Pharmacy NCPDP Reject Codes

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Pharmacy NCPDP Reject CodesNCPDPRejectCode05NCPDP Reject Code DescriptioninterChangeEditDescriptionM/I Service Provider Number0201BILLING PROVIDER ID NUMBER MISSING05M/I Service Provider Number0202BILLING PROVIDER ID IN INVALID FORMAT05M/I Service Provider Number1004PROVIDER NOT ALLOWED TO BILL FROM SERVICE LOCATION05M/I Service Provider Number102505M/I Service Provider Number1927OUT OF STATE PROVIDER DOES NOT HAVE A VALID LICENSEON FILE FOR CLAIM DATES OF SERVICENPI REQUIRED: BILLING PROVIDER (HEALTHCARE)05M/I Service Provider Number1945MULTIPLE SERVICE LOCATIONS FOR BILLING PROVIDER07M/I Cardholder ID0203RECIPIENT I.D. NUMBER MISSING09M/I Date Of Birth0255CLIENT DOB DISAGREES WITH SUBMITTED DOB09M/I Date Of Birth832DATE OF BIRTH MISSING (304-C4)09M/I Date Of Birth0833DATE OF BIRTH INVALID (304-C4)09M/I Date Of Birth2807CLIENT DATE OF BIRTH IS NOT ON FILE10M/I Patient Gender Code0834MISSING/INVALID PATIENT GENDER (305-C5)12M/I Place of Service0800PATIENT LOCATION IS MISSING/INVALID15M/I Date of Service0215DATE DISPENSED IS MISSING15M/I Date of Service0216DATE DISPENSED IS INVALID15M/I Date of Service0397HEADER STMT COVERS PERIOD "THROUGH" DATE MISSING15M/I Date of Service0503DATE DISPENSED AFTER BILLING DATE16M/I Prescription/ Service Reference Number0212PRESCRIPTION NUMBER IS MISSING17M/I Fill Number0211REFILL INDICATOR IS MISSING OR INVALID191921M/I Days SupplyM/I Days SupplyM/I Product/Service ID022102220217DAYS SUPPLY MISSINGDAYS SUPPLY INVALIDNDC IS MISSING21M/I Product/Service ID0218NDC INVALID FORMAT25M/I Prescriber ID0205PRESCRIBING PRACTITIONER'S LICENSE NO. MISSING25M/I Prescriber ID0206PRESCRIBING PRACTITIONR LICENSE NO. FORMAT INVALID2528M/I Prescriber IDM/I Date Prescription Written02090213PRESCRIBER ID OF GROUP; RESUBMIT INDIVIDUAL’S NPIDATE PRESCRIBED IS MISSING28M/I Date Prescription Written0214DATE PRESCRIBED IS INVALID28M/I Date Prescription Written0256DATE DISPENSED IS 1YR, OR 6 MO, FROM DTE WRITTEN28M/I Date Prescription Written0500DATE PRESCRIBED AFTER BILLING DATE28M/I Date Prescription Written0502DATE DISPENSED EARLIER THAN DATE PRESCRIBED39M/I Diagnosis Code2819TB DIAGNOSIS CODE REQUIRED39M/I Diagnosis Code034939M/I Diagnosis Code4040DIAGNOSIS REQUIRED FOR SHORT AND LONG ACTINGOPIOIDS.PRIMARY DIAGNOSIS CODE NOT ON FILE39M/I Diagnosis Code4041SECONDARY DIAGNOSIS CODE NOT ON FILE40Pharmacy Not Contracted With Plan On DateOf ServiceSubmit Bill To Other Processor Or PrimaryPayer1001PROVIDER DOES NOT HAVE A CONTRACT FOR CLAIM TYPE2508RECIPIENT COVERED BY PRIVATE INSURANCE (PHARMACY)41Last Updated 10/2019

