Health PAS-Rx Help Desk Hints Version 1.58 West Virginia Medicaid Health PAS-Rx Help Desk Hints

Transcription

1 West Virginia Medicaid Health PAS-Rx Help Desk Hints Date of Publication: 12/15/2017 Document Version: 1.58

2 Privacy and Security Rules The Health Insurance Portability and Accountability Act of 1996 (HIPAA Public Law ) and the HIPAA Privacy Final Rule 1 and the American Recovery and Reinvestment Act (ARRA) of 2009 requires that covered entities protect the privacy and security of individually identifiable health information. Protected health information (PHI) includes demographic information and other health information and confidential information, whether verbal, written, or electronic, created, received, or maintained by Molina Healthcare about members and patients. It is healthcare data plus identifying information that would allow the data to tie the medical information to a particular person. PHI relates to the past, present, and future physical or mental health of any individual or recipient; the provision of healthcare to an individual; or the past, present, or future payment for the provision of healthcare to an individual. Claims data, prior authorization information, and attachments such as medical records and consent forms are all PHI CFR Parts 160 and 164, Standards for Privacy of Individually Identifiable Health Information; Final Rule Page 1 of 69

3 Disclaimer This document and information contains proprietary information. WV MMIS Provider Enrollment and Revalidation Authorization is hereby provided to you to copy documents published by Molina Medicaid Solutions on the Health PAS-OnLine portal provided such copies are used for non-commercial purposes and solely for use within your organization. This authorization is specifically conditioned upon including all legends, copyright, proprietary, and other notices that appear herein on all copies you make of such documents whether they pertain to Molina Medicaid Solutions or another party. No license is granted herein expressly, impliedly, by estoppel or otherwise under any patent or to use any trademark of any party. No other rights under any copyrights are granted herein, except as expressly stated above. The documents herein may refer to products and/or services that are neither available nor planned for availability in your particular locality. In referring to such products and/or services, Molina Medicaid Solutions incurs no obligation to subsequently make them available in your locality. DOCUMENTS PUBLISHED HEREIN ARE FURNISHED TO YOU "AS IS." THERE ARE NO WARRANTIES, EXPRESS, OR IMPLIED, BY OPERATION OF LAW OR OTHERWISE. MOLINA MEDICAID SOLUTIONS DISCLAIMS THE IMPLIED WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE AND NON- INFRINGEMENT AS TO BOTH MOLINA MEDICAID SOLUTIONS AND NON-MOLINA DOCUMENTS FURNISHED HEREIN. Some states or territories do not allow the exclusion of implied warranties and the foregoing exclusions may not be applicable to you. Any communication provided by you to Molina Medicaid Solutions relating to the documents furnished herein by Molina Medicaid Solutions will be received only on a non-confidential basis. There shall be no obligation on the part of Molina Medicaid Solutions with respect to use or disclosure of any information in such communication. Molina Medicaid Solutions shall have the unrestricted right to copy, use, and distribute any information you communicate including but not limited to any ideas, concepts, know-how, techniques, software, documentation, diagrams, schematics, or blueprints. Additionally, Molina Medicaid Solutions may use all such information in any manner or for any purpose including but not limited to developing products or providing services. The documents furnished herein by Molina Medicaid Solutions are subject to change without notice. All brand names and product names are acknowledged to be the trademarks or registered trademarks of their respective owners. Page 2 of 69

4 Table of Contents WV MMIS Provider Enrollment and Revalidation 1. INTRODUCTION EDIT RULES/DESCRIPTION/HELP DESK HINTS Edit 101 No Active Provider Contract Edit 104 Incomplete Provider Edit 108 Un-credentialed Provider Edit 149 Benefit does NOT meet date criteria on claim Edit 150 No Contract Term Found for Service Edit 152 Provider Type Does Not Match Required Type Required by Benefit Edit 155 Benefit Has Age Restriction Edit 156 Provider Type Does Not Match Type Required by Contract Term Edit 172 Term Does Not meet the Date Criteria of the Claim Edit 199 Benefit Rider Not Valid for Member DOS Edit 202 No Benefit for Service Edit 205 Benefit Requires Authorization Edit 217 Member May Be Incarcerated Edit 272 No Benefit For Service Edit 7001 No Copay for Children Edit 7002 No Copay for Pregnant Member Edit 7004 No Copay for Member in Nursing Home or ICF Edit 7005 No Copay for Family Planning Edit 7006 No Copay for 3 Day Emergency Supply Edit 7007 Medicare eligible; file Medicare first Edit 7009 Date Written is After Date Filled Edit 7010 Usual and Customary Charge Missing/Invalid format Edit 7011 Submit to Other Payer First Edit 7012 Claim Too Old to File Edit 7013 Claim Too Old to Reverse Edit 7018 Need Therapeutically Equivalent Generic Drug for Non-Compound Drug Edit 7019 Date Prescription Written Missing or Invalid Edit 7020 Claim is Post-Dated Edit 7021 No Product ID on Transaction Page 3 of 69

