliter’
AND
Calculated Daily Dose must be more than the Maximum
Daily Dose on the Drug Record
88
DUR Reject Error
4194
B
Accompanied by DUR conflict code: TD
The claim dates of service overlap: (NOT (History LDOS is
less than IP FDOS and History FDOS is greater than IP
LDOS)
AND((History Route Code equals IP Route Code
OR (IP Route Code equals (A or B or C or H or L or S or T
or 1 or 2 or 3 or 7)
AND History Route Code equals (A or B or C or H or L or
S or T or 1 or 2 or 3 or 7))
AND History Therapeutic Class Code Specific equals IP
Therapeutic Class Code Specific
AND NOT (History Generic Code equals IP Generic Code
OR History NDC equals IP NDC
OR IP Generic Code equals “01697” AND History Generic
Code equals “02521”
OR History NDC equals IP NDC
OR IP Generic Code equals “01698” AND History Generic
Code equals “02529”)
OR History NDC equals IP NDC
OR IP Generic Code equals “92989” AND History Generic
Code equals “08453”
OR IP Generic Code equals “04348” AND History Generic
Code equals “08450”
OR IP Generic Code equals “92999” AND History Generic
Code equals “08452”)
If the previous “NOT” condition occurs, then post the edit if
one of the following conditions occurs:
IP FDOS is greater than History FDOS
AND IP Days Supplied is greater than DUR Grace Period
AND IP FDOS is greater than (History FDOS plus History
Days Supplied minus DUR Grace Period)
OR NOT (IP FDOS is greater than History FDOS
AND IP Days Supplied is greater than DUR Grace Period)
AND History Days Supplied is greater than DUR Grace
Period AND History FDOS is less than (IP FDOS plus IP
Days Supplied minus DUR Grace Period)
Page: 113
88
DUR Reject Error
4197
B
Client Specific (IN) Accompanied by DUR conflict code:
DD Drug/Drug Interactions with a Severity Level of 1;
require Prior Authorization from Health Care Excel 800457-4518
P
P
P
P
B
B
B
B
The claim dates of service overlap
AND The History NDC found on Drug Record
AND NOT ((History Generic Code equals IP Generic Code
OR History NDC equals IP NDC
OR IP Generic Code equals “01697” AND History Generic
Code equals “02521”)
OR IP Generic Code equals “01698” AND History Generic
Code equals “02529”
OR IP Generic Code equals “92989” AND History Generic
Code equals “08453”
OR IP Generic Code equals “04348” AND History Generic
Code equals “08450”
OR IP Generic Code equals “92999” AND History Generic
Code equals “08452”)
AND The number of drug interactions on each drug record
must be greater than zero
AND The sum of any two interaction codes (1 from the
current record and 1 from the history record) must be 32000
AND The History Generic Sequence Number is equal to any
Override Add Generic Sequence Number listed on the Drug
Interaction Override Record.
Note: the edit is overridden and not posted if any Drug
Interaction Code on the History Drug Record is equal to any
Drug Interaction Code on the Drug Interaction Override
Record
AND The severity level equals 1
AND The history pharmacy provider is not equal to the IP
pharmacy provider, then post reject 75.
Accompanied by DUR conflict code for DC (Disease
precaution) sent in DUR segment
88
DUR Reject Error
4839
B
88
DUR Reject Error
4199
B
Age Exception
(History FDOS is greater than IP FDOS
OR
After processing through all of history claims)
AND
The IP participant is older than the maximum age on the
drug record.
AND
The IP participant is younger than the minimum age on the
Drug Record
AND
Default values of all zeros or all nines on the Drug Record
will prevent an age exception from posting
P
P
P
P
88
DUR Reject Error
4195
B
Prenatal Exception
(History FDOS is greater than IP FDOS
OR
After processing through all of history claims)
AND
IP Participant Sex Code equals “Female”
AND
IP Therapeutic Class Code Specific equals “Pre-Natal
Vitamins”
AND
IP Participant Age is greater than 11 and IP Participant Age
is less than 60
P
P
P
P
Page: 114
88
DUR Reject Error
4196
B
Excessive Duration Exception
This edit is posted after accumulating the Total Number of
Days Supplied for all History claims and adding the IP Days
Supply to the total when:
The IP Participant is younger than 13
AND
The pediatric duration of therapy maximum number of days
on the Drug Record using the IP NDC is less than the Total
Number of Days Supplied
OR
The IP Participant is older than 60
OR
The Geriatric Duration of Therapy Maximum Number of
Days on the Drug Record using the IP NDC is less than the
Total Number of Days Supplied
AND
The IP Participant is any other age
AND
The Adult Duration of Therapy Maximum Number of Days
on the Drug Record Using the IP NDC is less than the Total
Number of Days Supplied
P
P
P
P
88
DUR Reject Error
4198
B
Ingredient Duplication
First date of service on the current claim must be after the
first date of service on the history claim.
AND
First date of service on the current claim must be before the
date calculated to be the history claim’s first date of service
plus days supplied less the grace period.
AND
The claim dates of service overlap
AND
(History Route Code equals IP Route Code
OR
(IP Route Code equals (A or B or C or H or L or S or T or 1
or 2 or 3 or 7)
AND
History Rout Code equals (A or B or C or H or L or S or T
or 1 or 2 or 3 or 7))
AND
The History NDC found on Drug Record
AND NOT
(History Generic Code equals IP Generic Code
OR
History NDC equals IP NDC
OR
IP Generic Code equals “01697” AND History Generic
Code equals “02521”
OR
History NDC equals IP NDC
OR
IP Generic Code equals “01698” AND History Generic
Code equals “02529”
OR
History NDC equals IP NDC
OR
IP Generic Code equals “92989” AND History Generic
Code equals “08453”
OR
IP Generic Code equals “04348” AND History Generic
Code equals “08450”
OR
IP Generic Code equals “92999” AND History Generic
Code equals “08452”)
AND
The route codes must be the same or they must both be
systemic route
(History Route Code equals IP Route Code
OR
(IP Route Code equals (A or B or C or H or L or S or T or 1
or 2 or 3 or 7)
AND
P
P
P
P
Page: 115
History Rout Code equals (A or B or C or H or L or S or T
or 1 or 2 or 3 or 7)))
AND
Specific therapeutic class must be the same. Any
Therapeutic Class Code Specific on the Drug Record from
the IP NDC is equal to any Therapeutic Class Code specific
on the Drug Record from the History NDC.
88
DUR Reject Error
4200
B
Gender Exception
(History FDOS is greater than IP FDOS
OR
After processing through all of history claims)
AND
IP Participant’s sex code (‘M’ or ‘F’) must match the sex
code on the Drug Record
P
P
P
P
88
DUR Reject Error
4201
B
Low Dose Exception
(History FDOS is greater than IP FDOS
OR
After processing through all of history claims)
AND
The Dose Form on the Drug Record from the IP NDC must
equal ‘each’ or ‘milliliter’
AND
IP Participant must be at least 18 years old and not older
than 60 years
AND
Calculated Daily Dose must be less than the Minimum Daily
Dose on the Drug Record
P
P
P
P
Page: 116
88
DUR Reject Error
4203
B
Allergy Exception
(History FDOS is greater than IP FDOS
OR
After processing through all of history claims)
AND
The IP Participant must have a prior authorization
AND
The condition type on the prior authorization table must be
set to ‘AC‘
AND
One of the Condition Range fields on the prior authorization
table must match one of the three Allergy Codes on the Drug
Record for the IP NDC.
B
B
B
B
88
DUR Reject Error
4204
B
– Pregnancy Exception
(History FDOS is greater than IP FDOS
OR
After processing through all of history claims)
AND
Pregnancy precaution codes must be present on the Drug
Record for the IP NDC
AND
The IP Participant may have a prior authorization table with
pregnancy flagged on it
AND
The pregnancy indicator on the prior authorization table
must be set to ‘Y’
AND
The pregnancy end date must be greater than or equal to the
first date of service on the current claim
AND
(The severity level of the pregnancy precaution master file
for the pregnancy precaution code on the Drug Record for
the IP NDC must be a ‘D’ - ‘X’ - or ‘1’)
P
P
P
P
88
DUR Reject Error
4431
B
DUR Reject Deny
Edit 88 from the DUR Program has been posted and the
conflict code exists on the DUR Filter Record
AND
Generic code or Therapeutic Class Code Specific (From the
history or IP claim - depending on the 88 exception that was
posted) is on the DUR Filter Record
AND
The Adjudication Indicator on the DUR Filter Record is
equal to “Deny”
AND
If the history claim is being processed for DUR
AND
(History Participant Age is less than the Minimum Age on
the DUR Filter Record
OR
History Participant Age is greater than the Max Age on the
DUR Filter Record
OR
History Day Supplied is greater than Days Supplied on the
DUR Filter Record
OR
IP Submitted Quantity / IP Days Supplied is greater than
Max Daily Dose Units on the DUR Filter Record)
B
B
B
B
88
DUR Reject Error
4432
Claim failed a Pro-DUR alert
B
B
B
B
89
Rejected Claim Fees Paid
4776
Rejected Claim Fees Paid
B
B
B
B
Page: 117
90
91
Host Hung Up
Host Response Error
4777
4778
B
B
Host Hung Up
Host Response Error
B
B
B
B
B
B
B
B
92
System Unavailable/Host Unavailable
4779
B
System Unavailable/Host Unavailable
D
D
D
D
93
Planned Unavailable
4780
B
Planned Unavailable
B
B
B
B
94
95
96
Invalid Message
Time Out
Scheduled Downtime
4781
4782
4783
B
B
B
Invalid Message
Time Out
Scheduled Downtime
B
D
D
B
D
D
B
D
D
B
D
D
97
98
Payer Unavailable
Connection to Payer is Down
4784
4785
B
B
Payer Unavailable
Connection to Payer is Down
B
B
B
B
B
B
B
B
99
Host Processing Error
4786
B
Host Processing Error
B
B
B
B
AA
Patient Spenddown Not Met
4929
B
Patient Spenddown Not Met
B
B
B
B
AB
Date Written Is After Date Filled
4206
B
The Date Prescription Written is greater than the Date Of
Service.
D
D
D
D
AC
Product Not Covered NonParticipating Manufacturer
4683
B
THE PRODUCT/SERVICE ID QUALIFIER INDICATES
THAT THE PRODUCT/SERVICE ID FIELD CONTAINS
AN NDC AND DRUG REBATE DATA IS FOUND FOR
THE CLAIM’S NDC AND DATE OF SERVICE ON THE
DRUG REBATE TABLE AND THE DRUG REBATE
CODE FOR THE NDC = NO REBATE (‘0’) AND THE
NDC IS NOT A REBATE EXEMPT NDC
D
D
D
D
**5.1 edit only - see 4684 for equivalent 3.2 edit**
AC
Product Not Covered NonParticipating Manufacturer
4207
B
The Product/Service ID Qualifier indicates that the
Product/Service ID field contains a NDC
AND
((Drug Rebate data is found for the Claim’s NDC and Date
of Service on the Drug Rebate Table
AND
The Drug Rebate Code for the NDC = “No Rebate” (‘0’)
AND
The NDC is not a “Rebate Exempt” NDC (hard-coded
table – Massachusetts specific))
OR
(Drug Rebate data is not found for the Claim’s NDC and
Date of Service on the Drug Rebate Table))
AND
The Drug’s Class Code not = “OTC” (‘O’)
AND
The Drug’s Therapeutic Class not = “Vaccine” (‘W7B’ thru
‘W7Q’)
AND
The Drug’s GCN not = “Non-Drug Item” (‘94200’)
AND
The Claim’s Drug Compound Code not = “Compound” (‘2’)
B
B
B
B
AD
Billing Provider Not Eligible To Bill
This Claim Type
4930
B
Billing Provider Not Eligible To Bill This Claim Type
B
B
B
B
Page: 118
AE
QMB (Qualified Medicare
Beneficiary)-Bill Medicare
4931
B
QMB (Qualified Medicare Beneficiary)-Bill Medicare
B
B
B
B
AF
Patient Enrolled Under Managed
Care
4208
B
Patient Enrolled Under Managed Care
B
B
B
B
AG
Days Supply Limitation For
Product/Service
4209
B
D
D
D
D
AH
Unit Dose Packaging Only Payable
For Nursing Home Recipients
4932
B
Exceeds Custom Days Supplied Limits – 5.1 Only
The Custom Plan Days Supplied Accum equals “A” (All
Doses)
AND
The Claim Submitted Days greater than Custom Plan Days
Supplied
AND
The Custom Plan Days Supplied Status equals “D” (Deny)
AND
The Prior authorization indicator is not equal to (“Prior
Authorized” or “Covered”).
Unit Dose Packaging Only Payable For Nursing Home
Recipients
D
D
D
D
AJ
Generic Drug Required
4210
B
Generic Drug Required
B
B
B
B
AK
M/I Software Vendor/Certification ID
4211
B
The Software Vendor/Certification ID is missing (spaces).
B
B
B
B
AM
M/I Segment Identification
4212
B
D
D
D
D
A9
M/I Transaction Count
4213
B
The segment is a mandatory segment and the segment
Identifier is missing (spaces) or it does not match one of the
valid values specified for the field
The Transaction Count is missing (spaces) or it does not
match one of the valid values specified for the field.