Pharmacy NCPDP Reject CodesNCPDPRejectCode50NCPDP Reject Code DescriptioninterChangeEditDescriptionNon-Matched Pharmacy Number0551PROVIDER ID ON ADJUSTMENT DOES NOT MATCH MOTHER50Non-Matched Pharmacy Number1000BILLING PROVIDER ID. NUMBER NOT 0N FILE52Non-Matched Cardholder ID2001RECIPIENT ID NUMBER NOT ON FILE54Non-Matched Product/Service ID Number4004NDC NOT ON FILE55Non-Matched Product Package Size0801QUANTITY BILLED DOES NOT EQUAL PACKAGE SIZE604025AGE RESTRICTION FOR COVERED NDC4044NO REIMBURSEMENT RULE FOR ASSOCIATED AGE3318THE NDC IS NOT CONSISTENT WITH THE CLIENT'S GENDER4023GENDER RESTRICTION FOR COVERED NDC4962GENDER RESTRICTION FOR BILLED NDC62Product/Service Not Covered For PatientAgeProduct/Service Not Covered For PatientAgeProduct/Service Not Covered For PatientGenderProduct/Service Not Covered For PatientGenderProduct/Service Not Covered For PatientGenderPatient/Card Holder ID Name Mismatch0513RECIPIENT NAME AND NUMBER DISAGREE62Patient/Card Holder ID Name Mismatch0825CLIENT NAME DISAGREES WITH NAME ON FILE633308DRUG/DEVICE INCLUDED IN NH PER DIEM69Product/Service ID Not Covered ForInstitutionalized PatientFilled After Coverage Terminated0777ConnPACE TERMINATED69Filled After Coverage Terminated0778CHARTER OAK PROGRAM TERMINATED70Product/Service Not Covered – Plan/BenefitExclusionProduct/Service Not Covered – Plan/BenefitExclusionProduct/Service Not Covered – Plan/BenefitExclusionProduct/Service Not Covered – Plan/BenefitExclusionProduct/Service Not Covered – Plan/BenefitExclusionProduct/Service Not Covered – Plan/BenefitExclusionProduct/Service Not Covered – Plan/BenefitExclusionProduct/Service Not Covered – Plan/BenefitExclusionProduct/Service Not Covered – Plan/BenefitExclusionProduct/Service Not Covered – Plan/BenefitExclusionProduct/Service Not Covered – Plan/BenefitExclusionProduct/Service Not Covered – Plan/BenefitExclusionProduct/Service Not Covered – Plan/BenefitExclusion0709PHARMACY SERVICE NOT COVERED FOR HOSPICE CLIENT3304NDCIS LESS EFFECTIVE/DESI DRUG3307SUBMIT CLAIM WITH OUTER PACKAGE NDC3309PATIENT RESIDENCE RESTRICTION FOR THE COVERED NDC3317INSTITUTIONAL NDC NOT COVERED33194002OTC DIABETIC TESTING SUPPLIES N/C FOR PHARMACY (AGE 20)NO COVERAGE FOR BILLED NDC4061NO REIMB RULE FOR ASSOCIATED CLAIM TYPE4164INACTIVE DRUG4222MED REVIEW RESTRICTION FOR COVERED NDC4256PRIMARY DIAGNOSIS RESTRICTION FOR BILLED NDC4257SECONDARY DIAGNOSIS RESTRICTION FOR COVERED NDC4258SECONDARY DIAGNOSIS RESTRICTION FOR BILLED NDC60616161707070707070707070707070Last Updated 10/2019

Pharmacy NCPDP Reject CodesNCPDPRejectCode70NCPDP Reject Code DescriptioninterChangeEditDescription4831NO REIMB RULE4960BENEFIT PLAN RESTRICTION FOR COVERED NDC4965BENEFIT PLAN RESTRICTION FOR BILLED NDC71Product/Service Not Covered – Plan/BenefitExclusionProduct/Service Not Covered – Plan/BenefitExclusionProduct/Service Not Covered – Plan/BenefitExclusionPrescriber ID Is Not Covered0204PRESCRIBING PROVIDER NOT AUTHORIZED TO PRESCRIBE71Prescriber ID Is Not Covered0237STUDENT OR RESIDENT NOT AUTHORIZED TO PRESCRIBE71Prescriber ID Is Not Covered1801PRESCRIBING PROVIDER WITHOUT ACTIVE LICENSE ON FILE74050575Other