5 WV MMIS Provider Enrollment and Revalidation Edit 7024 Missing or Invalid Days Supply Edit 7025 Missing or Invalid Quantity Dispensed Edit 7026 Quantity Dispensed Exceeds Maximum Allowed Edit 7028 Compound Indicated but no Compound Segment Edit 7032 Missing or Invalid Compound Route of Administration Edit 7034 Compound Ingredient Component Count Exceeds Maximum Edit 7035 Missing or Invalid Claim Segment Edit 7039 Missing or Invalid Compound Product ID Qualifier Edit 7040 Missing or Invalid Compound Product ID Edit 7041 Invalid Other Coverage Code Edit 7043 Missing or Invalid Prescriber ID Qualifier Edit 7044 Missing or Invalid Coordination of Benefits/Other Payment Counts Edit 7045 Missing or Invalid Other Payer Coverage Type Edit 7046 Verify Other Payer Reject Code is Valid NCPDP Code Edit 7047 Missing Prescriber ID Edit 7048 Missing or Invalid Other Payer Amount Paid Edit 7050 Other Payer Reject Count Does not match Number of Repetitions Edit 7051 Missing or Invalid Other Payer Date Edit 7054 COB - Hospice Patient, so Hospice is primary payer Edit 7056 Invalid Transaction Count for Compounds Edit 7057 Missing or Invalid Transaction Count Edit 7060 Missing or Invalid Compound Ingredient Drug Cost Edit 7062 Non-Matched Unit of Measure to NDC for Non-Compound Drug Edit 7064 Non Matching Birth Date Edit 7067 Rx DUR DD Severity Edit 7068 Rx DUR DD Severity 3 thru Edit 7069 Rx DUR TD Severity Edit 7070 Rx DUR TD Severity 3 thru Edit 7071 Rx DUR ID Severity Edit 7072 Rx DUR ID Severity 3 thru Edit 7073 Rx DUR ER Severity Edit 7074 Rx DUR ER Severity 3 thru Edit 7075 Rx DUR LR Severity Page 4 of 69

6 Edit 7076 Rx DUR LR Severity 3 thru Edit 7077 Rx DUR PG Severity 1 Member is Pregnant Edit 7078 Rx DUR SX Severity 1 thru Edit 7079 Rx DUR HD Event Edit 7080 Rx DUR LD Event Edit 7081 Rx DUR MX Event Edit 7082 Invalid DUR/PPS Code Counter Edit 7085 Missing or Invalid Version Number Edit 7086 Missing or Invalid Transaction Code Edit 7087 Missing or Invalid Processor Control Code Edit 7091 Prescribing physician is not on file Edit 7092 Product/Service Not Covered DESI for Non-Compound Drug Edit 7093 Non Numeric DUR/PPS Code Counter Edit 7094 Invalid Step Therapy NDC Edit 7095 Invalid Number of Refills Edit 7096 Invalid Product/Service ID Qualifier for Pharmacy Edit 7097 Days Supply Exceeds Max for 3 Day Emergency Supply Edit 7100 Original Claim Not Found for Reversal Edit 7101 Dispensing fee for Nursing Home Edit 7102 Date of Service less than (LT) Date of Birth Edit 7103 Date of Service greater than (GT) Date of Death Edit 7106 Product/Service Not Covered Categorically Removed for Non-Compound Drug Edit 7107 Product/Service Not Covered Lot Terminated for Non-Compound Drug Edit 7109 Product/Service Not Covered NDC Not Activated for Non-Compound Drug 30 Edit 7111 Product/Service Not Covered Gender Check Edit 7112 Processing cannot be Completed Edit 7116 Pre-Natal Vitamin Checks Edit 7117 Missing DUR/PPS segment for DUR Override Edit 7118 Invalid Product/Service ID value for DUR Override Edit 7119 Limited Pharmacy Services - Claim Too Old to File Edit 7121 Recipient is Locked In Edit 7122 No Copay for Diabetic Supplies Page 5 of 69

7 Edit 7124 Missing or Invalid Prescriber Segment Edit 7125 Invalid Product/Service ID value for Compound Drug Edit 7126 Invalid Product/Service ID Qualifier value for Compound Drug Edit 7127 Medicare eligible; not enrolled Edit 7130 Partial Fill Transaction Not Supported Edit 7131 Provider not active for Plan on DOS Edit 7134 Scheduled Drug Claim Refill Too Old to File Edit 7135 Invalid Service Provider ID Qualifier Edit 7136 Claim Date Written is Post-Dated Edit 7137 Member not eligible on DOS Edit 7138 No Product ID Qualifier on Transaction for DUR Override Edit 7139 Invalid Professional Service Code DUR OVR Edit 7140 Invalid Reason for Service Code DUR OVR Edit 7141 Invalid Result of Service Code DUR OVR Edit 7142 Days Supply Exceeds Max for 3-Day Emergency Supply for Compound Drug Edit 7143 Invalid Time Span for Refills Edit 7146 Scheduled Drug Claim Too Old to File for Compound Drugs Edit 7147 For Non-Compound Drug Claim No Vacation Supply allowed for Scheduled Drugs (IGNORE) Edit 7148 For Non-Compound Drug Claim No Lost Script Supply allowed for Scheduled Drugs Edit 7149 Invalid Product/Service ID Qualifier for Reversals Edit 7151 For Compound Scheduled Drug Claim No Vacation Supply allowed (IGNORE) Edit 7152 For Compound Scheduled Drug Claim No Lost Script Supply allowed (IGNORE) Edit 7154 For Non-Compound Drug Claim, Invalid Vacation Supply for Non-Scheduled drugs (IGNORE) Edit 7155 For All Drug Claims, MaxRxDays limitation of Days Supply check Edit 7156 Missing or Invalid Ingredient Cost Submitted Edit 7157 Compound Drug requires 1 Legend NDC Edit 7158 No Copay for Limited Pharmacy Services Edit 7159 Compound Drug requires more than 1 Ingredient Page 6 of 69