D
D
D
D
BE
M/I Professional Service Fee
Submitted
4214
B
The product/service Id qualifier is not NDC and the
professional service fee submitted is missing (zeros).
D
D
D
D
B2
M/I Service Provider ID Qualifier
4215
B
The Service Provider ID Qualifier is missing (spaces) or it
does not match one of the valid values specified for the
field.
D
D
D
D
CA
M/I Patient's First Name
4787
B
B
B
B
B
CB
M/I Patient's Last Name
4789
B
Client Specific (IN) First name not edited separately. If the
first name is missing on the claim; system returns COB
0238. This edit has been mapped to CB; M/I Patient’s Last
name.
Member name missing
B
B
B
B
CC
M/I CARDHOLDER FIRST NAME
4216
M/I CARDHOLDER FIRST NAME
B
B
B
B
CD
M/I CARDHOLDER LAST NAME
4217
M/I CARDHOLDER LAST NAME
B
B
B
B
CE
CF
HOME PLAN
EMPLOYER NAME
4890
4891
HOME PLAN
EMPLOYER NAME
B
B
B
B
B
B
B
B
CG
EMPLOYER STREET ADDRESS
4892
EMPLOYER STREET ADDRESS
B
B
B
B
CH
EMPLOYER CITY ADDRESS
4893
EMPLOYER CITY ADDRESS
B
B
B
B
CI
EMPLOYER STATE/PROVINCE
ADDRESS
4894
EMPLOYER STATE/PROVINCE ADDRESS
B
B
B
B
Page: 119
CJ
EMPLOYER ZIP/POSTAL ZONE
4895
EMPLOYER ZIP/POSTAL ZONE
B
B
B
B
CK
EMPLOYER PHONE NUMBER
4896
EMPLOYER PHONE NUMBER
B
B
B
B
CL
EMPLOYER CONTACT NAME
4897
EMPLOYER CONTACT NAME
B
B
B
B
CM
PATIENT STREET ADDRESS
4898
PATIENT STREET ADDRESS
B
B
B
B
CN
PATIENT CITY ADDRESS
4912
PATIENT CITY ADDRESS
B
B
B
B
CO
PATIENT STATE/PROVINCE
ADDRESS
4900
PATIENT STATE/PROVINCE ADDRESS
B
B
B
B
CP
PATIENT ZIP / POSTAL ZONE
4901
PATIENT ZIP / POSTAL ZONE
B
B
B
B
CQ
PATIENT PHONE NUMBER
4902
PATIENT PHONE NUMBER
B
B
B
B
CR
CW
CX
CARRIER ID
M/I Alternate ID
M/I Patient ID Qualifier
4903
4218
4219
B
B
B
CARRIER ID
The Alternate ID is missing (spaces).
The Patient ID Qualifier is missing (spaces) or it does not
match one of the valid values specified for the field.
D
B
B
D
B
B
D
B
B
D
B
B
CY
CZ
DC
M/I Patient ID
M/I Employer ID
Dispensing Fee Submitted
4220
4221
4222
B
B
B
The Patient ID is missing (spaces).
The Employer ID is missing (spaces).
The Dispensing Fee Submitted is missing (zeros).
B
B
B
B
B
B
B
B
B
B
B
B
DN
M/I Basis Of Cost Determination
4223
B
B
B
B
B
DQ
M/I Usual & Customary Charge
4790
B
The Basis Of Cost Determination is missing (spaces) or it
does not match one of the valid values specified for the
field.
M/I Usual & Customary Charge
D
D
D
D
DQ
M/I Usual & Customary Charge
4872
B
Edit will check for both MISSING and INVALID
conditions
B
B
B
B
DQ
M/I Usual & Customary Charge
4844
B
Claim priced at zero
B
B
B
B
DQ
M/I Usual & Customary Charge
4917
B
M/I Usual & Customary Charge
B
B
B
B
DR
M/I DOCTORS LAST NAME
4225
B
M/I DOCTORS LAST NAME
B
B
B
B
DT
M/I UNIT DOSE INDICATOR
4568
B / FL
B
B
B
B
DT
M/I UNIT DOSE INDICATOR
4226
B
If the unit dose indicator on the drug file is set to
manufacturer packaging and a unit dose indicator is
submitted on the claim; then the error posts.
The Unit Dose Indicator is missing or it does not match one
of the valid values specified for the field.
B
B
B
B
DU
M/I GROSS AMOUNT DUE
4227
B
Client Specific (NM) The Gross Amount Due is missing
(zeros).
B
B
B
B
DV
M/I Other Payer Amount Paid
4855
B
If the other insurance indicator = 3 or 4; and the primary
payer date not numeric or not > zeroes or the other amount
is not equal to zeroes; then the error is posted.
D
D
D
D
Page: 120
DV
M/I Other Payer Amount Paid
4229
DV
M/I Other Payer Amount Paid
4959
DV
M/I Other Payer Amount Paid
4231
DX
M/I Patient Paid Amount Submitted
DY
B
Missing Deny Date
(If the Other Coverage Code is “3” (other coverage exists This claim not covered) OR
“4” (other coverage exists - Payment not collected))
AND
The payerid date is not numeric
OR
The payerid date is not greater than zeros
OR
The payerid paid amount is greater than zeros.
D
D
D
D
Edit needed to create additinoal reports for PA Subsystem
(CSR 14).
B
B
B
B
C
If the Other Coverage Code is 2 (Other Coverage Exists –
Payment Collected)
AND
The payerid paid amount is missing (zero).
OR
If the Other Coverage Code is ‘0’ (Not specified) OR ‘1’
(No other coverage identified) ‘3’ (Other coverage exists this clam not covered) OR ‘4’ (Other coverage exists payment not collected)
AND
The payerid paid amount is greater than zero.
D
D
D
D
4233
B
The Patient Paid Amount Submitted not numeric
OR
Patient Paid Amount Submitted is numeric and is greater
than $0.00 and less than $2.00
B
B
B
B
INJURY DATE
4234
B
The claim is a workers compensation claim and the Date Of
Injury is missing (zeros).
B
B
B
B
DZ
CLAIM / REFERENCE ID
4235
B
The claim is a workers compensation claim and the
Claim/Reference ID is missing (spaces).
B
B
B
B
EA
M/I Originally Prescribed
Product/Service Code
4933
B
M/I Originally Prescribed Product/Service Code
D
D
D
D
EB
M/I Originally Prescribed Quantity
4934
B
M/I Originally Prescribed Quantity
D
D
D
D
EC
Compound Ing Component Count
4236
B
A compound segment is present and the Compound
Ingredient Component Count is zeros.
D
D
D
D
ED
Compound Ing Quantity
4237
B
The Compound Ingredient Quantity is missing (zeros).
D
D
D
D
EE
M/I Compound Ingredient Drug Cost
4238
B
The Ingredient Drug Cost is missing (zeros).
B
B
B
B
EF
M/I Compound Dosage Form
Description Code
4935
B
D
D
D
D
EG
M/I Compound Dispensing Unit
Form Indicator
4936
B
The Compound Dosage Form Description
Code does not match one of the NCPDP
Valid Values
The Compound Dosage Form Description
Code does not match values of 1-18.
D
D
D
D
EH
Compound Route of Administration
4937
B
The Compound Dispensing Unit Form
Indicator does not match one of the NCPDP
Valid Values
D
D
D
D
EJ
M/I Originally Prescribed
Product/Service Id Qualifier
4938
B
M/I Originally Prescribed Product/Service Id Qualifier
D
D
D
D
Page: 121
EK
Scheduled Prescription ID Number
4939
B
Scheduled Prescription ID Number
B
B
B
B
EM
M/I Prescription/Service Reference
Number Qualifier
4239
B
The Prescription/Service Reference Number Qualifier does
not match one of the valid values specified for the field.
D
D
D
D
EN
M/I Associated Prescription/Service
Reference Number
4240
B
The Associated Prescription/Service Reference Number is
missing (zeros) on a reversal for a completion transaction.
D
D
D
D
D
D
D
D
Used for Partial Fills
When dispensing a partial fill, the Dispensing Status code is
submitted to indicate the transaction is for an “initial” partial
fill. When the “outstanding” quantity is dispensed, the
transaction 1) indicates the Dispensing Status code is for the
“completion” of the partial fill; 2) identifies the Associated
Prescription/Service Reference Number; and 3) identifies
the Associated Prescription/Service Date.
EP
M/I Associated Prescription/Service
Date
4241
B
The Associated Prescription/Service Date is missing (zeros)
on the reversal of a completion transaction
Used for Partial Fills
ER
M/I Procedure Modifier Code
4242
B
The Procedure Modifier Code is missing (spaces).
B
B
B
B
ET
M/I Quantity Prescribed
4243
B
The Quantity Prescribed is missing (zeros).
D
D
D
D
EU
M/I Prior Authorization Type Code
4244
B
The Prior Authorization Type Code does not match one of
the valid values specified for the field (see below)
OR
The Prior Authorization type code is missing and the Prior
Authorization number is present.
D
D
D
D
Edits 30 (m/i pa/mc code and number) and 57 (pa/mc#) are
not supported in 5.1. The corresponding 5.1 edits are EU
(m/i pa type code - 1 byte) and EV (m/i pa number
submitted - 11 bytes )
valid values
Ø=Not Specified1=Prior Authorization
2=Medical Certification
3=EPSDT (Early Periodic Screening Diagnosis Treatment)
4=Exemption from Copay
5=Exemption from RX
6=Family Plan. Indic.
7=AFDC (Aid to Families with Dependent Children)
8=Payer Defined Exemption
EU
M/I Prior Authorization Type Code
4584
B
IN Medicaid: valid values = 0 or 6 - family planning
(pregnancy indicator now uses field 2C)
B
B
B
B
EV
M/I Prior Authorization Number
Submitted
4245
B
The Prior Authorization Number Submitted is missing and
the prior authorization type code equals ‘PA’.
B
B
B
B
EW
M/I Intermediary Authorization Type
ID
4940
B
M/I Intermediary Authorization Type ID
B
B
B
B
EX
M/I Intermediary Authorization ID
4941
B
M/I Intermediary Authorization ID
B
B
B
B
Page: 122
EY
M/I Provider ID Qualifier
4246
B
The Pharmacy Provider ID Qualifier is missing or it does
not match one of the valid values specified for the field
OR
The Pharmacy Provider Id Qualifier is missing and the
Pharmacy Provider Id is present.
B
B
B
B
The Prescriber ID Qualifier is missing and a prescriber id
exists
OR
or it does not match one of the valid values specified for the
field
The Product/Service ID Qualifier is missing or it does not
match one of the valid values specified for the field.
D
D
D
D
D
D
D
D
This field is used in the Pharmacy Provider Segment which
we aren't using (unless there's a bus. case for it). The
pharmacy id is contained in the Transaction Header
Segment, field 201-B1 qualified by 202-B2 (Ø7=NCPDP
Provider ID). So, the edit can probably be set to Ignore.
EZ
M/I Prescriber ID Qualifier
4247
B
E1
M/I Product/Service ID Qualifier
4248
B
E3
M/I Incentive Amount Submitted
4249
B
The Incentive Amount Submitted is present but is not
numeric.
B
B
B
B
E4
M/I Reason for Service Code
4250
B
The Reason For Service Code(DUR Conflict) is present and
does not match one of the valid values specified for the field
D
D
D
D
E4
M/I Reason for Service Code
4251
B
A Reason For Service Code does not match one of the valid
values specified for the field.
B
B
B
B
E4
M/I Reason for Service Code
4430
B
DUR Override Conflict
The reason for service is missing and the DUR intervene
code or DUR outcome code is present.
D
D
D
D
E5
M/I Professional Service Code
4252
B
D
D
D
D
E5
M/I Professional Service Code
4253
B
B
B
B
B
E6
M/I Result of Service Code
4254
B
D
D
D
D
E6
M/I Result of Service Code
4255
B
The Professional Service Code(DUR Intervene Code) is
present and does not match one of the valid values specified
for the field
OR
The professional service code is missing and the DUR
conflict code or DUR outcome code is present.
Client Specific (MA) The Professional Service Code is
missing (spaces) or it does not match one of the valid values
specified for the field.
Client Specific (IN) The Result of Service Code(DUR
Outcome) is present and does not match one of the valid
values specified for the field
OR
The result of service code is missing and the DUR intervene
code or DUR conflict code is present.
Client Specific (MA) The Result Of Service Code is missing
(spaces) or it does not match one of the valid values
specified for the field.
B
B
B
B
D
D
D
D
E7
M/I Quantity Dispensed
4873
B
DUR Outcome Code was rename to Result Of Service Code
in Version 5.1.
Edit will check for both MISSING and INVALID conditions
E7
M/I Quantity Dispensed
4847
C
quant > estimd price by 800%
B
B
B
B
E7
M/I Quantity Dispensed
4256
X
The Quantity Dispensed is missing (zeros).
D
D
D
D
Page: 123
E8
M/I Other Payer Date
4257
B
If the carrier is found on the carrier table
AND
The Other Payerid Date is greater than 0001-01-01
AND
The Other Payerid Date is not greater than the batch Julian
date portion of the transaction control number (TCN).
D
D
D
D
Primary Deny Date has been renamed Other Payer Date.