Carrier Payment Meets Or ExceedsPayablePrior Authorization Required3002THIRD PARTY PAYMENT AMOUNT MORE THAN CLAIMCHARGENDC REQUIRES PA75Prior Auth Required3100PA REQUIRED- DISPENSE GENERIC EQUIVALENT75Prior Auth Required3101PA REQUIRED- DISPENSE PREFERRED DRUG75Prior Auth Required3104PA REQUIRED ON NDC-CALL DSS 1-800-233-250375Prior Auth Required3105NON-PREFERRED MH DRUG; CONTACT MD OR DXC for PA75Prior Auth Required31067575Prior Auth RequiredPrior Auth Required31093301TRANSMUCOSAL FENTANYL REQUIRES PA FOR MORE THAN4 DOSES PER DAY.PA REQUIRED FOR LONG ACTING OPIOID DRUGSOPTIMAL DOSAGE EXCEEDED76Plan Limitations Exceeded4026MAXIMUM UNIT RESTRICTION FOR COVERED NDC76Plan Limitations Exceeded655476Plan Limitations Exceeded6555MILLIGRAM MORPHINE EQUIVALENCY (MME) LIMITEXCEEDEDEXCEEDED ENTERAL QUANTITY76Plan Limitations Exceeded6556DURATION OF THERAPY EXCEEDED77Discontinued Product/Service ID Number4007NON-COVERED NDC DUE TO CMS TERMINATION78Cost Exceeds Maximum3306DETAIL ALLOWED AMOUNT GREATER THAN 50,00078Cost Exceeds Maximum333079Early Refill7003CLAIM DETAIL EXCEEDS ALLOWABLE LIMIT. CONTACT THEPROVIDER ASSISTANCE CENTER.PRODUR ALERT REQUIRES PA OVERRIDE80Drug-Diagnosis Mismatch3302NDC NOT CONSISTENT WITH ANY BILLED DIAGNOSIS80Drug-Diagnosis Mismatch33148081Drug-Diagnosis MismatchClaim Too Old43610515HEADER DIAGNOSIS RESTRICTION for NDC UNDERPROVIDER CONTRACTPRIMARY DIAGNOSIS RESTRICTION FOR COVERED NDCCHARTER OAK 120 DAY TIMELY FILLING LIMIT EXCEEDED81Claim Too Old0545TIMELY FILLING83Duplicate Paid/ Captured Claim5000POSSIBLE DUPLICATE83Duplicate Paid/ Captured Claim5001EXACT DUPLICATE85Claim Not Processed0589SUSPEND ADJUSTMENT FOR PRE-PAYMENT VERIFICATION88DUR Reject Error7000CLAIM FAILED A PRODUR ALERT88DUR Reject Error7001INFORMATIONAL PRODUR ALERT88DUR Reject Error7002CLAIM DENIED FOR PRODUR REASONS88DUR Reject Error7004CLAIM DENIED FOR PRODUR ALERT7070Last Updated 10/2019

Pharmacy NCPDP Reject CodesNCPDPRejectCode506NCPDP Reject Code ION QUALIFIER IS INVALID0807DIAGNOSIS CODE QUALIFIER IS INVALID0808OTHER AMOUNT CLAIM SUBMITTED QUALIFIER IS INVALID535Prescription/ Service Reference NumberQualifier Value Not SupportedDiagnosis Code Qualifier Value NotSupportedOther Amount Claimed Submitted QualifierValue Not SupportedOther Coverage Code Value Not Supported0643INVALID OTHER COVERAGE CODE535Other Coverage Code Value not supported2802CLIENT PLAN REQUIRED CO-PAY ONLY BILLING FOR MDD536Other Payer-Patient Responsibility AmountQualifier Value Not SupportedPrescriber ID Qualifier Value Not Supported08830805PATIENT RESPONSIBILITY AMOUNT QUALIFIER NOTSUPPORTEDPRESCRIBER QUALIFIER IS INVALID0836MISSING/INVALID PRESCRIPTION ORIGIN CODE (419-DJ)600Prescription Origin Code Value NotSupportedCoverage Outside Submitted Date Of Service2800SERVICE IS AFTER DATE OF DEATH606Prior Auth Required3107NON-PREFERRED MH DRUG; DISPENSE PREFERRED BRAND606Brand