8 Edit 7160 Product/Service Not Covered Categorically Removed on Compound Drug Ingredient Edit 7161 Product/Service Not Covered Lot Terminated for Compound Drug Edit 7162 Product/Service Not Covered NDC Not Activated for Compound Drug Edit 7166 No Drug Rebate Agreement exists for this NDC for Compound Drug Edit 7167 Product/Service Not Covered DESI for Compound Drug Edit 7169 Need Therapeutically Equivalent Generic Drug for Compound Drug Edit 7170 Rx DUR DD Severity 1 or 2 for Compound Secondary Occurrences Edit 7171 Rx DUR TD Severity 1 for Compound Secondary Occurrences Edit 7172 Rx DUR ID Severity 1 for Compound Secondary Occurrences Edit 7173 Rx DUR ER Severity 1 for Compound Secondary Occurrences Edit 7174 Rx DUR LR Severity 1 or 2 for Compound Secondary Occurrences Edit 7175 Rx DUR HD Event for Compound Secondary Occurrences Edit 7176 For Non-Scheduled Compound Drug, Invalid Vacation Supply (IGNORE) Edit 7178 Member not found Edit 7179 Rx DUR Stopped Processing so Not Performed Edit 7180 Secondary DESI Ingredient Reimburse at zero for Compound Drug Edit 7181 Non-Rebateable Secondary Ingredient Reimburse at zero for Compound Drug.. 44 Edit 7184 Refill not allowed as too soon (IGNORE) Edit 7185 Missing or Invalid Birth Date Edit 7187 User Max Units limitation Exceeded Edit 7189 Submission Clarification Code so turn off Rx DUR processing (Ignore) Edit 7190 No price available on NDC tables for drug Edit 7191 After COB calculation reimbursement amount is $ Edit 7192 Lost/Stolen Prescriptions - Exceeds Days Supply Allowed (IGNORE) Edit 7193 Batch Claim Verification Edit 7194 Medicare eligible; file Medicare first For compound drugs Edit 7195 Missing Prior Authorization Number Submitted Edit 7196 User Sum of quantity dispensed within script time span exceeds limits Edit 7197 Submission of Claim on Paper is required Edit 7198 No units remaining on PA Edit 7199 Insufficient units remaining on PA Edit 7200 Claim DOS too old to file Page 7 of 69

9 Edit 7202 Rx DUR DD Severity Edit 7203 Rx DUR TD severity Edit 7204 Rx DUR ID severity Edit 7205 Rx DUR ER severity Edit 7206 Rx DUR LR severity Edit 7208 Insulin User Max Units limitations Edit 7209 Insulin User Sum of quantity dispensed within script time span exceeds limits.. 49 Edit 7210 Days Supply of 30 for Limited Pharmacy Services Edit 7212 Other Payer Amount Paid not Zero Edit 7214 Scheduled Drug Claim Too Old to File Edit 7215 PA Daily Dose Units Exceeded Edit 7216 Invalid Number of Refills for Compound Drugs Edit 7217 Duplicate Claim by Provider and GCN Sequence Number Edit 7218 PA Daily Dose Units Exceeded Compound Drug Edit Insufficient units remaining on PA Compound Drug Edit Submit to Other Payer First Part D Edit Wrap Around Part-D Edit 7223 Need Therapeutically Equivalent Generic Drug for Non-Compound Drug Pre Edit 7224 Need Therapeutically Equivalent Generic Drug for Compound Drug Pre Edit 7225 Missing Prescriber ID Qualifier Edit 7226 Missing Reason for Service Code Edit 7227 Missing Professional Service Code Edit 7228 Missing Result of Service Code Edit 7229 Missing or Invalid Patient Segment Edit 7230 Claim Amount Threshold Edit 7231 Basic Medicaid Plan Limitations Edit 7232 Prescribing DEA Number is Invalid Edit 7233 Provider ID Not a Valid NPI Number Edit 7234 Prescriber ID Not a Valid NPI Number Edit 7235 DAW Code Edit 7236 Basic Medicaid Plan Transition Period Page 8 of 69

10 WV MMIS Provider Enrollment and Revalidation Edit 7237 Provider NPI Entered as Prescriber NPI Edit 7238 Prescriber Used is DEA and Not NPI Edit 7239 Package Unit Billing Enforced Edit 7240 PA Check on Compound Secondary Ingredients Edit B Provider Price Assurance Edit Edit 7242 Prescriber Type Validation Edit 7243 Prescriber Exclusion Edit 7244 Rx DUR PG Severity 1 Member is Not Pregnant Edit 7245 Rx DUR PG Severity 2 Member is Pregnant Edit 7246 Rx DUR PG Severity 2 Member is Not Pregnant Edit 7247 Rx DUR PG Severity Edit 7248 Duplicate Ingredient NDC or GSN in Compound Edit 7249 Duplicate Therapy In Compound Ingredient Edit 7250 Rx DUR TD Severity 2 for Compound Secondary Occurrences Edit 7251 Rx DUR ID Severity 2 for Compound Secondary Occurrences Edit 7252 Rx DUR ER Severity 2 for Compound Secondary Occurrences Edit 7253 Invalid or Incomplete Compound Claim Edit 7254 Compound Max Units limitation exceeded Edit 7255 Cmpd User Sum qty disp within script time span exceeds limit Edit 7256 Compound NDC Daily Dose Exceeds Maximum Allowed Edit 7257 Compound: No Pricing for DME Products Edit 7258 Invalid Other Payer Reject Code Edit 7259 Patient Paid Amount Submitted is Required Edit 7260 Member Does Not Have Current External Eligibility Edit 7261 Missing Coordination of Benefits/Other Payer Reject Count Edit 7262 Reject Code Not Allowed with OCC Edit 7263 Missing Patient Gender Edit 7264 Missing Patient Last Name Edit 7265 Missing Fill Number Edit 7266 Missing Compound Code Edit 7267 Missing DAW Code Edit 7268 Missing Gross Amount Due Edit 7269 Compound Route of Administration Is Not Allowed Page 9 of 69