E8
M/I Other Payer Date
4258
B
Invalid Other Payerid Date – 5.1 Only
If the other payerid date is greater than 0001-01-01
AND
The other payerid date is greater than the batch Julian date
portion of the transaction control number (TCN).
D
D
D
D
E8
M/I Other Payer Date
4259
B
Other payer date – If other insurance indicator = 0 or 1 and
primary payer deny date is numeric and > zero; or other
amount is not equal to zero; error is posted.
D
D
D
D
E8
M/I Other Payer Date
4261
B
Invalid Other Insurance 2 – 5.1 Only
If the Other Coverage Code is “2” (other coverage exists Payment collected)
AND
The Other Payer Amount Paid equals zeros
OR
The Other Payerid Date = 0001-01-01
D
D
D
D
E8
M/I Other Payer Date
4261
B
Invalid Other Insurance 2 – 5.1 Only
If the Other Coverage Code is “2” (other coverage exists Payment collected)
AND
The Other Payer Amount Paid equals zeros
OR
The Other Payerid Date = 0001-01-01
D
D
D
D
E9
Provider Id
4263
B
The pharmacy provider id is missing and the pharmacy
provider id qualifier is present.
B
B
B
B
FO
GE
M/I Plan ID
M/I Percentage Sales Tax Amount
Submitted
4264
4682
B
B
The Plan ID is missing (spaces).
Percentage Sales Tax Amount Submitted is equal to or
greater than U&C, silk ticket 988
B
B
B
B
B
B
B
B
GE
M/I Percentage Sales Tax Amount
Submitted
4265
B
The Percentage Sales Tax Amount Submitted is missing
(zeros)
AND
The flat tax amount is missing or zeroes.
B
B
B
B
HA
M/I Flat Sales Tax Amount
Submitted
4681
B
submitted sales tax is equal to or greater than U&C, silk
ticket 988
B
B
B
B
HA
M/I Flat Sales Tax Amount
Submitted
4266
B
The Flat Sales Tax Amount Submitted is missing (zeros)
AND
The percentage sales tax amount is missing or zeroes.
B
B
B
B
HB
M/I Other Payer Amount Paid Count
4267
B
A COB segment is present and the Other Payer Amount
Paid Count is missing (zeros).
D
D
D
D
HB
M/I Other Payer Amount Paid Count
4268
B
The Other Payer Amount Paid Count does not match the
number of Other Payer Amount Paid fields received on a
COB/Other Payments segment.
D
D
D
D
HC
M/I Other Payer Amount Paid
Qualifier
4269
B
The Other Payer Amount Paid Qualifier is missing (spaces)
and the Other Payer Amount Paid is greater than zeros.
D
D
D
D
Page: 124
HC
M/I Other Payer Amount Paid
Qualifier
4270
B
The Other Payer Amount Paid Qualifier does not match one
of the valid values specified for the field
D
D
D
D
HD
M/I Dispensing Status
4271
B
D
D
D
D
HD
M/I Dispensing Status
4272
B
If the Dispensing Status is missing (spaces)
AND
The Quantity Intended To Be Dispensed is greater than
zeros
OR
The Days Supply Intended To Be Dispensed is greater than
zeros.
The Dispensing Status does not match one of the valid
values specified for the field.
D
D
D
D
HD
M/I Dispensing Status
4416
B
Compound Code is equal to ‘2’ and the Dispensing Status is
greater than spaces.
D
D
D
D
HE
M/I Percentage Sales Tax Rate
Submitted
4273
B
The Percentage Sales Tax Rate Submitted is missing (zeros).
B
B
B
B
HF
M/I Quantity Intended To Be
Dispensed
4274
B
The Quantity Intended To Be Dispensed is missing (zeros)
and the Dispensing Status indicates a partial fill (‘P’) or ‘C’.
D
D
D
D
HF
M/I Quantity Intended To Be
Dispensed
4275
B
The Quantity Intended To Be Dispensed is greater than
zeros but the Dispensing Status does not indicate a partial
fill (‘P’).
D
D
D
D
HG
M/I Days Supply Intended To Be
Dispensed
4276
B
The Days Supply Intended To Be Dispensed is missing
(zeros) and the Dispensing Status indicates a partial fill
(‘P’).
D
D
D
D
HG
M/I Days Supply Intended To Be
Dispensed
4277
B
The Days Supply Intended To Be Dispensed is greater than
zeros but the Dispensing Status does not indicate a partial
fill (‘P’).
D
D
D
D
H1
M/I Measurement Time
4278
B
The Measurement Time is missing (zeros).
B
B
B
B
H2
M/I Measurement Dimension
4279
B
The Measurement Dimension is missing (spaces) or it does
not match one of the valid values specified for the field.
B
B
B
B
H3
M/I Measurement Unit
4280
B
The Measurement Unit is missing (spaces) or it does not
match one of the valid values specified for the field.
B
B
B
B
H4
M/I Measurement Value
4281
B
The Measurement Value is missing (spaces).
B
B
B
B
H5
M/I Primary Care Provider Location
Code
4282
B
The Primary Care Provider Location Code is missing
(spaces) or it does not match one of the valid values
specified for the field.
B
B
B
B
H6
M/I DUR Co-Agent ID
4283
B
The DUR Co-Agent ID is missing (spaces).
B
B
B
B
H7
M/I Other Amount Claimed
Submitted Count
4284
B & IN
The Other Amount Claimed Submitted Count is missing
(zeros) and the other amount claimed submitted qualifier or
amount is present.
B
B
B
B
B
B
B
B
B
B
B
B
H8
M/I Other Amount Claimed
Submitted Qualifier
4285
B & IN
Indiana Only: If Other Coverage Code = 8 (billing for
copay), then field H7 must = 1
The Other Amount Claimed Submitted Qualifier is missing
(spaces) or it does not match one of the valid values
specified for the field and the other amount claimed
submitted amount is greater than zero.
Indiana Only: If Other Coverage Code = 8 (billing for
copay), then field H8 must = 99
H9
M/I Other Amount Claimed
Submitted
4286
B & IN
The Other Amount Claimed Submitted is missing (zeros)
and the other amount claimed submitted qualifier is present
Indiana Only: If Other Coverage Code = 8 (billing for
copay), then field H9 must = Gross Amt (field id: DU)
Page: 125
JE
M/I Percentage Sales Tax Basis
Submitted
4287
B
The Percentage Sales Tax Basis Submitted is missing
(spaces) or it does not match one of the valid values
specified for the field.
B
B
B
B
J9
M/I DUR Co-Agent ID Qualifier
4288
B
The DUR Co-Agent ID Qualifier is missing (spaces) or it
does not match one of the valid values specified for the
field.
B
B
B
B
KE
M1
M/I Coupon Type
Patient Not Covered in this Aid
Category
4942
4856
B
B
M/I Coupon Type
Patient Not Covered in this Aid Category
B
B
B
B
B
B
B
B
M1
Patient Not Covered in this Aid
Category
4289
C
Aid Category Message Plans
B
B
B
B
C
If the “70 - Claim First Date Of Service Less Than Date of
Injury” exception code (4111) was posted and the claim Plan
ID equals one of the Aid Category Message Plans specified
below:
001, 002, 102, 106, 109, 110, 111, 119, 202, 206, 209, 210,
211, 219
Category Of Eligibility
B
B
B
B
If the “70” reject code was posted and the claim Plan ID
equals one of the Aid Category Message Plans specified
below:
001, 002, 102, 106, 109, 110, 111, 119, 202, 206, 209, 210,
211, 219
If Prior Authorization matching the claim is found
And
The Plan Id = ‘001’ or ‘002’
B
B
B
B
B
B
B
B
M1
Patient Not Covered in this Aid
Category
4290
The claim Category of Eligibility (COE) is equal to one of
the values specified below:
19, 22, 23, 24, 25, 35, 63, 70, 72, 73, 74, 75, 76, 77, 78, 88,
89, 96, 97
or the Plan is a No COA Plan = ‘001’ or ‘002’.
M1
Patient Not Covered in this Aid
Category
4291
C
M1
Patient Not Covered in this Aid
Category
4428
C
M2
Member Locked into Specific
Provider
4987
B
Member locked to specific DR
B
B
B
B
M2
Member Locked into Specific
Provider
4857
B
Member Locked into Specific Provider
D
D
D
D
M2
Member Locked into Specific
Provider
4293
B
D
D
D
D
M3
HOST PA/MC ERROR
4908
B
Participant/Provider Lockin Mismatch
The claim First Date Of Service fell within the date range of
one of the providers in the lockin table but the claim
Provider Number is not equal to the provider number in the
lockin table.
HOST PA/MC ERROR
B
B
B
B
Page: 126
M4
Maximum number of refills has been
reached
4294
B
Prescription Number Time Limit
If the drug is a schedule II drug and refills have been
authorized.
OR
If the drug is a schedule 0, or V, or VI drug
AND
The number of refills authorized is greater than 11
OR
The days supplied plus the refills would last for more than
366 days
OR
It has been more than 366 days since the prescription was
written.
OR
If the drug is a schedule III, or IV drug
AND
The number of refills authorized is greater than 5
OR
The days supplied plus the refills would last for more than
185 days
OR
It has been more than 185 days since the prescription was
written.
Edit posted for compounds in 3.2 which require a manual /
paper claim. Ignore for 5.1 claims.
B
B
B
B
B
B
B
B
M5
Requires Manual Claim
4793
B
M5
Requires Manual Claim
4956
C
Edit posted when spenddown date is same as date of service.
Should accompany edit 65 (Patient not covered) - exception
code 4808 - EOB 0385 (Spenddown date same as DOS).
B
B
B
B
M6
HOST ELIGIBILITY ERROR
4909
B
HOST ELIGIBILITY ERROR
B
B
B
B
M8
Host Provider File Error
4850
B
Host Provider File Error
B
B
B
B
ME
M/I Coupon Number
4943
B
M/I Coupon Number
B
B
B
B
MZ
NE
Error Overflow
M/I Coupon Number
4899
4944
B
B
Error Overflow
B
B
B
B
B
B
B
B
NN
Transaction Rejected At Switch Or
Intermediary
4945
B
M/I Coupon Number
Transaction Rejected At Switch Or Intermediary
B
B
B
B
PA
PA Exhausted/Not Renewable
4295
B
PA Exhausted/Not Renewable
B
B
B
B
PB
Invalid Transaction Count For This
Transaction Code
4297
B
The Transaction Count is greater than 4 for a Billing Reversal - or Rebill request.
D
D
D
D
PC
M/I Claim Segment
4298
B
A Claim Segment was not received with a billing request.
D
D
D
D
PC
M/I Claim Segment
4299
B
A Claim segment was received with an Eligibility request.
D
D
D
D
PD
M/I Clinical Segment
4300
B
A Clinical segment was received with an
Eligibility, a Reversal, a Prior Authorization
Reversal, or a Prior Authorization Inquiry
request.
D
D
D
D
PE
M/I COB/Other Payments Segment
4302
B
M/I COB/Other Payments Segment
D
D
D
D
Page: 127
PE
M/I COB/Other Payments Segment
4303
B
A COB/Other Payments Segment was received with an
Eligibility - a Reversal - or a Prior Authorization Reversal
request.
D
D
D
D
PF
M/I Compound Segment
4304
B
M/I Compound Segment
D
D
D
D
PF
M/I Compound Segment
4305
B
A Compound Segment was received with an Eligibility or a
Reversal request.
D
D
D
D
PG
M/I Coupon Segment
4306
B
A Coupon segment was received and the customer does not
process Coupon segments.
B
B
B
B
PH
M/I DUR/PPS Segment
4307
B
D
D
D
D
PH
M/I DUR/PPS Segment
4308
B
This error is similar to other M/I Segment errors indicating
the segment was malformed or not sent correctly in the
claim.
DUR/PPS Segment Invalid With Eligibility Request – 5.1
Only
A DUR/PPS segment was received with an Eligibility
request.
D
D
D
D
D
D
D
D
PJ
M/I Insurance Segment
4309
B
DUR/PPS segment is not allowed for eligibility transactions
(E1) and we don't accept E1 transactions.
M/I Insurance Segment
PJ
M/I Insurance Segment
4310
B
M/I Insurance Segment
D
D
D
D
PK
M/I Patient Segment
4311
B
M/I Patient Segment
B
B
B
B
PK
M/I Patient Segment
4312
B
M/I Patient Segment
B
B
B
B
PM
M/I Pharmacy Provider Segment
4313
B
M/I Pharmacy Provider Segment
B
B
B
B
PM
M/I Pharmacy Provider Segment
4314
B
B
B
B
B
PN
M/I Prescriber Segment
4315
B
Pharmacy Provider Segment Invalid With Reversal Request
– 5.1 Only
A Pharmacy Provider segment was received with a Reversal
request.
M/I Prescriber Segment
D
D
D
D
PN
M/I Prescriber Segment
4316
B
D
D
D
D
PP
M/I Pricing Segment
4317
B
Prescriber Segment Invalid With Request Type - 5.1 Only
A Prescriber segment was received with an Eligibility or a
Reversal request.
Pricing Segment Invalid With Eligibility Request - A
Pricing segment was received with an Eligibility request.
