Common Insurance Rejections - Revision history

Cecswiki: /* Pharmacy Service Type and Patient Residence Code */

2023-02-09T19:11:05Z

Pharmacy Service Type and Patient Residence Code

← Older revision		Revision as of 19:11, 9 February 2023
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	===Pharmacy Service Type and Patient Residence Code===		===Pharmacy Service Type and Patient Residence Code===
	These two rejects are commonly bundled together. Some insurances require that we transmit the Pharmacy Service Type (Field U7-147, the kind of service that has been provided by the pharmacy) and the Patient Residence Code (4X-384). These can be set in the SIG Lines or the Third Party Notes as /PSTxx and /PRSxx. Additionally, QuickSCRIP can set this to always be sent on an insurance company. Pull up the insurance company in the Vendor File Maintenance, type 'O3' to go to screen three, and add '''/PST''' and '''/PRS''' to line 22.		These two rejects are commonly bundled together. Some insurances require that we transmit the Pharmacy Service Type (Field U7-147, the kind of service that has been provided by the pharmacy) and the Patient Residence Code (4X-384). These can be set in the SIG Lines or the Third Party Notes as /PSTxx and /PRSxx. Additionally, QuickSCRIP can set this to always be sent on an insurance company. Pull up the insurance company in the Vendor File Maintenance, type 'O3' to go to screen three, and add '''/PST=1''' and '''/PRS=1''' to line 22.

	=== M/I Product ID (on a Compound Drug) ===		=== M/I Product ID (on a Compound Drug) ===

Cecswiki: /* Primary Claims */

2022-11-18T21:00:33Z

Primary Claims

← Older revision		Revision as of 21:00, 18 November 2022
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	===Pharmacy Service Type and Patient Residence Code===		===Pharmacy Service Type and Patient Residence Code===
	These two rejects are commonly bundled together. Some insurances require that we transmit the Pharmacy Service Type (Field U7-147, the kind of service that has been provided by the pharmacy) and the Patient Residence Code (4X-384). These can be set in the SIG Lines or the Third Party Notes as /PSTxx and /PRSxx. Additionally, QuickSCRIP can set this to always be sent on an insurance company. Pull up the insurance company in the Vendor File Maintenance, type 'O3' to go to screen three, and add '''/PST''' ~~amd~~ '''/PRS''' to line 22.		These two rejects are commonly bundled together. Some insurances require that we transmit the Pharmacy Service Type (Field U7-147, the kind of service that has been provided by the pharmacy) and the Patient Residence Code (4X-384). These can be set in the SIG Lines or the Third Party Notes as /PSTxx and /PRSxx. Additionally, QuickSCRIP can set this to always be sent on an insurance company. Pull up the insurance company in the Vendor File Maintenance, type 'O3' to go to screen three, and add '''/PST''' and '''/PRS''' to line 22.

			=== M/I Product ID (on a Compound Drug) ===
			Some insurances want a product ID type of 00 sent on compound drugs (QuickSCRIP defaults to a 0). To fix this pull up the insurance company in the Vendor File Maintenance, type 'O3' to go to screen three, and add '''/C0''' to line 16.

	==Secondary Claims==		==Secondary Claims==

Cecswiki: /* M/I Patient E-mail - HN */

2022-06-21T15:09:19Z

M/I Patient E-mail - HN

← Older revision		Revision as of 15:09, 21 June 2022
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	===M/I Patient E-mail - HN===		===M/I Patient E-mail - HN===
	~~'''~~Might also accompany a 614 -Uppercase Required- message~~'''~~		(Might also accompany a 614 -Uppercase Required- message)
	Some insurances ask that we send a patient ~~email~~ address if it's available. This can be found in the '''Patient File Main., on Screen 4, line 10.''' If you are getting this reject, it may be because the insurance wants the email to be sent entirely in uppercase, which will need to be corrected manually, '''or''' you can use a switch '''/EMX''' on the ~~ins vendor~~ file, screen 3, line 16, to not send the patient's ~~email~~ entirely.		Some insurances ask that we send a patient e-mail address if it's available. This can be found in the '''Patient File Main., on Screen 4, line 10.''' If you are getting this reject, it may be because the insurance wants the email to be sent entirely in uppercase, which will need to be corrected manually, '''or''' you can use a switch '''/EMX''' on the '''Insurance Vendor file, screen 3, line 16,''' to not send the patient's e-mail entirely.