11 WV MMIS Provider Enrollment and Revalidation Edit 7270 Claim Route of Administration Is Required (IGNORE) Edit 7271 Submission Clarification Code Is Not Supported Edit 7272 Place of Service Not Supported Edit 7273 Other Payer Coverage Type Not Supported Edit 7274 Other Payer ID Qualifier Not Supported Edit 7275 Missing or Invalid Patient Responsibility Amount Count Edit 7276 Other Payer-Patient Responsibility Qualifier Edit 7277 Other Payer-Patient Responsibility Amount is Required Edit 7278 Patient Paid Amount No longer Supported Edit 7279 Missing or Invalid Compound Ingredient Quantity Edit Claim is Not Supported Edit 7281 MCO Exclusions Edit 7282 DAW Code 4 for Brand Product Edit 7283 MCO Exclusions Compounds Edit 7284 Special Pharmacy Requires COB Edit 7285 Special Prescriber List Edit 7286 No Diabetic SMAC Price Edit 7287 Gender or Age Invalid for Pregnancy Indicator Edit 7288 No Refills Allowed for NDC Edit 7289 Edit Override One-time use only Edit 7290 One Flu Vaccine per Season Edit 7301 Mismatch of Quantity/Days Supply for EO to claim Edit 7302 Invalid Authority to do this EO Edit 7501 No DEA for Controlled Substance Edit 7502 Provider Type Class 2 Narcotics Edit Day Emergency Refill Limitation Edit 7504 Provider Denied for All Claims Edit 7505 Member Excluded from Receiving Dispensed Drug Edit 7506 Recipient is Locked into Prescriber Edit Recipient is Locked into Prescriber and Submitted Drug Edit 7508 Member is not in an MCO Edit 7509 Provider Not Enrolled As 340B Edit 7510 Billed to Wrong Payer Page 10 of 69

12 Edit 7511 Requires Specialized Review Edit B SCC indicated incorrectly Edit 7513 No Benefit For Service Edit 7514 Drug Class Requires Prescriber Enrollment Edit 7515 DAW Code 8 - for Brand Product Edit 7516 Pharmacist cannot dispense drug type Edit Claim in process for Same Household Edit 7999 Same Member is Already in Process Introduction The purpose of this document is to guide Pharmacy providers with the various claim edits, or submission errors that may cause a claim to not pay. 2. Edit Rules/Description/Help Desk Hints Edit 101 No Active Provider Contract Description The provider must have an active contract. If not, this edit is posted. Hints Verify that the provider has an active contract. Edit 104 Incomplete Provider Description The provider information is invalid or incomplete. Hints Contact the help desk for further information. Edit 108 Un-credentialed Provider Description The provider must have an active license and credentials on file. If not, this edit is posted. Hints Verify that the provider has an active license and credentials on file. Edit 149 Benefit does NOT meet date criteria on claim Description The claim is being filled before the benefit is effective, so this edit is posted. Hints Correct the National Drug Code (NDC) or contact the help desk for further information. Edit 150 No Contract Term Found for Service Description The service billed is a service not identified in the provider s contract. Hints Contact the help desk for further information. Edit 152 Provider Type Does Not Match Required Type Required by Benefit Description The provider type on file does not match the required type that is Page 11 of 69

13 Hints required by the benefit. Contact the help desk for further information. Edit 155 Benefit Has Age Restriction Description The drug benefit is not covered for the member s age. Hints Correct the National Drug Code (NDC) or contact the help desk for further information. Edit 156 Provider Type Does Not Match Type Required by Contract Term Description The provider type on file does not match the type that is required by the contract term on the Date of Service (DOS). Hints Contact the help desk for further information. Edit 172 Term Does Not meet the Date Criteria of the Claim Description The pharmacy is not contracted with the plan on the Date of Service (DOS). Hints Contact the help desk for further information. Edit 199 Benefit Rider Not Valid for Member DOS Description The benefit rider is not valid for the member on the Date of Service (DOS). Hints The member is not eligible for End Stage Renal Disease (ESRD) benefits on DOS. Contact the help desk for further information. Edit 202 No Benefit for Service Description The Pharmacy benefit National Drug Code (NDC) must be in NDC file and active on Date of Service (DOS). Hints NDC is either not a known NDC or it is marked as obsolete on DOS. Edit 205 Benefit Requires Authorization Description A claim is received for a service which requires Prior Authorization (PA), but the PA has not been issued. Hints Contact the help desk for further information. Edit 217 Member May Be Incarcerated Description A claim is received for a member who may be incarcerated. If the database indicates the member is incarcerated, this edit is posted. Hints Contact the help desk for further information. Edit 272 No Benefit For Service Description The Pharmacy benefit (NDC) must be in NDC file and active on Date of Service and have coverage code equaling the coverage code of the member on the claim Page 12 of 69

14 Hints NDC doesn t have a coverage code that equals the member coverage code. Edit 7001 No Copay for Children Description Members under the age of 18 (17 years and 11months or less) have no copay on pharmacy claims. Hints Member is under 18 years of age so no copay should be charged. Page 13 of 69

15 Edit 7002 No Copay for Pregnant Member Description Female Members who are pregnant have no copay on pharmacy claims. They also have no copay for 60 days beyond the end of the pregnancy. Member/recipient s pregnancy must be indicated either by an indicator on file, or submitted on the Patient Segment in the Pregnancy Indicator field (335-2C) as a value 2 for pregnant. If member is pregnant, no copay is due on the claim. Hints Member is pregnant so no copay should be charged. Edit 7004 No Copay for Member in Nursing Home or ICF Description No copay required on pharmacy claims for members residing in Nursing Home (NH) or Intermediate Care Facility/Mental Retardation (ICF/MR) facilities. Basic Nursing Facility/ICF is identified based on a description on file. Member is in Nursing Home/Intermediate Care Facility (NH/ICF) so no copay should be charged. Edit 7005 No Copay for Family Planning Description No copay required for approved family planning items. Hints Prescription is for Family Planning Items so no copay should be charged. Edit 7006 No Copay for 3 Day Emergency Supply Description No copay is required for a three-day emergency supply. The three-day emergency supply does not count as a refill and no Prior Authorization (PA) is required. However, an override code of 99 must be submitted in the Submission Clarification Code. There is no limit on the number of three-day emergency supply claims for any specific prescription for a member, and there is no limit on the total number of prescriptions that a member can receive for a three-day emergency supply. The claim could be the original filling waiting for a PA or a refill during off hours. Hints Prescription is for emergency three day supply so no copay should be charged. Edit 7007 Medicare eligible; file Medicare first Description A member is Medicare eligible when he has Medicare AB or Medicare B. If the member has active Medicare coverage and the member is in a nursing home (NH), check whether the non-compound claim National Drug Code (NDC) is for inhalation therapy. If it is, this edit is bypassed. Otherwise, if the claim NDC for a Medicare member is for a Medicare covered drug, this edit is posted. Hints If the member has Medicare and the drug is for inhalation therapy, this edit will not post, but if the drug for the Medicare member is covered by Medicare, the pharmacist must file with Medicare first. Page 14 of 69