D
D
D
D
Pricing segment only allowed with Billing (B1), Rebill (B3)
and PA Req & Billing (P1)
PP
M/I Pricing Segment
4318
B
M/I Pricing Segment
D
D
D
D
PR
M/I Prior Authorization Segment
4319
B
M/I Prior Authorization Segment
B
B
B
B
PR
M/I Prior Authorization Segment
4320
B
B
B
B
B
PS
M/I Transaction Header Segment
4321
B
Prior Authorization Segment Invalid With Request Type –
5.1 Only
A Prior Authorization segment was received with an
Eligibility or a Reversal request.
Missing Mandatory Transaction Header Segment – 5.1 Only
An Eligibility - Billing - Reversal - or Re-bill request was
received without a mandatory Transaction Header segment.
D
D
D
D
PS
M/I Transaction Header Segment
4322
B
Exception code deleted and replace with 4321
D
D
D
D
Nashville comment:
Is this necessary since this is a mandatory segment and all
the fields on the segment have their own edits?
Page: 128
PT
M/I Workers’ Compensation
Segment
4323
B
A Workers’ Compensation segment was received with an
Eligibility or a Reversal request.
B
B
B
B
B
B
B
B
D
D
D
D
B
B
B
B
Duplicate edit of 4324 (below)
PT
M/I Workers’ Compensation
Segment
4324
B
Workers’ Compensation Segment Invalid With Request
Type – 5.1 Only
A Workers’ Compensation segment was received with an
Eligibility or a Reversal request.
PV
Non-Matched Associated
Prescription/Service Date
4325
B
PW
Non-Matched Employer ID
4946
B
A Work's Comp segment is not allowed in an elig or
reversal transaction
Associated Prescription/Service Date Does Not Match DOS
- 5.1 Only
The Associated Prescription/Service Date on a Claim
segment with a Dispensing Status of “C” (completion fill)
did not match the Date Of Service on the matching partial
fill transaction.
Non-Matched Employer ID
PX
Non-Matched Other Payer ID
4947
B
Non-Matched Other Payer ID
B
B
B
B
PY
Non-Matched Unit Form/Route of
Administration
4948
B
Non-Matched Unit Form/Route of Administration
B
B
B
B
PZ
Non-Matched Unit Of Measure To
Product/Service ID
4949
B
Non-Matched Unit Of Measure To Product/Service ID
B
B
B
B
P1
Associated Prescription/Service
Reference Number Not Found
4326
B
The Associated Prescription/Service Reference Number on a
Claim segment with a Dispensing Status of “C” (completion
fill) did not match the Reference Number on the matching
partial fill transaction
D
D
D
D
P2
Clinical Information Counter Out Of
Sequence
4327
B
The Clinical segments were not received in the correct
numerical sequence.
B
B
B
B
P3
Compound Ingredient Component
Count Does Not Match Number Of
Repetitions
4328
B
The Compound Ingredient Component Count does not
match the number of Compound Product ID’s received on a
Compound segment.
B
D
B
B
P4
Coordination Of Benefits/Other
Payments Count Does Not Match
Number Of Repetitions
4329
B
The Coordination Of Benefits/Other Payments Count does
not match the number of COB/Other Payment segments
received.
D
D
D
D
P5
P6
Coupon Expired
Date Of Service Prior To Date Of
Birth
4950
4330
B
B
Coupon Expired
DOS Less Than DOB – 5.1 Only
The claim Date Of Service is less than the claim Date Of
Birth.
B
D
B
D
B
D
B
D
P7
Diagnosis Code Count Does Not
Match Number Of Repetitions
4331
B
The Diagnosis Code Count does not match the number of
Diagnosis Codes on a Clinical segment.
B
B
B
B
Page: 129
P8
DUR/PPS Code Counter Out Of
Sequence
4332
B
The sets of DUR/PPS information were received out of
numerical sequence.
D
D
D
D
B
B
B
B
P9
Field Is Non-Repeatable
4333
B
This error is returned when the DUR/PPS Segment in the
inquiry contains an out of sequence DUR/PPS Code
Counter. In other words, the data elements in the DUR/PPS
Segment can be repeated several times and with each
repitition, the counter field should increment by 1, so if you
got a series of loops with the counter = 1, 3, 2 vs. 1, 2, 3
then you'd get this error. There's an example on pg 7-24 of
the 5.1 Implementation Guide as well as a decription of the
DUR/PPS Segment on page 4-4.
Error returned when non-repeatable field is repeated.
RA
PA Reversal Out Of Order
4951
B
PA Reversal Out Of Order
D
D
D
D
RB
Multiple Partials Not Allowed
4334
B
More than one partial fill transactions were received for the
same Prescription/Service ID.
D
D
D
D
RC
Different Drug Entity Between Partial
& Completion
4335
B
The Product/Service ID and/or Qualifier on the completion
transaction (Dispensing Status of “C”) does not match the
Product/Service ID and/or Qualifier on the associated partial
fill transaction (Dispensing Status of “P”).
D
D
D
D
RD
Mismatched Cardholder/Group IDPartial To Completion
4336
B
D
D
D
D
RE
M/I Compound Product ID Qualifier
4337
B
The member ID and the Group ID on the Insurance segment
of a completion transaction (Dispensing Status of “C”) does
not match the member ID and Group ID on the Insurance
segment of the associated partial fill transaction (Dispensing
Status of “P”).
The Compound Product ID Qualifier is missing (spaces) or
it does not match one of the valid values specified for the
field.
D
D
D
D
RF
Improper Order Of ‘Dispensing
Status’ Code On Partial Fill
Transaction
4338
B
Completion With No Partial – 5.1 Only
A Claim segment with a Dispensing Status of “C” was
received but no matching partial fill transaction (Dispensing
Status of “P”) could be found
D
D
D
D
RG
M/I Associated Prescription/service
Reference Number On Completion
Transaction
4339
B
The Associated Prescription/Service Reference Number on a
claim segment with a Dispensing Status of “C” is missing
(zeros).
D
D
D
D
RH
M/I Associated Prescription/Service
Date On Completion Transaction
4340
B
The Associated Prescription/Service Date on a Claim
segment with a Dispensing Status of “C” is missing (zeros)
or it is not a valid date.
D
D
D
D
RH
M/I Associated Prescription/Service
Date On Completion Transaction
4417
B
Partial and Completion not Allowed on Same Day 5.1 Only
First Date of Service equal Associated Prescription/Service
Date.
D
D
D
D
RJ
Associated Partial Fill Transaction
Not On File
4341
B
D
D
D
D
RK
Partial Fill Transaction Not
Supported
4952
B
A “Paid” or “To Be Paid” claim with a Dispensing Status of
“P” and an Associated Prescription/Service Reference
Number that matches the In-process claim’s
Prescription/Service Reference Number and an Associate
Prescription/Service Date that matches the In-process
claim’s Date Prescription Written could not be found.
Partial Fill Transaction Not Supported
B
B
B
B
Page: 130
RM
Completion Transaction Not
Permitted With Same ‘Date Of
Service’ As Partial Transaction
4953
B
Completion Transaction Not Permitted With Same ‘Date Of
Service’ As Partial Transaction
D
D
D
D
RN
Plan Limits Exceeded On Intended
Partial Fill Values
4343
B
D
D
D
D
RN
Plan Limits Exceeded On Intended
Partial Fill Values
4342
B
Intended Days Supply Exceeds Plan Limits – 5.1 Only
The Days Supply Intended To Be Dispense received on a
claim segment with a “P” Dispensing Status exceeds the
maximum submitted days limits on the plan for which the
participant is eligible.
Intended Quantity Exceeds Plan Limits
The Quantity Intended To Be Dispense received on a claim
segment with a “P” Dispensing Status exceeds the
maximum dispensed quantity limits on the plan for which
the participant is eligible.
D
D
D
D
RP
Out Of Sequence ‘P’ Reversal On
Partial Fill Transaction
4344
B
D
D
D
D
RS
M/I Associated Prescription/Service
Date On Partial Transaction
4345
B
Partial Reversed Before Completion Reversed – 5.1 Only
A reversal for a partial fill transaction was submitted before
the completion transaction was reversed. The Replacement
TCN Number on the matching completion TCN is zeros.
Note: 5.1 Same day inspect dispensing status in order to
reverse correct transaction
The Associated Prescription/Service Date is missing (zeros)
or is an invalid date when a claim segment with a
Dispensing Status of “P” was received.
Associated fields are not required on a partial transaction.
D
D
D
D
RT
M/I Associated Prescription/Service
Reference Number On Partial
Transaction
4346
B
The Associated Prescription/Service Reference Number is
missing (zeros) and the Dispensing Status is “P”.
Associated fields are not required on a partial transaction.
This edit does not make sense.
D
D
D
D
RU
Mandatory Data Elements Must
Occur Before Optional Data Elements
In A Segment
4347
B
Optional Fields Precede Mandatory Fields
A segment of any type was received with an optional field or
fields preceding the mandatory fields.
D
D
D
D
R1
Other Amount Claimed Submitted
Count Does Not Match Number Of
Repetitions
4348
B
The Other Amount Claimed Submitted Count does not
match the number of Other Amount Claimed Submitted
fields received on a Pricing segment.
D
D
D
D
R2
Other Payer Reject Count Does Not
Match Number Of Repetitions
4349
B
The Other Payer Reject Count does match the number of
Other Payer Reject Codes received on a COB/Other
Payments segment
D
D
D
D
R3
Procedure Modifier Code Count Does
Not Match Number Of Repetitions
4350
B
The Procedure Modifier Code Count does not match the
number of Procedure Modifier Codes received on a Claim
segment.
D
D
D
D
If the client isn't supporting Procedure Code Modifiers then
this can be set to Ignore.
Page: 131
R4
Procedure Modifier Code Invalid For
Product/Service ID
4351
B
The Procedure Code Identifies special circumstances related
to the performance of the service. List of codes available
from: Health Care Financing Administration (HCFA)
D
D
D
D
R5
Product/Service ID Must Be Zero
When Product/Service ID Qualifier
Equals Ø6
4352
B
The Product/Service ID on the Claim Segment was not zeros
when the Product/Service ID Qualifier indicated that the
claim was for DUR/Professional Pharmacy Service.
D
D
D
D
D
D
D
D
When submitting a claim with a DUR/PPS segment (for
DUR conflict resolution or professional billing), the
product/service id qualifier (436-E1) must be 06 (DUR/PPS
- Drg Use Review/ Prof pharm svc) vs. the 03 (NDC#) and
the actual DUR/PPS code would go in the produce/service id
(407-D7). The NDC# would go in the Originally Prescribed
Product/Service Code and qualifier fields (453-EJ AND
445-EA) in the Claim Segment.
See page 4-4 in the Implementation Guide for more info
R6
Product/Service Not Appropriate For
This Location
4353
B
Drug to Patient Location
Drug not appropriate for patient location (field 307-C7):
1=Home
2=Inter-Care
3=Nursing Home
4=Long Term/Extended Care
5=Rest Home6=Boarding Home
7=Skilled Care Facility
8=Sub-Acute Care Facility
9=Acute Care Facility
1Ø=Outpatient11=Hospice
R7
Repeating Segment Not Allowed In
Same Transaction
4354
B
An identical segment was submitted on a single transaction.
D
D
D
D
R8
R9
Syntax Error
Value In Gross Amount Due Does
Not Follow Pricing Formulae
4954
4355
B
B
Syntax Error
Gross Amount Due for RX =
+
+
submitted
+
submitted
+
submitted
+
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
SE
M/I Procedure Modifier Code Count
4356
B
ingredient cost submitted
dispensing fee submitted
flat sales tax amount
percentage sales tax
incentive amount
other amount claimed
Gross Amount Due for PPS = PPS fee submitted
+ flat sales tax submitted
+ percentage sales tax
amount submitted
+ other amount claimed
The Procedure Modifier Code Count is missing (zeros) and a
procedure modifier is present.
If you include a procedure code modifier, then you must
indicate the count. But since most clients only accept NDCs
(vs. procedure/CPT codes), this can probably be set to
Ignore.
TE
M/I Compound Product ID
4357
B
The Compound Product ID is missing (spaces).
Page: 132
UE
M/I Compound Ingredient Basis Of
Cost Determination
4358
B
The Compound Ingredient Basis Of Cost Determination is
missing (spaces) or it does not match one of the valid values
specified for the field.
B
B
B
B
VE
M/I Diagnosis Code Count
4359
B
The Diagnosis Code Count is missing (zeros) and a
diagnosis code is present.
D
D
D
D
WE
M/I Diagnosis Code Qualifier
4360
B
The Diagnosis Code Qualifier is missing (spaces) or it does
not match one of the valid values specified for the field.
D
D
D
D
XE
M/I Clinical Information Counter
4361
B
The Clinical Information Counter is missing (zeros) or it
does not match the number of sets of measurement fields on
a Clinical segment.
D
D
D
D
ZE
M/I Measurement Date
4362
B
The Measurement Date is missing (zeros).
D
D
D
D
5.1 New (N) or (C) - (3rd
column)
"N" = new 5.1 edits, "C" =
field name change from
3.2.