Drug / Specific Labeler Code Required3108NON-PREFERRED DRUG; DISPENSE PREFERRED BRAND621This Medicaid Patient Is Medicare Eligible2514RECIPIENT COVERED BY MEDICARE (A AND B), NO MED D621This Medicaid Patient Is Medicare Eligible2521RECIPIENT COVERED BY MEDICARE A AND/OR B, NO MED D621This Medicaid Patient Is Medicare Eligible2801MEDICARE ELIGIBLE, CLIENT MUST ENROLL IN PART D8260207PRESCRIBING PROVIDER NOT ENROLLED1026PRESCRIBING PHYSICIAN LICENSE NUMBER NOT ON FILE2809MED D NF DRUG REQUIRES PA2810ONE TIME BYPASS FILL HAS BEEN USED3111MME EXCEEDED925Prescriber NPI Submitted Not Found WithinProcessor’s NPI FilePrescriber NPI Submitted Not Found WithinProcessor’s NPI FilePlan/Beneficiary Case ManagementRestriction In PlacePlan/Beneficiary Case ManagementRestriction In PlaceMorphine Milligram Equivalency(MME)Exceeds LimitsInitial Fill Days Supply Exceeds Limits3110SHORT TERM OPIOIDS DAYS SUPPLY 71RVersion/Release Value Not Supported0617INVALID CLAIM VERSION – SUBMIT IN HIPAA 50101T0818INVALID PROCESSOR CONTROLL NUMBER0826INVALID PROCESSOR CONTROLL NUMBER. USE CTPCNPTD0828INVALID PROCESSOR CONTROLL NUMBER. USE CTPCNFMD2803MED D COVERED DRUG –BILL MEDICARE FIRST4YPCN Must Contain Processor/Payer AssignedValuePCN Must Contain Processor/Payer AssignedValuePCN Must Contain Processor/Payer AssignedValueSubmit Bill To Other Processor Or PrimaryPayerPatient Residence Value Not Supported0831MISSING/INVALID PATIENT RESIDENCE (384-4X)6CM/I Other Payer ID Qualifier0882OTHER PAYER ID QUALIFIER NOT APPLICABLE6EM/I Other Payer Reject Code0819OTHER PAYER REJECT CODE REQUIRED6EM/I Other Payer Reject Code0820OTHER PAYER REJECT CODE NOT ACCEPTED FOR TPL6EM/I Other Payer Reject Code0829REJECT CODE NOT ACCEPTED FOR TPL BILLING5215345435458268288289221T1T41Last Updated 10/2019

Pharmacy NCPDP Reject CodesNCPDPRejectCode6ENCPDP Reject Code DescriptioninterChangeEditDescriptionM/I Other Payer Reject Code0849REJECT CODE REQUIRED6GCoordination Of Benefits/Other PaymentsSegment Required For AdjudicationCoordination Of Benefits/Other PaymentsSegment Required For Adjudication0847MDD CO-PAY ONLY CLAIM WITHOUT PRIMARY BILLINGINFO, PLEASE CORRECT/RESUBMIT.OCC CODE SUBMITTED WITHOUT PRIMARY PAYER INFO,PLEASE CORRECT/RESUBMIT.Provider Not Eligible To PerformService/Dispense ProductProvider Not Eligible To PerformService/Dispense ProductProvider Not Eligible To PerformService/Dispense ProductProvider Not Eligible To PerformService/Dispense ProductProvider Not Eligible To PerformService/Dispense ProductService Provider ID Qualifier Value NotSupported For Processor/PayerM/I Other Payer ID41397KDiscrepancy Between Other Coverage CodeAnd Other Coverage Information On File08307kDiscrepancy Between Other Coverage CodeAnd Other Payer Amount0846OTHER PAYER PATIENT RESPONSIBILITY AMOUNT INVALIDFOR COVERAGE CODE7MDiscrepancy Between Other Coverage CodeAnd Other Coverage Information On