16 WV MMIS Provider Enrollment and Revalidation Edit 7009 Date Written is After Date Filled Description For each prescription within the claim, if the date the prescription was written is after the date the prescription is attempting to be filled by the pharmacy provider, this edit is posted. Hints Date written for the prescription is incorrect. Correct and resubmit. Edit 7010 Usual and Customary Charge Missing/Invalid format Description For each prescription within the claim, the Usual and Customary Charge is a required entry and must contain a valid dollar value. If not, the claim is denied. Hints Usual and Customary charge is missing or invalid. Correct and resubmit. Edit 7011 Submit to Other Payer First Description For each prescription within the claim, if no Coordination of Benefits (COB)/Other Payments Segments were submitted the member s eligibility is reviewed to determine if the member has external coverage. If the member has external coverage, this edit is posted, as Medicaid is not the primary payer. Hints Need to submit to Other Payer first as defined in the returned text of the error message. Medicaid is not the primary payer. Edit 7012 Claim Too Old to File Description For each prescription within the claim, if the date the prescription was written is more than one year older than the claim Date of Service (DOS), this edit is posted. Hints Claim was filled after the one-year deadline for filing, based on the date the prescription was written. Edit 7013 Claim Too Old to Reverse Description For each prescription within the Reversal request, the original pharmacy prescription must be reversed within one year of date of the original pharmacy claim submission. If not, this edit is posted. Hints Reversal Claim was submitted more than one year after the original claim that the pharmacist is attempting to reverse was submitted. Edit 7018 Need Therapeutically Equivalent Generic Drug for Non-Compound Drug Description For each prescription within the claim, if the Dispense As Written (DAW) code contains the value 1, 4, 5, 6, 8, or 9; or the National Drug Code (NDC) is found on the preferred drug list, this edit is not posted. Otherwise, if the NDC is a Brand Name drug, this edit will post, if a therapeutically equivalent generic drug is available. DAW Codes: 1=Substitution Not Allowed by Prescriber 4=Substitution Allowed-Generic Drug Not in Stock Page 15 of 69

17 5=Substitution Allowed-Brand Drug Dispensed as a Generic 6=Override 8=GENERIC NOT AVAILABLE IN MARKETPLACE 9=Substitution Allowed By Prescriber but Plan Requests Brand - Patient's Plan Requested Brand Hints Review therapeutically equivalent generic NDCs on file, select a substitute NDC, and re-submit claim. Edit 7019 Date Prescription Written Missing or Invalid Description For each prescription within the claim, if the Date Prescription Written is blank or contains an invalid date value, the claim is denied. Hints Correct date and resubmit claim. Edit 7020 Claim is Post-Dated Description A pharmacy claim cannot be post-dated. If the Date of Service (DOS) of the claim being submitted for processing is after the current system date, this edit is posted. Hints Correct DOS and resubmit claim. Edit 7021 No Product ID on Transaction Description This edit is not performed for compound claims. Each prescription within the claim must have a valid and complete National Drug Code (NDC) to identify the drug being processed. If not, this edit is posted. Hints The claim NDC was not found on the drug file; check with the Prescriber to validate the NDC. Edit 7024 Missing or Invalid Days Supply Description For each prescription within the claim, if the Days Supply specified is missing or not a valid value, the claim is denied. Hints Correct days supply field and resubmit the claim. Edit 7025 Missing or Invalid Quantity Dispensed Description The quantity dispensed must be expressed in metric decimal quantity and not be zero. If quantity dispensed expressed in metric decimal units is missing or invalid, deny the claim. Hints Correct the quantity dispensed and resubmit the claim Edit 7026 Quantity Dispensed Exceeds Maximum Allowed Description This edit is not performed for compound claims. For each prescription within the claim, determine if there is a maximum daily dose for the National Drug Code (NDC) being prescribed. If one is defined, determine the daily dose being prescribed which is calculated as quotient of Quantity Dispensed divided by the Days Supply. If the quotient exceeds Page 16 of 69

18 Hints the defined maximum daily dose, this edit is posted. Correct the quantity dispensed and resubmit the claim Edit 7028 Compound Indicated but no Compound Segment Description When processing a compound claim (Compound Code = 2 ), if there is no valid compound segment within the claim, this edit is posted. Hints Claim compound code suggests a compound drug is being submitted but the compound drug information segment is missing or invalid. Revise information and resubmit the claim. Edit 7032 Missing or Invalid Compound Route of Administration Description When processing a compound drug claim, if the Compound Route of Administration is missing or not valid, the claim is denied. Valid values are 1 through 22. Hints The segment for compounds has an invalid compound route of administration value submitted. Revise information and resubmit the claim. Edit 7034 Compound Ingredient Component Count Exceeds Maximum Description When processing a compound drug claim, if the Compound Ingredient Component Count is greater than 25, this edit is posted. Hints The segment for compounds has an invalid number of ingredients submitted. Revise information and resubmit the claim. Edit 7035 Missing or Invalid Claim Segment Description Pharmacy billing and pharmacy reversal requests must have a claim segment. If no valid claim segments exist within the request, the request is denied. Hints The transmission is missing a Claim segment for one or more of the transactions submitted. Revise information and resubmit the claim. Edit 7039 Missing or Invalid Compound Product ID Qualifier Description When processing a compound drug claim, each ingredient must have a Compound Product ID Qualifier containing the value 03 National Drug Code (NDC), otherwise, this edit is posted. Hints The claim has invalid or missing data in the Compound Product ID Qualifier field for one or more of the compound drug ingredients. Revise information and resubmit the claim. Edit 7040 Missing or Invalid Compound Product ID Description When processing a compound claim, each compound ingredient must be specified with a valid National Drug Code (NDC); otherwise, this edit is posted. Hints For a compound drug, an ingredient s NDC is not found on the NDC file. Correct the NDC and resubmit the claim. Page 17 of 69