Client or Base Edit - (5th
column)
"B" = base edit, "C" or
cilent abbrev. = client
specific edit
Disposition Legend - (last 3
columns)
D
Post Exception
and Deny
I
Ignore Exception
(Pay)
P
Post Exception
and Pay
S
Suspend and
Recycle
Note 1: Disposition reflect
Base Exception Code, not
Client-Specific
Note 2: Management
override can be set to YES
for paper claims
5.1 Exception Table General Info
Deletions - entries for the
following edits were
deleted as they're no
longer supported in 5.1:
18 (M/I Metric Quantity)
Page: 133
replaced by edit E7
(Quantity Dispensed/Metric
Decimal Quantity)
30 (M/I PA/MC Code)
replaced by EU (m/i pa
type code) and EV (m/i pa
number submitted)
57 (Non-Matched PA/MC
Number) replaced by EU
(m/i pa type code) and EV
(m/i pa number submitted)
Deleted 3.2 exception
codes can be viewed in the
table: Deleted Entries from
3.2.xls on the P drive
(Mapping Docs dir)
Name changes: Approx 31
edits have been renamed.
The edit#s and exception
codes stayed the same.
Look for "C" entries in
column C.
The following reference
docs are on the LAN: 5.1
Deleted Fields, 5.1 Field
Name Change Cross
Reference, 5.1 Error
Codes (P:\PDCS\Indiana
Medicaid\Systems\Mapping
Docs\Exception Tables)
The complete 5.1 data
dictionary is at: P:\ PDCS \
NCPDP \ NCPDP \
DOWNLOAD
DUR Fields:
When denials for ProDUR edits are received, providers may override these denials using the
appropriate DUR Reason of Service (Conflict), Professional Results (Intervention), and Result of
Service (Outcome Codes).
Early Refill (ER) –Providers must contact the ACS Technical Call Center to request overrides.
(provider overrides not allowed.)
Therapeutic Duplication (TD)- selected therapeutic classes deny, others return warning message only.
88 DUR Reject Error
Maryland Medicaid Therapeutic Duplication Denial NCPDP 88, DUR Reject Error TD
Alpha-Adrenergic Blocking Agents
Anticholingergic/Antispasmodics
Page: 134
Antihistamines
Barbiturates
Bile Salt Sequestrants
Bile Salts
Calcium Channel Blocking Agents
Cerivastin, Lovastatin, Simvastatin, Pravastatin, Fluvastatin, Atrovastatin
Diabetic Therapy
Digitalis Glycosides
Gastric Acid Secretion Reducers
Hypotensives, ACE Inhibitors
Hypotensives, Sympatholytic
Hypotensives, Vasolidators
Loop Diuretics
NSAIDS
Potassium Sparing Diuretics
Psychostimulants-Antidepressants
Quinolones
Thiazide and Related Diuretics
KDP ProDUR Therapeutic Duplication Denial NCPDP 88, ‘DUR Reject Error TD’.
Alpha-Adrenergic Blocking Agents
Antihistamines
Barbiturates
Calcium Channel Blocking Agents
Diabetic Therapy
Digitalis Glycosides
Gastric Acid Secretion Reducers
Hypotensives, ACE Inhibitors
Hypotensives, Sympatholytic
Hypotensives, Vasolidators
Loop Diuretics
NSAIDS
Potassium Sparing Diuretics
Psychostimulants-Antidepressants
Quinolones
Thiazide and Related Diuretics
Note: Provider overrides are on a per claim (date of service only) basis. For quality of care purposes,
pharmacists are required to retain documentation relative to these overrides.
DUR Reason for Service/ Conflict Code:
The DUR Reason for Service is used to define the type of utilization conflict that was detected
(NCPDP field 439).
Valid DUR Reason for Service for the MA, BCCDT, MADAP and KDP are:
ER = EARLY REFILL
TD = THERAPEUTIC DUPLICATION
NCPDP Message
Page: 135
E4 M/I DUR conflict/reason for service code
DUR Professional Service/ Intervention Code:
The DUR Professional Service is used to define the type of interaction or intervention that was
performed by the pharmacist (NCPDP field 440).
Override Codes: Designated Professional Service must accompany the designated Result of Service to
allow the override.
NCPDP Message
E5 M/I DUR intervention/professional service code
DUR Result of Service/ Outcome Code:
The DUR Result of Service is used to define the action taken by the pharmacist in response to a
ProDUR Reason for Service or the Result of Service (NCPDP field 441).
Override Codes: Note that designated Professional Service must accompany the designated Result of
Service to allow the override
NCPDP Message
E6 M/I DUR outcome/ result of service code
Override Codes for both Maryland Medicaid and KDP: the following codes will be used to allow for
provider level overrides for Therapeutic Duplication (TD) denials
Professional Service/ Description (NCPCP field #440-E5)
Result of Service/ Description (NCPDP field #441-E6)
00/ no intervention
M0/ prescriber consulted
PE/ patient education
P0/ patient consulted
R0/ pharmacist consulted other source
1A/ filled as is, false positive
1B/ filled prescription as is
1C/ filled with different dose
1D/ filled with different directions
1F/ filled with different quantity
1G/ filled with prescriber approval
Page: 136
Page: 137
APPENDIX A
PAYER SPECIFICATIONS
NCPDP VERSION 5.1 PAYER SHEET – B1/B3 Transactions
**GENERAL INFORMATION**
Payer Name: Maryland Medical Assistance Date: February 4, 2007
Program
Plan Name/Group Name: Maryland Department of Health and Mental Hygiene
Processor: ACS
Help Desk: TBD
Effective as of: February 4, 2007
Version/Release #: 5.1
Contact/Information Source: Help Desk, Payer Sheet
Certification Testing Window:N/A
Provider Relations Help Desk Info: TBD
Other versions supported: None
** OTHER TRANSACTIONS SUPPORTED **
Transaction Code
B1
B3
Transaction Name
Billing
ReBill
BILLING TRANSACTION:
Transaction Header Segment: Mandatory in all cases
Value
Field # NCPDP Field
Name/length
1Ø1-A1 BIN Number
1Ø2-A2 Version/Release Number
1Ø3-A3 Transaction Code
1Ø4-A4 Processor Control Number
1Ø9-A9 Transaction Count
2Ø2-B2 Service Provider ID
Qualifier
2Ø1-B1 Service Provider ID
M/R/R Comment
W
61ØØ84
51
B1 = Billing
B2 = Reversals
B3 = Rebill
DRMDPROD = Production
DRMDACCP = Test
1 = One Occurrence
2 = Two Occurrences
3 = Three Occurrences
4 = Four Occurrences
07 – NCPDP ID Number
M
M
M
NABP / NCPDP Provider
number
M
Page: 138
M
M
M
4Ø1-D1 Date of Service
11ØSoftware
AK
Vendor/Certification ID
CCYYMMDD
M
ØØØØØØØØØØ (zeros) or M
current certification number
Zero fill or use
current
Certification
number
Patient Segment: Required
NCPDP Field Name
Value
Field
Comment
M/R/R
W
111AM
304-C4
305-C5
Segment Identification
Ø1
M
Date of Birth
Patient Gender Code
CCYYMMDD
Ø =Not specified
1=Male
2=Female
R
R
310 –
CA
Patient First Name
R
311 –
CB
Patient Last Name
R
307-C7
Patient Location
0=Not specified
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
10=Outpatient
11=Hospice
RW
Patient Segment
First 3 characters –
verify what should
be submitted
First 5 characters
verify what should
be submitted
Use location Code
4 or 11 when the
patient is in a LTC
setting or hospice
Bolded values are
the current
accepted values
Insurance Segment: Mandatory
Field #
NCPDP Field Name
Value
M/R/R Comment
W
111Segment Identification
AM
3Ø2-C2 Cardholder ID
Ø4
M
Insurance Segment
Recipient’s Medicaid ID
Number
M
11 character
number
Page: 139
336-8C
Facility ID
301-C1
306-C6
Group ID
Patient Relationship Code
RW
MDMEDICAID
1 = Cardholder
2 = Spouse
3=Child
4=Other
R
R
Required when
recipient Is in a
Hospice and
submits an ‘11’ or
LTC and submits a
‘4’ in Patient
Location
1 = Cardholder
Claim Segment: Mandatory
Field #
NCPDP Field Name
Value
M/R/R Comment
W
111AM
455EM
4Ø2D2
436E1
4Ø7D7
456EN
Segment Identification
Ø7
M
Prescription/Service Reference
Number Qualifier
Prescription/Service Reference
Number
Product/Service ID Qualifier
1 = Rx Billing
M
Rx Number assigned
by the pharmacy
Ø3 = National Drug
Code
NDC Number
M
Associated Prescription/Service
Reference #
New to MD Medicaid
RW
457EP
Associated Prescription/Service
Date
New to MD Medicaid
RW
442E7
403D3
Quantity Dispensed
Metric Decimal
Quantity
Ø = Original
Dispensing
1-99 = Number of
refills
R
405D5
Days Supply
Product/Service ID
Fill Number
M
M
R
R
Page: 140
Claim Segment
Required when
submitting a claim
for a completion
fill
Required when
submitting a claim
for a completion
fill
Edited when
number is above
11.
406D6
Compound Code
Ø = Not specified
1= Not a compound
2 = Compound
R
408D8
Dispense as Written (DAW)
Ø =Default, no product selection
indicated
RW
414DE
420DK
Date Prescription Written
Submission Clarification Code
1=Physician request
2=patient request
3=pharmacist request
4=generic out of stock
(temp)
5=brand used as
generic
6=override
7=brand mandated by
law
8=generic not
available in
marketplace
9=not used
CCYYMMDD
Ø =Not specified,
default
1=No override
2=Other override
3=Vacation Supply
4=Lost Prescription
5=Therapy Change
6=Starter Dose
7=Medically
Necessary
8=Process compound
for Approved
Ingredients
9=Encounters
99=Other
Page: 141
2 must be entered
for submission of a
multi line
compound.
Allow Ø, 1, 5 or 6
R
RW
Used when
provider is willing
to accept payment
only for covered
items of a multi
line compound.
99 is used for the
submission of an
IV claim.
308C8
Other Coverage Code
Ø=Not Specified
R
1=No other Coverage Identified
2=Other coverage
exists-payment
collected
3=Other coverage exists-this
claim not covered
4=Other coverage exists-payment
not collected
5=Managed care plan
denial
6=Other coverage
exists, not a
participating provider
7=Other Coverage
exists-not in effect at
time of service
8=Claim is a billing
for a copay
429DT
Unit Dose Indicator
418-DI Level of Service
Ø =Not specified
1=Not Unit Dose
2=Manufacturer Unit
Dose
3=Pharmacy Unit
Dose
3 = Emergency
Page: 142
RW
3 = Pharmacy Unit
Dose
Denies as noncovered at Retail.
RW
Required when
submitting a claim
for an emergency
fill.
Logic – NH
recipients can
receive 1 per
month and they
receive a 30-day
supply. This is per
Rx.
Retail – 2 per
script per month.
Only for PDL
denials.
461EU
Prior Authorization Type Code
462EV
343HD
Prior Authorization Number
Submitted
Dispensing Status
344HF
Quantity Intended to be
Dispensed
345HG
Days Supply Intended to be
Dispensed
Ø=Not Specified
1=Prior Authorization
2=Medical
Certification
3=EPSDT (Early
Periodic Screening
Diagnosis Treatment)
4=Exemption from
Copay
5=Exemption from
RX
6=Family Plan. Indic.
7=AFDC (Aid to
Families with
Dependent Children)
8=Payer Defined
Exemption
RW
MD Medicaid
accepts the
following valid
values:
4 = Exempt from
co-pay
5 = Exempt from
Rx
2= Medical Cert.
RW
P = initial Fill
C=Completion Fill
New to MD Medicaid
New to MD Medicaid
RW
New to MD Medicaid
RW
RW
Required when
submitting a claim
for a partial fill
Required when
submitting a claim
for a partial fill
Required when
submitting a claim
for a partial fill
Pharmacy Provider Segment: Optional - Not used by MD
Medicaid
Field #
NCPDP Field Name
Value
Prescriber Segment: Required
Field # NCPDP Field Name
Value
M/R/R
W
Comment
M/R/R Comment
W
111AM
466EZ
411DB
Segment Identification
Ø3
M
Prescriber ID Qualifier
12 = DEA
R
Prescriber ID
DEA Number
R
Page: 143
Prescriber
Segment
.