File2804CLAIM MUST BE BILLED AS CROSSOVER.7MDiscrepancy Between Other Coverage CodeAnd Other Coverage Information On File2817MEDICARE D NF DRUG NOT COVERED7Q0881OTHER PAYER ID QUALIFIER NOT SUPPORTED7WOther Payer ID Qualifier Value NotSupportedRefills Exceed Allowable Refills3300EXCEEDS MAXIMUM REFILLS ALLOWED.8KDAW Code Value Not Supported0210BRAND MEDICALLY NECESSARY INDICATOR INVALID8WDiscrepancy Between Other Coverage CodeAnd Other Payer Amount PaidCompound Ingredient Component CountExceeds Number Of Ingredients Supported0227THIRD PARTY PAYMENT AMOUNT INVALID0247MAXIMUM NUMBER OF CLAIM DETAILS EXCEEDEDThis Product/ Service May Be Covered UnderMedicare Part BPatient Spenddown Not Met2509RECIPIENT COVERED BY MEDICARE B (PHARMACY)2010CLIENT HAS NOT SATISFIED SPEND-DOWN.Product Not Covered Non-ParticipatingManufacturerBilling Provider Not Eligible To Bill This ClaimTypeBilling Provider Not Eligible To Bill This ClaimTypeBilling Provider Not Eligible To Bill This ClaimType10160788MANUFACTURER IS NOT PARTICIPATING IN DRUG REBATEON DATE OF SERVICE DISPENSED.ENCOUNTER SUBMITTED FOR INVALID CLAIM TYPE0845PROVIDER NOT ALLOWED TO BILL CLAIM TYPE4131NO BENEFIT PLAN ASSOCIATED TO PAYER. CONTACT THEPROVIDER ASSISTANCE RMING PROVIDER TYPE/SPECIALTY IS RESTRICTEDFOR THE NDC UNDER THE CLIENT'SPERFORMING PROVIDER TYPE/SPECIALTY IS RESTRICTEDFOR THE NDC UNDER PROVIDER CONTRACTNDC CODE IS UNDER MEDICAL REVIEW FOR THIS PROVIDERCONTRACTCONTRACT RESTRICTION FOR NDC UNDER PROVIDERCONTRACTNDC IS NOT BILLABLE UNDER PROVIDER CONTRACT.0802SERVICE PROVIDER QUALIFIER MISSING OR INVALID.0809OTHER INSURANCE CARRIER CODE (PAYER ID) IS MISSING,INVALID OR NOT APPLICABLE.OTHER AMOUNT SUBMITTED INVALID FOR COVERAGECODE414841534160Last Updated 10/2019

Pharmacy NCPDP Reject CodesNCPDPRejectCodeADNCPDP Reject Code DescriptioninterChangeEditDescription4138AGBilling Provider Not Eligible To Bill This ClaimTypeBilling Provider Not Eligible To Bill This ClaimTypeBilling Provider Not Eligible To Bill This ClaimTypeDays Supply Limitation For Product/Service3316BILLING PROVIDER TYPE/SPECIALTY IS RESTRICTED FOR NDCIN CLIENT BENEFIT PLANNO REIMBURSEMENT RULE FOR THE ASSOCIATEDPROVIDER TYPE/PROVIDER SPECIALTYBILLING PROVIDER NOT AUTHORIZED TO BILL FORSUBMITTED NDCEXCEEDS THE MAXIMUM DAYS SUPPLY ALLOWEDAGDays Supply Limitation For Product/Service4165MAX DAY SUPPLY RESTRICTION FOR COVERED NDCAH4113UNIT DOSE PACKAGING COVERED FOR LTC RESIDENTS ONLYCCUnit Dose Packaging Only Payable ForNursing Home RecipientsM/I Cardholder First Name0817CLIENT'S FIRST NAME IS MISSINGCDM/I Cardholder Last Name0238CLIENT'S LAST NAME IS MISSINGCDM/I Cardholder Last Name0815CLIENT'S LAST NAME IS NOT VALIDDQM/I Usual And Customary Charge0268DETAIL BILLED AMOUNT IS MISSINGDQM/I Usual And Customary Charge0269DETAIL BILLED AMOUNT INVALIDDQM/I Usual And Customary Charge4009ALLOWED AMOUNT LESS THAN DRUG CHARGE VARIANCEDVM/I