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20 Edit 7041 Invalid Other Coverage Code Description For each prescription within a claim that has a Coordination of Benefits (COB)/Other Payments Segment, the Other Coverage Code (OCC) is required and must contain one of these valid values: 2=Other coverage exists payment collected 3=Other coverage exists this claim not covered 4=Other coverage exists payment not collected (commonly used for 100% copay) If not supplied or not one of these values, this edit is posted. Hints When submitting information from other payer, Other Coverage Code (OCC) on the claim segment must also be submitted. Correct this information and resubmit the claim. Edit 7043 Missing or Invalid Prescriber ID Qualifier Description For each prescription within the claim, if the Prescriber ID Qualifier in the Prescriber Segment does not contain the value of 12 (indicating a Drug Enforcement Agency (DEA) number is used for the Prescriber ID), or a value of 01 for National Provider Identifier (NPI), this edit is posted. Hints An invalid Prescriber ID Qualifier value was submitted. Correct it and resubmit the claim. Edit 7044 Missing or Invalid Coordination of Benefits/Other Payment Counts Description For each prescription within the claim, if the Coordination of Benefits (COB)/Other Payments Segment exist, the count must match the number of other insurers/payers to whom the claim was filed before being filed to Medicaid. Information for up to three other insurers/payers is accepted. For each Other Payer ID, either the Payment Amount or Reject Codes must be submitted. If not, the claim is denied. Hints The Other Payer count does not match the number of Other Payer information submitted. Correct information and resubmit the claim. Edit 7045 Missing or Invalid Other Payer Coverage Type Description For each prescription within the claim, if the Coordination of Benefits (COB)/Other Payments Segment exists, and the code identifying the type of Other Payer Coverage Type is missing or invalid, this edit is posted. Other Payer Coverage Type must be entered for each occurrence of Other Payer information submitted and be a valid National Council for Prescription Drug Programs (NCPDP) value of either: blank=not Specified, 01 =Primary, 02 =Secondary, or 03 =Tertiary. Hints An invalid Other Payer Coverage Type value was submitted. Correct it and resubmit the claim. Page 19 of 69

21 WV MMIS Provider Enrollment and Revalidation Edit 7046 Verify Other Payer Reject Code is Valid NCPDP Code Description For each prescription within the claim, if the Coordination of Benefits (COB)/Other Payments Segment exist, and any of the first five occurrences of Other Payer Reject Code (472-6E) is an invalid National Council for Prescription Drug Programs (NCPDP) error code, this edit is posted. For each Other Payer not making a payment, the reasons for rejection must be reported. The Other Payer Reject Count identifies the number of reasons being reported with a maximum of five reject reasons per Other Payer being checked. Ignore any further reject codes. There can be a maximum of 20 occurrences per payer, but recommended usage is five or less. Hints An invalid Other Payer Reject Code value was submitted. Validate information and resubmit the claim. Edit 7047 Missing Prescriber ID Description For each prescription within the claim, if the Prescriber ID field is not present within the prescription s Prescriber Segment, the claim is denied. Hints The Prescriber ID field is missing and not submitted. Validate information and resubmit the claim. Edit 7048 Missing or Invalid Other Payer Amount Paid Description For each prescription within a claim that has a Coordination of Benefits (COB)/Other Payments Segment where the Other Coverage Code is 2, sum all of the Other Payer Amount Paid values. If this sum is not greater than $0.00, this edit is posted for the last occurrence of the Other Payer Amount Paid value. Note: It is possible to have a Coordination of Benefits (COB)/Other Payments Segment for each prescription that does not have any payments at all but contain only reject codes. For this case when the Other Coverage Code is 2 and there are no payments submitted, this edit is posted. Hints Invalid Other Payer Amount Paid was submitted; must be numeric and greater than $0.00 for each occurrence if Other Coverage Code does not equal 4 for no money from other payer due to copay or deductible amounts. Validate information and resubmit the claim. Edit 7050 Other Payer Reject Count Does not match Number of Repetitions Description For each prescription within the claim, if the Coordination of Benefits (COB)/Other Payments Segment exists, and the value in Other Payer Reject Count does not match the number of reject codes submitted, this edit is posted. Hints Number of Other Payer reject code occurrences does not match the actual number of occurrences submitted. Validate information and resubmit the claim. Page 20 of 69