COB/Other Payments Segment: Optional
Field # NCPDP Field Name
111AM
Segment Identification
3374C
3385C
Coordination of Benefits/Other
Payments Count
Other Payer Coverage Type
3396C
Other Payer Id Qualifier
3407C
443E8
Other Payer ID
341HB
Other Payer Amount Paid Count
342HC
Other Payer Amount Paid
Qualifier
Other Payer Date
Value
Ø5
M/R/R
W
Comment
M
COB/Other
Payments
Segment
M
Blank=Not Specified
Ø1=National Payer ID
Ø2=Health Industry
Number
Ø3=Bank Information
Number (BIN)
Ø4=National
Association of
Insurance
Commissioners
(NAIC)
Ø9=Coupon
99-Other
M
(Repeatin
g)
R
Required when
submitting a
COB claim
R
CCYYMMDD
Blank=Not specified
Ø1=Delivery
Ø2=Shipping
Ø3=Postage
Ø4=Administrative
Ø5=Incentive
Ø6=Cognitive Service
Ø7=Drug Benefit
Ø 8=Sum of all
Reimbursement
98=Coupon
99=Other
Page: 144
R
Required when
there is payment
from another
source
R
Required when
submitting this
segment
R
Required when
(Repeatin the re is payment
g)
from another
source
431DV
Other Payer Amount Paid
DUR/PPS Segment: Optional
Field # NCPDP Field Name
R
Value
111AM
4737E
Segment Identification
439E4
Reason For Service Code
See Attached list of
valid values
R
(Repeati
ng)
440E5
Professional Service Code
See Attached list of
valid values
R
441E6
Result of Service Code
See attached list of
valid values
R
Value
M/R/R
W
M
DUR/PPS Code counter
Pricing Segment: Mandatory
Field # NCPDP Field Name
111AM
426DQ
430–
DU
Ø8
M/R/R
W
M
Segment Identification
M
11
Usual and Customary Charge
R
Gross Amount Due
R
Coupon Segment: Segment is not supported
Field # NCPDP Field Name
Value
Page: 145
M/R/R
W
Required when
there is payment
from another
source
Comment
DUR/PPS
Segment
Required when
submitting this
segment
Required when
there is a conflict
to resolve or
reason for service
to be explained
Required when
there is a
professional
service to be
identified
Required when
There is a result
of service to be
submitted
Comment
Pricing Segment
Comment
Compound Segment: Required When Submitting a Multi-Line
Compound Claim
Field #
NCPDP Field Name
Value
111AM
45ØEF
Segment Identification
1Ø
Compound Dosage Form
Description Code
M
451EG
Compound Dispensing Unit Form
Indicator
M
Page: 146
M/R/R
W
M
Comment
Compound
Segment
Ø1=Capsule
Ø2=Ointment
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
1=Each
2=Grams
3=Milliliters
452EH
Compound Route of
Administration
M
447EC
Compound Ingredient Component
(Count)
488RE
Compound Product ID Qualifier
489TE
Compound Product ID
448ED
Compound Ingredient Quantity
M
(Repeat
ing)
M
(Repeat
ing)
M
(Repeat
ing)
M
(Repeat
ing)
Prior Authorization Segment: Not Used by MD Medicaid
Field # NCPDP Field Name
Value
1=Buccal
2=Dental
3=Inhalation
4=Injection
5=Intraperitoneal
6=Irrigation
7=Mouth/Throat
8=Mucous
Membrane
9=Nasal
1Ø=Ophthalmic
11=Oral
12=Other/Miscella
neous
13=Otic
14=Perfusion
15=Rectal
16=Sublingual
17=Topical
18=Transdermal
19=Translingual
2Ø=Urethral
21=Vaginal
22=Enteral
Ø3=National Drug
Code (NDC)
M/R/R
W
Comment
M/R/R
W
NA
Comment
Clinical Segment: Optional for MD Medicaid
Field #
NCPDP Field Name
Value
111AM
Segment Identification
13
Page: 147
Clinical Segment
491-VE
Diagnosis Code
RW
Required when a DX
is used to determine
coverage
492WE
Diagnosis Code
RW
Required when a
DX is used to
determine
coverage
Page: 148
KDP Payer Sheet
B1-B3 Transactions
NCPDP VERSION 5.1 PAYER SHEET – B1/B3 Transactions
**GENERAL INFORMATION**
Payer Name: Maryland Medical Assistance Date: January 1, 2007
Program
Plan Name/Group Name: Maryland Kidney Disease Program
Processor: ACS
Help Desk: TBD
Effective as of: January 1, 2007
Version/Release #: 5.1
Contact/Information Source: Help Desk, Payer Sheet
Certification Testing Window:N/A
Provider Relations Help Desk Info: TBD
Other versions supported: None
** OTHER TRANSACTIONS SUPPORTED **
Transaction Code
B1
B3
Transaction Name
Billing
ReBill
BILLING TRANSACTION:
Transaction Header Segment: Mandatory in all cases
Value
Field # NCPDP Field
Name/length
1Ø1-A1 BIN Number
1Ø2-A2 Version/Release Number
1Ø3-A3 Transaction Code
1Ø4-A4 Processor Control Number
1Ø9-A9 Transaction Count
2Ø2-B2 Service Provider ID
Qualifier
2Ø1-B1 Service Provider ID
4Ø1-D1 Date of Service
M/R/R Comment
W
61ØØ84
51
B1 = Billing
B2 = Reversals
B3 = Rebill
DRKDPROD = Production
DRKDACCP = Test
1 = One Occurrence
2 = Two Occurrences
3 = Three Occurrences
4 = Four Occurrences
07 – NCPDP ID Number
M
M
M
NABP / NCPDP Provider
number
CCYYMMDD
M
Page: 149
M
M
M
M
KDP Payer Sheet
11ØAK
Software
Vendor/Certification ID
B1-B3 Transactions
ØØØØØØØØØØ (zeros) or M
current certification number
Zero fill or use
current
Certification
number
Patient Segment: Required
NCPDP Field Name
Value
Field
Comment
M/R/R
W
111AM
304-C4
305-C5
Segment Identification
Ø1
M
Date of Birth
Patient Gender Code
CCYYMMDD
Ø =Not specified
1=Male
2=Female
R
R
310 –
CA
311 –
CB
307-C7
Patient First Name
R
First 5 characters –
Patient Last Name
R
First 5 characters
RW
Use location Code
4 or 11 when the
patient is in a LTC
setting or hospice
Patient Location
0=Not specified
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
10=Outpatient
11=Hospice
Patient Segment
Bolded values are
the current
accepted values
Insurance Segment: Mandatory
Field #
NCPDP Field Name
Value
M/R/R Comment
W
111AM
Segment Identification
Ø4
M
Page: 150
Insurance Segment
KDP Payer Sheet
3Ø2-C2 Cardholder ID
B1-B3 Transactions
Recipient’s KDP Recipient
ID Number
M
KDP Recipient
number + 5
leading zeros
11 numeric
301-C1
306-C6
Group ID
Patient Relationship Code
MDDKDP
1 = Cardholder
2 = Spouse
3=Child
4=Other
R
R
1 = Cardholder
Claim Segment: Mandatory
Field #
NCPDP Field Name
Value
M/R/R Comment
W
111AM
455EM
4Ø2D2
436E1
4Ø7D7
456EN
Segment Identification
Ø7
M
Prescription/Service Reference
Number Qualifier
Prescription/Service Reference
Number
Product/Service ID Qualifier
1 = Rx Billing
M
Rx Number assigned
by the pharmacy
Ø3 = National Drug
Code
NDC Number
M
Associated Prescription/Service
Reference #
New to MD Medicaid
RW
457EP
Associated Prescription/Service
Date
New to MD Medicaid
RW
442E7
403D3
Quantity Dispensed
Metric Decimal
Quantity
Ø = Original
Dispensing
1-99 = Number of
refills
R
405D5
Days Supply
Product/Service ID
Fill Number
M
M
R
R
Page: 151
Claim Segment
Required when
submitting a claim
for a completion
fill
Required when
submitting a claim
for a completion
fill
Edited when
number is above
11.
KDP Payer Sheet
B1-B3 Transactions
406D6
Compound Code
Ø = Not specified
1= Not a compound
2 = Compound
R
408D8
Dispense as Written (DAW)
Ø =Default, no product selection
indicated
RW
414DE
308C8
Date Prescription Written
1=Physician request
2=patient request
3=pharmacist request
4=generic out of stock
(temp)
5=brand used as
generic
6=override
7=brand mandated by
law
8=generic not
available in
marketplace
9=not used
CCYYMMDD
R
Other Coverage Code
Ø=Not Specified
R
1=No other Coverage Identified
2=Other coverage
exists-payment
collected
3=Other coverage exists-this
claim not covered
4=Other coverage exists-payment
not collected
5=Managed care plan
denial
6=Other coverage
exists, not a
participating provider
7=Other Coverage
exists-not in effect at
time of service
8=Claim is a billing
for a copay
Page: 152
2 must be entered
for submission of a
multi line
compound.
Allow 0, 1, 5 and 6
KDP Payer Sheet
429DT
Unit Dose Indicator
461EU
Prior Authorization Type Code
462EV
343HD
Prior Authorization Number
Submitted
Dispensing Status
344HF
Quantity Intended to be
Dispensed
345HG
Days Supply Intended to be
Dispensed
B1-B3 Transactions
Ø =Not specified
1=Not Unit Dose
2=Manufacturer Unit
Dose
3=Pharmacy Unit
Dose
Ø=Not Specified
1=Prior Authorization
2=Medical
Certification
3=EPSDT (Early
Periodic Screening
Diagnosis Treatment)
4=Exemption from
Copay
5=Exemption from
RX
6=Family Plan. Indic.
7=AFDC (Aid to
Families with
Dependent Children)
8=Payer Defined
Exemption
3 = Pharmacy Unit
Dose
RW
Valid Values are:
4 = Exempt from
copay
5 = Exempt from
Rx
2= Medical Cert.
RW
P = initial Fill
C=Completion Fill
New to KDP
New to KDP
RW
New to KDP
RW
RW
Required when
submitting a claim
for a partial fill
Required when
submitting a claim
for a partial fill
Required when
submitting a claim
for a partial fill
Pharmacy Provider Segment: Optional - Not used by KDP
Field #
NCPDP Field Name
Value
Prescriber Segment: Required
Page: 153
M/R/R
W
Comment
KDP Payer Sheet
Field #
NCPDP Field Name
B1-B3 Transactions
Value
M/R/R Comment
W
111AM
466EZ
411DB
Segment Identification
Ø3
M
Prescriber ID Qualifier
12 = DEA
R
Prescriber ID
DEA Number
R
COB/Other Payments Segment: Optional
Field # NCPDP Field Name
111AM
Segment Identification
3374C
3385C
Coordination of Benefits/Other
Payments Count
Other Payer Coverage Type
3396C
Other Payer Id Qualifier
3407C
443E8
Other Payer ID
341HB
Other Payer Amount Paid Count
Other Payer Date
Prescriber
Segment
Value
Ø5
M/R/R
W
Comment
M
COB/Other
Payments
Segment
M
Blank=Not Specified
Ø1=National Payer ID
Ø2=Health Industry
Number
Ø3=Bank Information
Number (BIN)
Ø4=National
Association of
Insurance
Commissioners
(NAIC)
Ø9=Coupon
99-Other
M
(Repeatin
g)
R
Required when
submitting a
COB claim
R
CCYYMMDD
R
R
Page: 154
Required when
there is payment
from another
source
Required when
submitting this
segment
KDP Payer Sheet
342HC
Other Payer Amount Paid
Qualifier
431DV
Other Payer Amount Paid
DUR/PPS Segment: Optional
Field # NCPDP Field Name
B1-B3 Transactions
Blank=Not specified
Ø1=Delivery
Ø2=Shipping
Ø3=Postage
Ø4=Administrative
Ø5=Incentive
Ø6=Cognitive Service
Ø7=Drug Benefit
Ø 8=Sum of all
Reimbursement
98=Coupon
99=Other
R
Required when
(Repeatin the re is payment
g)
from another
source
R
Value
Ø8
M/R/R
W
M
111AM
4737E
Segment Identification
439E4
Reason For Service Code
See Attached list of
valid values
R
(Repeati
ng)
440E5
Professional Service Code
See Attached list of
valid values
R
441E6
Result of Service Code
See attached list of
valid values
R
DUR/PPS Code counter
M
Page: 155
Required when
there is payment
from another
source
Comment
DUR/PPS
Segment
Required when
submitting this
segment
Required when
there is a conflict
to resolve or
reason for service
to be explained
Required when
there is a
professional
service to be
identified – will
determine valid
values
Required when
There is a result
of service to be
submitted – will
determine valid
values
KDP Payer Sheet
Pricing Segment: Mandatory
Field # NCPDP Field Name
111AM
426DQ
430–
DU
Segment Identification
B1-B3 Transactions
Value
11
M/R/R
W
M
Usual and Customary Charge
R
Gross Amount Due
R
Coupon Segment: Segment is not supported
Field # NCPDP Field Name
Value
M/R/R
W
Comment
Pricing Segment
Comment
Compound Segment: Required When Submitting a Multi-Line
Compound Claim
Field #
NCPDP Field Name
Value
111AM
45ØEF
Segment Identification
1Ø
Compound Dosage Form
Description Code
M
451EG
Compound Dispensing Unit Form
Indicator
M
Page: 156
M/R/R
W
M
Comment
Compound
Segment
Ø1=Capsule
Ø2=Ointment
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
1=Each
2=Grams
3=Milliliters
KDP Payer Sheet
B1-B3 Transactions
452EH
Compound Route of
Administration
M
447EC
Compound Ingredient Component
(Count)
488RE
Compound Product ID Qualifier
489TE
Compound Product ID
448ED
Compound Ingredient Quantity
M
(Repeat
ing)
M
(Repeat
ing)
M
(Repeat
ing)
M
(Repeat
ing)
Prior Authorization Segment: Not Used by KDP
Field # NCPDP Field Name
Value
Clinical Segment: Optional for KDP
Page: 157
M/R/R
W
1=Buccal
2=Dental
3=Inhalation
4=Injection
5=Intraperitoneal
6=Irrigation
7=Mouth/Throat
8=Mucous
Membrane
9=Nasal
1Ø=Ophthalmic
11=Oral
12=Other/Miscella
neous
13=Otic
14=Perfusion
15=Rectal
16=Sublingual
17=Topical
18=Transdermal
19=Translingual
2Ø=Urethral
21=Vaginal
22=Enteral
Ø3=National Drug
Code (NDC)
Comment
KDP Payer Sheet
B1-B3 Transactions
Field #
NCPDP Field Name
Value
M/R/R
W
RW
Comment
111AM
Segment Identification
13
491-VE
Diagnosis Code Count
RW
Required when a DX
is used to determine
coverage
492WE
Diagnosis Code
RW
424DO
Diagnosis Code
RW
Required when a
DX is used to
determine
coverage
Required when a
DX is used to
determine
coverage
Page: 158
Clinical Segment
MADAP Payer Sheet
B1-B3 Transactions
NCPDP VERSION 5.1 PAYER SHEET – B1/B3 Transactions