Other Payer Amount Paid0810E7M/I Quantity Dispensed0219THE OTHER INSURANCE AMOUNT IS MISSING OR NOTAPPLICABLE.QUANTITY DISPENSED IS MISSINGE7M/I Quantity Dispensed0220QUANTITY DISPENSED IS INVALID FORMAT.E7M/I Quantity Dispensed0260UNITS OF SERVICE IS INVALIDM1Patient Not Covered In This Aid Category2002CLIENT INELIGIBLE FOR DATES OF SERVICE.M1Patient Not Covered In This Aid Category2101CLIENT IS NOT ELIGIBLE ON EMSM2Recipient Locked In0670M2Recipient Locked In2603CLAIM TYPE NOT COVERED FOR CLIENT WITH INPATIENTLOCK-INRECIPIENT /PROVIDER LOCK-IN VIOLATIONM5Requires Manual Claim0873M5Requires Manual Claim6000MANUALLY PRICED AT ZERO/ GREATER THAN BILLEDAMOUNTMANUAL PRICING REQUIREDM6Host Eligibility Error2102CLIENT ELIGIBILITY SYSTEM IS NOT AVAILABLEM6Host Eligibility Error2103UNABLE TO DETERMINE CLIENT ELIGIBILITYM6Host Eligibility Error4127CANNOT PRIORITIZE RECIPIENT'S PROGRAMSM6Host Eligibility Error4130PAYER HIERARCHY NOT FOUNDM7Host Drug File Error4014NO PRICING SEGMENT ON FILEM7Host Drug File Error4045NO REIMBURSEMENT RULE FOR ASSOCIATED BENEFIT PLANM7Host Drug File Error4068NO REIMBURSEMENT RULE FOR ASSOCIATED CONTRACTM8Host Provider File Error0912PROVIDER TYPE AND SPECIALTY CANNOT BE FOUNDM8Host Provider File Error7500BILLING PROVIDER ON PREPAYMENT REVIEWMRProduct Not On Formulary2811NON-FORMULARY DRUG UNDER CURRENT DSS THRESHOLDN1No patient Match Found2100CLIENT NOT FOUND ON ELIGIBILITY MANAGEMENT SYSTEM.NPM/I Other Payer-Patient ResponsibilityAmount Qualifier0838M/I PATIENT RESPONSIBILITY AMOUNT QUALIFIER (351-NP)ADAD42504775Last Updated 10/2019

Pharmacy NCPDP Reject CodesNCPDPRejectCodeNQNQNQNQP6R6R6R6R6R9NCPDP Reject Code DescriptioninterChangeEditDescriptionM/I Other Payer-Patient ResponsibilityAmountM/I Other Payer-Patient ResponsibilityAmountM/I Other Payer-Patient ResponsibilityAmountM/I Other Payer-Patient ResponsibilityAmountDate Of Service Prior To Date Of Birth2820CO-PAY ONLY CLAIM GREATER THAN 6.50 NOT ALLOWED2821CO-PAY ONLY CLAIM GREATER THAN 6.60 NOT ALLOWED2825CO-PAY ONLY CLAIM GREATER THAN 7.40 NOT ALLOWED2826CO-PAY ONLY CLAIM GREATER THAN 8.25 NOT ALLOWED2805SERVICE IS BEFORE DATE OF BIRTHProduct/Service Not Appropriate For ThisLocationProduct/Service Not Appropriate For ThisLocationProduct/Service Not Appropriate For ThisLocationProduct/Service Not Appropriate For ThisLocationGross Amt Due Value Does Not Follow PriceFormulae1003BILLING PROV NOT ELIG AT SERV LOC FOR PROG BILLED3303LIVING ARRANGEMENT RESTRICTION FOR THE COVEREDNDCNO REIMBURSEMENT RULE FOR ASSOCIATED PATIENTRESIDENCE.PATIENT RESIDENCE RESTRICTION FOR NDC ON PROVIDERCONTRACTBILLED AMOUNT IS GREATER THAN CMAP ALLOWEDAMOUNT330542540352Last Updated 10/2019

Pharmacy NCPDP Reject Codes Last Updated 10/2019 NCPDP Reject Code NCPDP Reject Code Description interChange Edit Description 50 Non-Matched Pharmacy Nu

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