22 Edit 7051 Missing or Invalid Other Payer Date Description For each prescription within the claim, if the Coordination of Benefits (COB)/Other Payments Segment exist, the Other Payer Date must exist and be a valid date, otherwise, the claim is denied. Hints The Other Payer date either does not exist or is not a valid date. Validate information and resubmit the claim. Edit 7054 COB - Hospice Patient, so Hospice is primary payer Description Pharmacy billing and pharmacy eligibility requests must have an Insurance Segment. If the Insurance Segment does not exist or is invalid, the request is denied. Hints Member is in a Hospice program. Claim must be submitted to Hospice first because Medicaid is not the primary payer. Edit 7056 Invalid Transaction Count for Compounds Description For a Billing request, there can only be one prescription when the prescription is for a compound, otherwise, this edit is posted. Also, if there are multiple prescriptions and if the second through fourth prescription is for a compound, this edit is posted. Hints The claim submitted is for a compound drug. Only one transaction per transmission is allowed for compounds. Edit 7057 Missing or Invalid Transaction Count Description For a B1 transaction, the count of prescriptions in the transmission is missing or invalid if it is not one through four, and does not correctly reflect the total occurrences of claims on the transaction. Hints An invalid transaction count number was submitted. Validate information and resubmit claim. Edit 7060 Missing or Invalid Compound Ingredient Drug Cost Description When processing a compound drug claim, if any Compound Ingredient Drug Cost is not expressed as a valid dollar amount value, this edit is posted. Hints An invalid Compound Ingredient Drug Cost was submitted for one or more of the ingredients in the claim. Validate information and resubmit claim. Page 21 of 69

23 Edit 7062 Non-Matched Unit of Measure to NDC for Non-Compound Drug Description This edit is not performed for compound drug claims. For each prescription within the claim, if the Unit of Measure within the prescription does not match the unit of measure as extracted from the Database for the prescribed NDC, this edit is posted. Valid Unit of Measure values are: EA=Each; GM=Grams; ML=Milliliters. Hints An invalid Unit of Measure value was submitted. Validate the information and resubmit claim. Edit 7064 Non Matching Birth Date Description When the claim member Date of Birth (DOB) does not match the DOB on file for the member, this edit is posted. Hints An invalid DOB value was submitted. Validate information and resubmit claim. Edit 7067 Rx DUR DD Severity 1 Description For each prescription within the claim, if the Rx Drug Utilization Review (DUR) module produces a Drug-to-Drug (DD) Event with a Severity Level of 1 and the Severity Ranking Code is less than or equal to 70, this edit is posted. This edit will be posted even if the prescription submitted has DUR/PPS (Prospective Payment System) information attempting to override this DD Event. The source National Drug Code (NDC) is extracted from either the Claim Segment for non-compound claims or from the Primary Ingredient (occurrence 1 ) within a compound drug claim. Hints For Severity Level 1, the help desk must be called and a Prior Authorization (PA) number obtained. If approved for an Override, the PA number must be submitted on the claim, to override the DUR event. A review of all drugs a member is taking needs to be performed. Validate information and resubmit claim with proper override, if necessary. Edit 7068 Rx DUR DD Severity 3 thru 5 Description For each prescription within the claim, if the Rx Drug Utilization Review (DUR) module produces a Drug-to-Drug (DD) Event with a Severity level of 3, 4, or 5, and the Severity Ranking Code is less than or equal to 70, this edit is posted. This edit will be posted even if the prescription submitted has DUR/PPS (Prospective Payment System) information attempting to override these DD Events. The source National Drug Code (NDC) is extracted from either the Claim Segment for noncompound claims or iterated for all Ingredients within a compound drug claim. Hints Need to review all drugs a member is taking and send a warning. Page 22 of 69

24 Edit 7069 Rx DUR TD Severity 1 Description For each prescription within the claim, if the Rx Drug Utilization Review (DUR) module produces a Therapeutic Duplication (TD) Event with a Severity Level of 1 and the Severity Ranking Code is less than or equal to 70, this edit is posted. This edit will be posted even if the prescription submitted has DUR/PPS (Prospective Payment System) information attempting to override this TD Event. The source National Drug Code (NDC) is extracted from either the Claim Segment for noncompound claims or from the Primary Ingredient (occurrence 1 ) within a compound drug claim. Hints For Severity Level 1, the help desk must be called and a Prior Authorization (PA) number requested. If approved for an Override, the PA number must be submitted on the claim, to override the DUR event. Need to review all drugs which a member is taking. Validate information and resubmit claim with proper override, if necessary. Edit 7070 Rx DUR TD Severity 3 thru 5 Description For each prescription within the claim, if the Rx Drug Utilization Review (DUR) module produces a Therapeutic Duplication (TD) Event with a Severity level of 3, 4, or 5, and the Severity Ranking Code is less than or equal to 70, this edit is posted. This edit will be posted even if the prescription submitted has DUR/PPS (Prospective Payment System) information attempting to override these TD Events. The source National Drug Code (NDC) is extracted from either the Claim Segment for noncompound claims or iterated for all Ingredients within a compound drug claim. Hints Need to review all drugs a member is taking and send a warning. Edit 7071 Rx DUR ID Severity 1 Description For each prescription within the claim, if the Rx Drug Utilization Review (DUR) module produces an Ingredient Duplication (ID) Event with a Severity Level of 1 and the Severity Ranking Code is less than or equal to 70, this edit is posted. This edit will be posted even if the prescription submitted has DUR/PPS (Prospective Payment System) information attempting to override this ID Event. The source National Drug Code (NDC) is extracted from either the Claim Segment for noncompound claims or from the Primary Ingredient (occurrence 1 ) within a compound drug claim. Hints For Severity Level 1, the help desk must be called and a Prior Authorization (PA) number requested. If approved for an Override, the PA number must be submitted on the claim, to override the DUR event. Need to review all drugs a member is taking. Validate information and resubmit claim with proper override, if necessary. Page 23 of 69