**GENERAL INFORMATION**
Payer Name: Maryland Medical Assistance Date: January 1, 2007
Program
Plan Name/Group Name: MADAP
Processor: ACS
Help Desk: TBD
Effective as of: January 1, 2007
Version/Release #: 5.1
Contact/Information Source: Help Desk, Payer Sheet
Certification Testing Window:
Provider Relations Help Desk Info:
Other versions supported: None
** OTHER TRANSACTIONS SUPPORTED **
Transaction Code
B1
B3
Transaction Name
Billing
ReBill
BILLING TRANSACTION:
Transaction Header Segment: Mandatory in all cases
Value
Field # NCPDP Field
Name/length
1Ø1-A1 BIN Number
1Ø2-A2 Version/Release Number
1Ø3-A3 Transaction Code
1Ø4-A4 Processor Control Number
1Ø9-A9 Transaction Count
M/R/R Comment
W
61ØØ84
51
B1 = Billing
B2 = Reversals
B3 = Rebill
DRAPPROD = Production
DRAPACCP = Test
1 = One Occurrence
2 = Two Occurrences
3 = Three Occurrences
4 = Four Occurrences
Page: 159
M
M
M
M
M
MADAP Payer Sheet
2Ø2-B2 Service Provider ID
Qualifier
2Ø1-B1 Service Provider ID
4Ø1-D1 Date of Service
11ØSoftware
AK
Vendor/Certification ID
B1-B3 Transactions
07 – NCPDP ID Number
M
NABP / NCPDP Provider
number
CCYYMMDD
ØØØØØØØØØØ (zeros)
M
M
M
Zero fill or use
current
Certification
number
Patient Segment: Required
NCPDP Field Name
Value
Field
Comment
M/R/R
W
111AM
304-C4
305-C5
Segment Identification
Ø1
M
Patient Segment
Date of Birth
Patient Gender Code
CCYYMMDD
Ø =Not specified
1=Male
2=Female
R
R
310 –
CA
311 –
CB
Patient First Name
R
First 5 characters
Patient Last Name
R
First 5 characters
Insurance Segment: Mandatory
Field #
NCPDP Field Name
Value
M/R/R Comment
W
111Segment Identification
AM
3Ø2-C2 Cardholder ID
301-C1
306-C6
Group ID
Patient Relationship Code
Ø4
M
Recipient MADAP ID
Number
MADAP
1 = Cardholder
2 = Spouse
3=Child
4=Other
M
Page: 160
R
R
Insurance Segment
1 = Cardholder
MADAP Payer Sheet
B1-B3 Transactions
Claim Segment: Mandatory
Field #
NCPDP Field Name
Value
M/R/R Comment
W
111AM
455EM
4Ø2D2
436E1
4Ø7D7
456EN
Segment Identification
Ø7
M
Prescription/Service Reference
Number Qualifier
Prescription/Service Reference
Number
Product/Service ID Qualifier
1 = Rx Billing
M
Rx Number assigned
by the pharmacy
Ø3 = National Drug
Code
NDC Number
M
Associated Prescription/Service
Reference #
RW
457EP
Associated Prescription/Service
Date
RW
442E7
403D3
Quantity Dispensed
405D5
406D6
Days Supply
Product/Service ID
Fill Number
Compound Code
Metric Decimal
Quantity
Ø = Original
Dispensing
1-99 = Number of
refills
M
M
R
R
R
Ø = Not specified
1= Not a compound
2 = Compound
Page: 161
Claim Segment
R
Required when
submitting a claim
for a completion
fill
Required when
submitting a claim
for a completion
fill
MADAP Payer Sheet
408D8
Dispense as Written (DAW)
414DE
420DK
Date Prescription Written
Submission Clarification Code
B1-B3 Transactions
Ø =Default, no product selection
indicated
1=Physician request
2=patient request
3=pharmacist request
4=generic out of stock
(temp)
5=brand used as
generic
6=override
7=brand mandated by
law
8=generic not
available in
marketplace
9=not used
CCYYMMDD
Ø =Not specified,
default
1=No override
2=Other override
3=Vacation Supply
4=Lost Prescription
5=Therapy Change
6=Starter Dose
7=Medically
Necessary
8=Process compound
for Approved
Ingredients
9=Encounters
99=Other
Page: 162
RW
R
RW
Allow 0, 1 or 5.
MADAP Payer Sheet
308C8
Other Coverage Code
B1-B3 Transactions
Ø=Not Specified
R
1=No other Coverage Identified
2=Other coverage
exists-payment
collected
3=Other coverage exists-this
claim not covered
4=Other coverage exists-payment
not collected
5=Managed care plan
denial
6=Other coverage
exists, not a
participating provider
7=Other Coverage
exists-not in effect at
time of service
8=Claim is a billing
for a copay
429DT
Unit Dose Indicator
418-DI Level of Service
461EU
Prior Authorization Type Code
Ø =Not specified
1=Not Unit Dose
2=Manufacturer Unit
Dose
3=Pharmacy Unit
Dose
3 = Emergency
RW
3 = Pharmacy Unit
Dose
RW
Required when
submitting a claim
for an emergency
fill.
Ø=Not Specified
1=Prior Authorization
2=Medical
Certification
3=EPSDT (Early
Periodic Screening
Diagnosis Treatment)
4=Exemption from
Copay
5=Exemption from
RX
6=Family Plan. Indic.
7=AFDC (Aid to
Families with
Dependent Children)
8=Payer Defined
Exemption
RW
Page: 163
MADAP Payer Sheet
462EV
343HD
Prior Authorization Number
Submitted
Dispensing Status
344HF
Quantity Intended to be
Dispensed
345HG
Days Supply Intended to be
Dispensed
B1-B3 Transactions
RW
P = initial Fill
C=Completion Fill
New to MADAP
New to MADAP
RW
New to MADAP
RW
RW
Required when
submitting a claim
for a partial fill
Required when
submitting a claim
for a partial fill
Required when
submitting a claim
for a partial fill
Pharmacy Provider Segment: Optional - Not used by MADAP
Field #
NCPDP Field Name
Value
Prescriber Segment: Required
Field # NCPDP Field Name
Value
M/R/R
W
Comment
M/R/R Comment
W
111AM
466EZ
411DB
Segment Identification
Ø3
M
Prescriber ID Qualifier
12 = DEA
R
Prescriber ID
DEA Number
R
COB/Other Payments Segment: Optional
Field # NCPDP Field Name
111AM
Segment Identification
3374C
Coordination of Benefits/Other
Payments Count
Prescriber
Segment
.
Value
Ø5
M/R/R
W
Comment
M
COB/Other
Payments
Segment
M
Page: 164
MADAP Payer Sheet
3385C
Other Payer Coverage Type
443E8
Other Payer Date
341HB
Other Payer Amount Paid Count
342HC
Other Payer Amount Paid
Qualifier
431DV
Other Payer Amount Paid
DUR/PPS Segment: Optional
Field # NCPDP Field Name
B1-B3 Transactions
CCYYMMDD
Blank=Not specified
Ø1=Delivery
Ø2=Shipping
Ø3=Postage
Ø4=Administrative
Ø5=Incentive
Ø6=Cognitive Service
Ø7=Drug Benefit
Ø 8=Sum of all
Reimbursement
98=Coupon
99=Other
M
(Repeatin
g)
R
Required when
there is payment
from another
source
R
Required when
submitting this
segment
R
Required when
(Repeatin the re is payment
g)
from another
source
R
Value
Ø8
M/R/R
W
M
111AM
4737E
Segment Identification
439E4
Reason For Service Code
See Attached list of
valid values
R
(Repeati
ng)
440E5
Professional Service Code
See Attached list of
valid values
R
DUR/PPS Code counter
M
Page: 165
Required when
there is payment
from another
source
Comment
DUR/PPS
Segment
Required when
submitting this
segment
Required when
there is a conflict
to resolve or
reason for service
to be explained
Required when
there is a
professional
service to be
identified
MADAP Payer Sheet
441E6
Result of Service Code
Pricing Segment: Mandatory
Field # NCPDP Field Name
B1-B3 Transactions
See attached list of
valid values
R
Required when
There is a result
of service to be
submitted
Value
M/R/R
W
M
Comment
RW
Required when
submitting a copay only claim
Required when
submitting a claim
for a co-pay only
Required when
submitting a claim
for a co-pay only.
Amount must
equal the amount
in 430-DQ
111AM
478H7
Segment Identification
11
Other Amount Claimed
Submitted Count
Used with Other
Coverage code 8
479H8
Other Amount Claimed
Submitted Qualifier
RW
480H9
Other Amount Claimed
Submitted
RW
426DQ
430–
DU
Usual and Customary Charge
R
Gross Amount Due
R
For copay only
claims – this
amount must equal
the amount in field
480-H9
M/R/R
W
Comment
Coupon Segment: Segment is not supported
Field # NCPDP Field Name
Value
Pricing Segment
Compound Segment: Required When Submitting a Multi-Line
Compound Claim
Field #
NCPDP Field Name
Value
111AM
Segment Identification
1Ø
Page: 166
M/R/R
W
M
Comment
Compound
Segment
MADAP Payer Sheet
B1-B3 Transactions
45ØEF
Compound Dosage Form
Description Code
M
451EG
Compound Dispensing Unit Form
Indicator
M
452EH
Compound Route of
Administration
M
Page: 167
Ø1=Capsule
Ø2=Ointment
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
1=Each
2=Grams
3=Milliliters
1=Buccal
2=Dental
3=Inhalation
4=Injection
5=Intraperitoneal
6=Irrigation
7=Mouth/Throat
8=Mucous
Membrane
9=Nasal
1Ø=Ophthalmic
11=Oral
12=Other/Miscella
neous
13=Otic
14=Perfusion
15=Rectal
16=Sublingual
17=Topical
18=Transdermal
19=Translingual
2Ø=Urethral
21=Vaginal
22=Enteral
MADAP Payer Sheet
447EC
Compound Ingredient Component
(Count)
488RE
Compound Product ID Qualifier
489TE
Compound Product ID
448ED
Compound Ingredient Quantity
B1-B3 Transactions
M
(Repeat
ing)
M
(Repeat
ing)
M
(Repeat
ing)
M
(Repeat
ing)
Prior Authorization Segment: Not Used by MADAP
Field # NCPDP Field Name
Value
Clinical Segment: Optional for MDMADAP
Field # NCPDP Field Name
Value
13
Ø3=National Drug
Code (NDC)
M/R/R
W
Comment
M/R/R
W
NA
Comment
111AM
Segment Identification
491-VE
Diagnosis Code Count
RW
Required when a DX
is used to determine
coverage
492WE
Diagnosis Code
RW
424DO
Diagnosis Code
RW
Required when a
DX is used to
determine
coverage
Required when a
DX is used to
determine
coverage
Page: 168
Clinical Segment
NCPDP VERSION 5.1 PAYER SHEET – B1/B3 Transactions
**GENERAL INFORMATION**
Payer Name: Maryland Medical Assistance Date: January 1, 2007
Program
Plan Name/Group Name: Breast and Cervical Cancer Diagnosis and Treatment
Processor: ACS
Help Desk: TBD
Effective as of: January 1, 2007
Version/Release #: 5.1
Contact/Information Source: Help Desk, Payer Sheet
Certification Testing Window:
Provider Relations Help Desk Info:
Other versions supported: None
** OTHER TRANSACTIONS SUPPORTED **
Transaction Code
B1
B3
Transaction Name
Billing
ReBill
BILLING TRANSACTION:
Transaction Header Segment: Mandatory in all cases
Value
Field # NCPDP Field
Name/length
1Ø1-A1 BIN Number
1Ø2-A2 Version/Release Number
1Ø3-A3 Transaction Code
1Ø4-A4 Processor Control Number
1Ø9-A9 Transaction Count
2Ø2-B2 Service Provider ID
Qualifier
2Ø1-B1 Service Provider ID
4Ø1-D1 Date of Service
M/R/R Comment
W
61ØØ84
51
B1 = Billing
B2 = Reversals
B3 = Rebill
DRDTPROD = Production
DRDTACCP = Test
1 = One Occurrence
2 = Two Occurrences
3 = Three Occurrences
4 = Four Occurrences
07 – NCPDP ID Number
M
M
M
NABP / NCPDP Provider
number
CCYYMMDD
M
Page: 169
M
M
M
M
11ØAK
Software
Vendor/Certification ID
ØØØØØØØØØØ (zeros)
M
Zero fill or use
current
Certification
number
Patient Segment: Required
NCPDP Field Name
Value
Field
Comment
M/R/R
W
111AM
304-C4
305-C5
Segment Identification
Ø1
M
Patient Segment
Date of Birth
Patient Gender Code
CCYYMMDD
Ø =Not specified
1=Male
2=Female
R
R
310 –
CA
311 –
CB
Patient First Name
R
First 5 characters
Patient Last Name
R
First 5 characters
Insurance Segment: Mandatory
Field #
NCPDP Field Name
Value
M/R/R Comment
W
111Segment Identification
AM
3Ø2-C2 Cardholder ID
301-C1
306-C6
Group ID
Patient Relationship Code
Ø4
M
Insurance Segment
Member’s MDBCCT ID
Number
MDBCCDT
1 = Cardholder
2 = Spouse
3=Child
4=Other
M
9 characters
R
R
1 = Cardholder
Claim Segment: Mandatory
Field #
NCPDP Field Name
Value
M/R/R Comment
W
111AM
Segment Identification
Ø7
Page: 170
M
Claim Segment
455EM
4Ø2D2
436E1
4Ø7D7
456EN
Prescription/Service Reference
Number Qualifier
Prescription/Service Reference
Number
Product/Service ID Qualifier
1 = Rx Billing
M
Rx Number assigned
by the pharmacy
Ø3 = National Drug
Code
NDC Number
M
Associated Prescription/Service
Reference #
New to MDBCCT
RW
457EP
Associated Prescription/Service
Date
New to MDBCCDT
RW
442E7
403D3
Quantity Dispensed
Metric Decimal
Quantity
Ø = Original
Dispensing
1-99 = Number of
refills
R
405D5
406D6
Days Supply
Compound Code
Ø = Not specified
1= Not a compound
2 = Compound
R
408D8
Dispense as Written (DAW)
Ø =Default, no product selection
indicated
RW
414DE
Date Prescription Written
Product/Service ID
Fill Number
M
M
R
Required when
submitting a claim
for a completion
fill
Required when
submitting a claim
for a completion
fill
The system will
edit on the 12th
refill
R
1=Physician request
2=patient request
3=pharmacist request
4=generic out of stock
(temp)
5=brand used as
generic
6=override
7=brand mandated by
law
8=generic not
available in
marketplace
9=not used
CCYYMMDD
Page: 171
R
Allow 0,1 or 5
415DF
420DK
Number of Refills Authorized
308C8
Other Coverage Code
Submission Clarification Code
Ø =Not Specified
1-99=number of refill
Ø =Not specified,
default
1=No override
2=Other override
3=Vacation Supply
4=Lost Prescription
5=Therapy Change
6=Starter Dose
7=Medically
Necessary
8=Process compound
for Approved
Ingredients
9=Encounters
99=Other
Ø=Not Specified
R
RW
Can be submitted
when submitting a
multi-line
compound claim.