	===M/I Quantity Prescribed===		===M/I Quantity Prescribed===

Cecswiki: /* Primary Claims */

2022-06-21T15:08:11Z

Primary Claims

← Older revision		Revision as of 15:08, 21 June 2022
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	==Primary Claims==		==Primary Claims==
	These are common rejections that are encountered when transmitting to a primary insurance.		These are common rejections that are encountered when transmitting to a primary insurance.

			===M/I Patient E-mail - HN===
			'''Might also accompany a 614 -Uppercase Required- message'''
			Some insurances ask that we send a patient email address if it's available. This can be found in the '''Patient File Main., on Screen 4, line 10.''' If you are getting this reject, it may be because the insurance wants the email to be sent entirely in uppercase, which will need to be corrected manually, '''or''' you can use a switch '''/EMX''' on the ins vendor file, screen 3, line 16, to not send the patient's email entirely.

	===M/I Quantity Prescribed===		===M/I Quantity Prescribed===

Cecswiki: /* Reversals */

2022-06-20T13:27:40Z

Reversals

← Older revision		Revision as of 13:27, 20 June 2022
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	===Missing/Invalid COB Segment===		===Missing/Invalid COB Segment===
	In rare instances, an insurance will want the Coordination of Benefits information included in the rejection (typically Other coverage code and copay info). To transmit this, pull up the secondary insurance company in the Vendor File Maintenance, type 'O3' to go to screen three, and add '''/CBR''' to line 16.		In rare instances, an insurance will want the Coordination of Benefits information included in the rejection (typically Other coverage code and copay info). To transmit this, pull up the secondary insurance company in the Vendor File Maintenance, type 'O3' to go to screen three, and add '''/CBR''' to line 16. Additionally, they may also require you add the other coverage code and amount paid fields. which can be added to the SIGS as '''/OCxx''' (where x is the other coverage code used) and '''/OPxx.xx''' (where x is the dollar amount the primary paid).

Cecswiki: /* Primary Claims */

2022-06-20T13:25:17Z

Primary Claims

← Older revision		Revision as of 13:25, 20 June 2022
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	==Primary Claims==		==Primary Claims==
	These are common rejections that are encountered when transmitting to a primary insurance.		These are common rejections that are encountered when transmitting to a primary insurance.

			===M/I Quantity Prescribed===
			There are separate fields to indicate how much medication was dispensed for this fill, and how much medication was prescribed by the doctor for this prescription. By default, we do not send the Quantity Prescribed field, unless the prescription is for a schedule 2 drug.

			* If the drug '''is''' a schedule 2 drug, make sure that is is correctly marked (Drug File screen, line 3). This may require you delete the Rx and create a new one, if your system uses different RX numbers for controls.
			* If the drug '''is not''' schedule 2, then the insurance may want this field regardless of the drug's schedule. Adding a '''/ARQ''' to the vendor file (screen 3, line 16) will force this field to be sent.

	===DOC Segment Bad Format===		===DOC Segment Bad Format===

Cecswiki: /* Insurance Segment Bad Format */

2019-02-28T16:14:56Z

Insurance Segment Bad Format

← Older revision		Revision as of 16:14, 28 February 2019
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	Occasionally, an electronic claim will be accepted by the insurance, but will reject when you try to reverse it. Some reversals may require that you contact the insurance company and get them to reverse it manually.		Occasionally, an electronic claim will be accepted by the insurance, but will reject when you try to reverse it. Some reversals may require that you contact the insurance company and get them to reverse it manually.

	===Insurance Segment Bad Format===		===Insurance / Group Segment Bad Format===
	Some insurance companies want the cardholder information transmitted on the reversal. To transmit this, pull up the secondary insurance company in the Vendor File Maintenance, type 'O3' to go to screen three, and add '''/IDR''' to line 16.		Some insurance companies want the cardholder information transmitted on the reversal. To transmit this, pull up the secondary insurance company in the Vendor File Maintenance, type 'O3' to go to screen three, and add '''/IDR''' (for Ins segment) and '''/GPR''' (for group number) to line 16.