25 Edit 7072 Rx DUR ID Severity 3 thru 5 Description For each prescription within the claim, if the Rx Drug Utilization Review (DUR) module produces an Ingredient Duplication (ID) Event with a Severity level of 3, 4, or 5, and the Severity Ranking Code is less than or equal to 70, this edit is posted. This edit will be posted even if the prescription submitted has DUR/PPS (Prospective Payment System) information attempting to override these ID Events. The source National Drug Code (NDC) is extracted from either the Claim Segment for noncompound claims or iterated for all Ingredients within a compound drug claim. Hints Need to review all drugs a member is taking and send a warning. Edit 7073 Rx DUR ER Severity 1 Description For each prescription within the claim, if the Rx Drug Utilization Review (DUR) module produces an Early Refill (ER) Event with a Severity Level of 1 and the Severity Ranking Code is less than or equal to 70, this edit is posted. This edit will be posted even if the prescription submitted has DUR/PPS (Prospective Payment System) information attempting to override this ER Event. The source National Drug Code (NDC) is extracted from either the Claim Segment for non-compound claims or from the Primary Ingredient (occurrence 1 ) within a compound drug claim. Hints For Severity 1, the help desk must be called and a Prior Authorization (PA) number requested. If approved for an Override, the PA number must be submitted on the claim, to override the DUR event. Need to review all drugs which a member is taking. Validate information and resubmit claim with proper override, if necessary. Edit 7074 Rx DUR ER Severity 3 thru 5 Description For each prescription within the claim, if the Rx Drug Utilization Review (DUR) module produces an Early Refill (ER) Event with a Severity level of 3, 4, or 5, and the Severity Ranking Code is less than or equal to 70, this edit is posted. This edit will be posted even if the prescription submitted has DUR/PPS (Prospective Payment System) information attempting to override these ER Events. The source National Drug Code (NDC) is extracted from either the Claim Segment for non-compound claims or iterated for all Ingredients within a compound drug claim. Hints Review all drugs a member is taking and send a warning. Page 24 of 69

26 Edit 7075 Rx DUR LR Severity 1 Description For each prescription within the claim, if the Rx Drug Utilization Review (DUR) module produces a Late Refill (LR) Event with a Severity Level of 1 and the Severity Ranking Code is less than or equal to 70, this edit is posted. This edit will be posted even if the prescription submitted has DUR/PPS (Prospective Payment System) information attempting to override this LR Event. The source National Drug Code (NDC) is extracted from either the Claim Segment for non-compound claims or from the Primary Ingredient (occurrence 1 ) within a compound drug claim. Hints For Severity 1, the help desk must be called and a Prior Authorization (PA) number requested. If approved for an Override, the PA number must be submitted on the claim, to override the DUR event. Need to review all drugs a member is taking. Validate information and resubmit claim with proper override, if necessary. Edit 7076 Rx DUR LR Severity 3 thru 5 Description For each prescription within the claim, if the Rx Drug Utilization Review (DUR) module produces a Late Refill (ER) Event with a Severity level of 3, 4, or 5, and the Severity Ranking Code is less than or equal to 70, this edit is posted. This edit will be posted even if the prescription submitted has DUR/PPS (Prospective Payment System) information attempting to override these LR Events. The source National Drug Code (NDC) is extracted from either the Claim Segment for non-compound claims or iterated for all Ingredients within a compound drug claim. Hints Review all drugs a member is taking and send a warning. Edit 7077 Rx DUR PG Severity 1 Member is Pregnant Description For each prescription within the claim, if the Rx Drug Utilization Review (DUR) module produces a Pregnancy Precaution (PG) Event with a Severity level of 1, the member is pregnant, and the Severity Ranking Code is less than or equal to 70, this edit is posted. This edit will be posted even if the prescription submitted has DUR/PPS (Prospective Payment System) information attempting to override these PG Events. The source National Drug Code (NDC) is extracted from either the Claim Segment for non-compound claims or iterated for all Ingredients within a compound drug claim. Hints Notify the member of the danger; call Rational Drug Therapy Program (RDTP) for an Edit Override (EO), if necessary, and resubmit. Page 25 of 69

27 WV MMIS Provider Enrollment and Revalidation Edit 7078 Rx DUR SX Severity 1 thru 3 Description For each prescription within the claim, if the Rx Drug Utilization Review (DUR) module produces a Drug Gender (SX) Event with a Severity level of 1, 2, or 3, and the Severity Ranking Code is less than or equal to 70, this edit is posted. This edit will be posted even if the prescription submitted has DUR/PPS (Prospective Payment System) information attempting to override these SX Events. The source National Drug Code (NDC) is extracted from either the Claim Segment for non-compound claims or iterated for all Ingredients within a compound drug claim. Hints Review all drugs which member is taking and send a warning. Edit 7079 Rx DUR HD Event Description For each prescription within the claim, if the Rx Drug Utilization Review (DUR) module produces a High Dose (HD) Event with the Severity Ranking Code less than or equal to 70, this edit is posted. The source National Drug Code (NDC) is extracted from either the Claim Segment for non-compound claims or from the Primary Ingredient (occurrence 1 ) within a compound drug claim. Hints For an HD event, an override for the DUR event can be done by a DUR/PPS (Prospective Payment System) segment, which must be submitted on the claim. Review all drugs the member is taking. Validate information and resubmit the claim with proper override, if necessary. Edit 7080 Rx DUR LD Event Description For each prescription within the claim, if the Rx Drug Utilization Review (DUR) module produces a Low Dose (LD) Event with the Severity Ranking Code less than or equal to 70, this edit is posted. This edit will be posted even if the prescription submitted has DUR/PPS (Prospective Payment System) information attempting to override these LD Events. The source National Drug Code (NDC) is extracted from either the Claim Segment for non-compound claims or iterated for all Ingredients within a compound drug claim. Hints Review dosage a member is taking and send warning. Edit 7081 Rx DUR MX Event Description For each prescription within the claim, if the Rx Drug Utilization Review (DUR) module produces an Excessive Duration (MX) Event with the Severity Ranking Code less than or equal to 70, this edit is posted. This edit will be posted even if the prescription submitted has DUR/PPS (Prospective Payment System) information attempting to override these MX Events. The source National Drug Code (NDC) is extracted from either the Claim Segment for non-compound claims or iterated for all Ingredients within a compound drug claim. Hints Review the length of treatment a member is taking and send warning. Page 26 of 69