R
1=No other Coverage Identified
2=Other coverage
exists-payment
collected
3=Other coverage exists-this
claim not covered
4=Other coverage exists-payment
not collected
5=Managed care plan
denial
6=Other coverage
exists, not a
participating provider
7=Other Coverage
exists-not in effect at
time of service
8=Claim is a billing
for a copay
429DT
Unit Dose Indicator
Ø =Not specified
1=Not Unit Dose
2=Manufacturer Unit
Dose
3=Pharmacy Unit
Dose
Page: 172
3 = Pharmacy Unit
Dose
418-DI Level of Service
3 = Emergency
RW
343HD
Dispensing Status
RW
344HF
Quantity Intended to be
Dispensed
P = initial Fill
C=Completion Fill
New to MDBCCDT
New to MDBCCDT
345HG
Days Supply Intended to be
Dispensed
New to MDBCCDT
RW
RW
Required when
submitting a claim
for an emergency
fill.
Required when
submitting a claim
for a partial fill
Required when
submitting a claim
for a partial fill
Required when
submitting a claim
for a partial fill
Pharmacy Provider Segment: Optional - Not used by MDBCCDT
Field #
NCPDP Field Name
Value
Prescriber Segment: Required
Field # NCPDP Field Name
Value
M/R/R
W
Comment
M/R/R Comment
W
111AM
466EZ
411DB
Segment Identification
Ø3
M
Prescriber ID Qualifier
12 = DEA
R
Prescriber ID
DEA Number
R
COB/Other Payments Segment: Optional
Field # NCPDP Field Name
111AM
Segment Identification
3374C
3385C
Coordination of Benefits/Other
Payments Count
Other Payer Coverage Type
Prescriber
Segment
.
Value
Ø5
M/R/R
W
Comment
M
COB/Other
Payments
Segment
M
M
(Repeatin
g)
Page: 173
3396C
Other Payer Id Qualifier
3407C
Other Payer ID
443E8
Other Payer Date
341HB
Other Payer Amount Paid Count
342HC
Other Payer Amount Paid
Qualifier
431DV
Other Payer Amount Paid
Blank=Not Specified
Ø1=National Payer ID
Ø2=Health Industry
Number
Ø3=Bank Information
Number (BIN)
Ø4=National
Association of
Insurance
Commissioners
(NAIC)
Ø9=Coupon
99-Other
R
Required when
submitting a
COB claim
Valid Value = 99
R
CCYYMMDD
Blank=Not specified
Ø1=Delivery
Ø2=Shipping
Ø3=Postage
Ø4=Administrative
Ø5=Incentive
Ø6=Cognitive Service
Ø7=Drug Benefit
Ø 8=Sum of all
Reimbursement
98=Coupon
99=Other
Only value
required is when
the recipient has
Medicare D
coverage and the
Other Payer ID =
77777
R
Required when
there is payment
from another
source
R
Required when
submitting this
segment
R
Required when
(Repeatin the re is payment
g)
from another
source
R
DUR/PPS Segment: Optional
Page: 174
Required when
there is payment
from another
source
Field #
NCPDP Field Name
Value
111AM
4737E
Segment Identification
Ø8
439E4
Reason For Service Code
See Attached list of
valid values
R
(Repeati
ng)
440E5
Professional Service Code
See Attached list of
valid values
R
441E6
Result of Service Code
See attached list of
valid values
R
Value
M/R/R
W
M
Comment
RW
Required when
submitting a copay only claim
Required when
submitting a claim
for a co-pay only
Required when
submitting a claim
for a copay only.
This amount must
equal Field 430DU.
DUR/PPS Code counter
Pricing Segment: Mandatory
Field # NCPDP Field Name
M/R/R
W
M
M
111AM
478H7
Segment Identification
11
Other Amount Claimed
Submitted Count
Used with Other
Coverage code 8
479H8
Other Amount Claimed
Submitted Qualifier
RW
480H9
Other Amount Claimed
Submitted
RW
426DQ
430–
DU
Usual and Customary Charge
R
Gross Amount Due
R
Page: 175
Comment
DUR/PPS
Segment
Required when
submitting this
segment
Required when
there is a conflict
to resolve or
reason for service
to be explained
Required when
there is a
professional
service to be
identified
Required when
There is a result
of service to be
submitted
Pricing Segment
For copay only
claims – this
amount must equal
the amount in field
480-H9
Coupon Segment: Segment is not supported
Field # NCPDP Field Name
Value
M/R/R
W
Comment
Compound Segment: Required When Submitting a Multi-Line
Compound Claim
Field #
NCPDP Field Name
Value
111AM
45ØEF
Segment Identification
1Ø
Compound Dosage Form
Description Code
M
451EG
Compound Dispensing Unit Form
Indicator
M
Page: 176
M/R/R
W
M
Comment
Compound
Segment
Ø1=Capsule
Ø2=Ointment
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
1=Each
2=Grams
3=Milliliters
452EH
Compound Route of
Administration
M
447EC
Compound Ingredient Component
(Count)
488RE
Compound Product ID Qualifier
489TE
Compound Product ID
448ED
Compound Ingredient Quantity
449EE
Compound Ingredient Drug Cost
M
(Repeat
ing)
M
(Repeat
ing)
M
(Repeat
ing)
M
(Repeat
ing)
NA
Prior Authorization Segment: Not Used by MDBCCDT Medicaid
Field # NCPDP Field Name
Value
Page: 177
M/R/R
W
1=Buccal
2=Dental
3=Inhalation
4=Injection
5=Intraperitoneal
6=Irrigation
7=Mouth/Throat
8=Mucous
Membrane
9=Nasal
1Ø=Ophthalmic
11=Oral
12=Other/Miscella
neous
13=Otic
14=Perfusion
15=Rectal
16=Sublingual
17=Topical
18=Transdermal
19=Translingual
2Ø=Urethral
21=Vaginal
22=Enteral
Ø3=National Drug
Code (NDC)
Not used by MD
BCCDT
Comment
Clinical Segment: Optional for MDBCCDT
Field # NCPDP Field Name
Value
13
M/R/R
W
NA
Comment
111AM
Segment Identification
491-VE
Diagnosis Code Count
RW
Required when a DX
is used to determine
coverage
492WE
Diagnosis Code
RW
424DO
Diagnosis Code
RW
Required when a
DX is used to
determine
coverage
Required when a
DX is used to
determine
coverage
Page: 178
Clinical Segment
APPENDIX B
OTHER CARRIER CODE LIST
OTHER_PAYER_ID OTHER_PAYER_NAME
I0288 ADVANCE PARADIGM
I1413 ADVANCED PCS
I1606 AETNA PHARMACY
I0340 AETNA PHARMACY MANAGEMENT
I1414 AETNA SERVICES INC
I1647 AETNA US HEALTHCARE
AT531 ALLIANCE PPO MAPST
I0255 AMERICAN COMMUNITY MUTUAL INS
I0411 ASSOCIATE PRESCRIPTION SERVICE
BB24D BC BS OF MD FED EMPLOYEES
AO655 BC/BS
I1758 BLUE CROSS BLUE SHIELD
I1174 CAREFIRST
BB24A CAREFIRST B/C B/S OF MD
AU146 CAREMARK
AY314 CAREMARK
I0530 CAREMARK
I0668 CAREMARK
I0691 CAREMARK
I1535 CAREMARK
AP622 CIGNA HEALTH CARE
I0534 CIGNA HEALTH CARE
AR983 CIGNA HEALTH PLAN
I1782 CIGNA PHARMACY
I1338 CIGNA RX
I1317 CLAIMS PRO
I0680 DIVERSIFIED PHARMACEUTICAL
I1329 ECKERD PHARMACY SERV
I1206 EXPRESS SCRIPT
I1061 EXPRESS SCRIPT VALUE RX
I0559 EXPRESS SCRIPTS
I0929 EXPRESS SCRIPTS
I1296 EXPRESS SCRIPTS
I1511 EXPRESS SCRIPTS
I1628 EXPRESS SCRIPTS
I1379 EXPRESS SCRIPTS/GOODYEAR
I0592 MEDCO
I0504 MEDCO BEHAVIORAL CARE
QD174 MEDCO MNG CARE-AIM COMP ASSOC
I0766 MERCK MEDCO
I1550 MERCK MEDCO
I0276 MERCK/MEDCO
I1783 MERCK/MEDCO
Maryland Medicaid Pharmacy Program Provider Manual
I1443 MERCK-MEDCO
I0907 MEREK MEDCO
AW076 MET LIFE
I1213 MMRX OF FLA
AT142 NATIONAL PRESCRIPTION ADM
I1214 NEIGHBOR CARE PHARMACY
I0262 NPA
I1158 NPA
I1778 PA BLUE SHIELD
AY653 PAID PRESCRIPTIONS
I0483 PAID PRESCRIPTIONS
I1074 PAID PRESCRIPTIONS
I1196 PAID PRESCRIPTIONS
I1259 PAID PRESCRIPTIONS
I1295 PAID PRESCRIPTIONS
I1579 PAID PRESCRIPTIONS
I1032 PAID PRESCRIPTIONS INC
I1180 PAID PRESCRIPTIONS INC
I0954 PCS
I1364 PCS
I0899 PCS HEALTH SYSTEM
QD185 PCS HEALTH SYSTEMS INC
I1106 PD PRESCRIPTIONS INS
I1250 PHARMACARE
I0856 PREFORM
I0498 PRO VANTAGE
AR076 PRUDENTIAL
I0323 RETAIL PHARMACY PROGRAM
I0244 RX PRIME
I1272 RX PRIME CUSSTOMER SERVICE
I1789 RX WEST
I0820 SCRIPT RX
I1621 SERVICE BENEFIT PLAN
AP070 TRIGON BC AND BS
I1330 UNITED CONCORDIA
I1439 UNITED HEALTH CARE
AT020 UNITED HEALTHCARE
I0491 VALUE RX
I0624 VALUE RX
I0824 VALUE RX
I0028 VALUE RX SERV
AY793 VALUE RX SERVICES
I1336 VSP
I1627 WELL POINT PHARMACY MANAGEMENT
88888 MEDICARE
99999 MEDICAID
PD999 MEDICARE D
Maryland Medicaid Pharmacy Program Provider Manual
Maryland Medicaid Pharmacy Program Provider Manual