	===Missing/Invalid COB Segment===		===Missing/Invalid COB Segment===
	In rare instances, an insurance will want the Coordination of Benefits information included in the rejection (typically Other coverage code and copay info). To transmit this, pull up the secondary insurance company in the Vendor File Maintenance, type 'O3' to go to screen three, and add '''/CBR''' to line 16.		In rare instances, an insurance will want the Coordination of Benefits information included in the rejection (typically Other coverage code and copay info). To transmit this, pull up the secondary insurance company in the Vendor File Maintenance, type 'O3' to go to screen three, and add '''/CBR''' to line 16.

Cecswiki: /* Secondary Claims */

2015-10-19T14:34:04Z

Secondary Claims

← Older revision		Revision as of 14:34, 19 October 2015
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	* The primary DIDN'T pay anything and the secondary won't cover		* The primary DIDN'T pay anything and the secondary won't cover
	* QuickSCRIP is calculating the copay amount incorrectly. Reverse the claim from the primary and reprocess from cash, or contact us.		* QuickSCRIP is calculating the copay amount incorrectly. Reverse the claim from the primary and reprocess from cash, or contact us.

			===M/I Benefit Stage Qualifier - MV===
			Insurance does not want us to send the benefit stage (MV) field. '''/XM''' on the Ins Vendor file for the Secondary, Screen 3, Line 16 should get this.

	==Reversals==		==Reversals==

Cecswiki: /* NR - Copay Amount sent / Count */

2015-10-05T19:52:17Z

NR - Copay Amount sent / Count

← Older revision		Revision as of 19:52, 5 October 2015
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	===NR - Copay Amount sent / Count===		===NR - Copay Amount sent / Count===
	Similar to the copay amount qualifier rejection above. This rejection is caused by the Other Payer Reject field. To correct it, pull up the secondary insurance company in the Vendor File Maintenance, type 'O3' to go to screen three, and add '''/OPR''' to line 16.		Similar to the copay amount qualifier rejection above. This rejection is caused by the Other Payer Reject field. To correct it, pull up the secondary insurance company in the Vendor File Maintenance, type 'O3' to go to screen three, and add '''/OPR''' to line 16.


			/OPR can also sometimes fix DV and HB rejects.

	===COB Segment Bad Format - AM===		===COB Segment Bad Format - AM===

Cecswiki: /* MI OP Copay Amount (DX) or NQ Missing Invalid Patient Responsibility */

2015-09-18T18:36:08Z

MI OP Copay Amount (DX) or NQ Missing Invalid Patient Responsibility

← Older revision		Revision as of 18:36, 18 September 2015
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	===MI OP Copay Amount (DX) or NQ Missing Invalid Patient Responsibility ===		===MI OP Copay Amount (DX) or NQ Missing Invalid Patient Responsibility ===
	The DX field is an optional field that specifies the patient's copay amount that was left over from the primary claim~~. By default, this field is not transmitted~~. To transmit the Copay Amount, pull up the secondary insurance company in the Vendor File Maintenance, and on line 20, add /CS on RXC Line. If you are still getting this reject, we may be transmitting the wrong copay value, or we may be transmitting the correct copay value, and the insurance simply won't cover it.		The DX field is an optional field that specifies the patient's copay amount that was left over from the primary claim. To transmit the Copay Amount, pull up the secondary insurance company in the Vendor File Maintenance, and on line 20, add /CS on RXC Line. If you are still getting this reject, we may be transmitting the wrong copay value, or we may be transmitting the correct copay value, and the insurance simply won't cover it.

			Some insurance companies do not want to receive the DX field. For these insurances, pull up the secondary insurance company in the Vendor File Maintenance, got to screen 3, and on line 16, add /NY on the RXOL51 Line

	===H8 Other Amount Claimed Type===		===H8 Other Amount Claimed Type===