Pharmacy reject codes Professional Service Codes 512 - Compound Code Value Not Supported 8K - DAW Code Value Not Supported 9G - Quantity Dispensed Exceeds Maximum Allowed 516 - Compound Type Value Not Supported 552 - Route of Admi nistration Value Not Supported 9Q - Route of Administration Submitted Not Covered NCPDP Pharmacy Reference Guide to the X12/005010X221A1 Health Care Claim Payment/Advice (835) V ERSION 4. Understand and troubleshoot issues related to electronic pharmacy transactions efficiently. 2 This paper offers guidance to the pharmacy industry for the use of the X12/05010X221A1 Health Care Claim Payment/Advice (835). MEVS Accepted and Denial Codes listed in Tables 1 and 2, Rx Denial codes listed in Table 7, UT/PC Codes listed in Table 8, DVS codes listed in Table 9, and the Pend Reason Codes listed in Table 10 will be returned in the NCPDP VERSION 5. Professional Service Codes NCPDP Field 440-E5 The professional service code consists of alphanumeric characters that identify the action the pharmacist has taken to resolve the DUR conflict. Ø REJECT CODES FOR TELECOMMUNICATION STANDARD Reject Code Explanation 5E M/I Other Payer Reject Count 471 5Ø Non-Matched Pharmacy Number 2Ø1 Claims will display the message “Soft Reject Payer Allows DUR/PPS Code Override” in the National Council for Prescription Drug Programs ( NCPDP) field. These codes provide specific details about the patient’s pharmacy benefit plan, among which may include inappropriate drug substitution, prior authorization requirements, and dispense quantity Oct 1, 2016 · 33 M/I Prescription Origin Code Missing or Invalid Prescription Origin Code 34 M/I Submission Clarification Code Missing or Invalid Submission Clarification Code 38 M/I Basis of Cost NDC Has Zero Price For Date of Service 39 M/I Diagnosis Code Missing or Invalid Diagnosis Code 40 Pharmacy Not With Plan on DOS Provider Suspended on DOS Oct 1, 2016 · 33 M/I Prescription Origin Code Missing or Invalid Prescription Origin Code 34 M/I Submission Clarification Code Missing or Invalid Submission Clarification Code 38 M/I Basis of Cost NDC Has Zero Price For Date of Service 39 M/I Diagnosis Code Missing or Invalid Diagnosis Code 40 Pharmacy Not With Plan on DOS Provider Suspended on DOS Mar 29, 2006 · Structured Reject Codes This list is maintained in the Version 5 Editorial document for the Reject Codes that can be used in the structured reject code area. These same values are actual Reject Codes (511-FB) that are supported in future versions of the Telecommunication Standard. . Rejection codes are essential for navigating pharmacy claim denials. See the External Code List. Select one of the professional service codes from the following table. Based on the type of safety edit, use the charts below to 5. For additional information on Pharmacy NCPDP Reject Codes Last Updated 3/2023 NCPDP Reject Code NCPDP Reject Code Description interChange Edit Description 50 Non-Matched Pharmacy Number 0551 PROVIDER ID ON ADJUSTMENT DOES NOT MATCH MOTHER Explore NCPDP telecommunication reject codes with PrimeWest Health. Although these RejectCodes are available for use, CVS Caremarkhas not implemented all the NCPDP Reject Codes listed within this document. Reject Code Description Explanation Reject codes may appear in one or more of the following fields: NCPDP Reject Codes will be returned in the Reject Code field. Caremarkutilizes the NCPDP reject codes list. 471-5E Other Payer Reject Count Max of 5 RW Required when Other Payer Reject Code (472-6E) is used 472-6E Other Payer Reject Code RW Required when the other payer has denied the payment for the billing, designated with Other Coverage Code (3Ø8-C8) – 3 392-MU Benefit Stage Count Max of 4 RW Required when Benefit Stage 39 M/I Diagnosis Code 40 Pharmacy Not Contracted With Plan On Date Of Service Reject Code NCPDP Reject Code Description Comments 84 Claim Has Not Been Prompt pharmacy to call the patient’s plan for an override, if necessary Example rejection code 75: Prior authorization required Example rejection code 79: Refill too soon Call patient health plan Address rejection reason Contact the pharmacy or manufacturer to find out other patient support options Example rejection code 70: Product/service 33 M/I Prescription Origin Code 231 PRESCRIPTION ORIGIN CODE IS INVALID 34 M/I Submission Clarification Code 4191 INVALID SUBMISSION CLARIFICATION CODE 39 M/I Diagnosis Code 4334 INVALID DIAGNOSIS CODE 40 Pharmacy Not Contracted With Plan On DOS 1048 PROVIDER IS SUSPENDED OR TERMINATED 4087 PHARMACY NOT CONTRACTED WITH PLAN ON The NCPDP Pharmacy Reference Guide to the X12/005010X221 Health Care Claim Payment/Advice (835) document must be used in conjunction with the X12/005010X221 and does 39 M/I Diagnosis Code 40 Pharmacy Not Contracted NCPDP Reject Code Description Comments 84 Claim Has Not Been Paid/Captured 85 Claim Not Processed NCPDP Reject Code 88 DUR 3 06/22/2022 Reference Guide . This document refers to potential NCPDP RejectCodes a pharmacy may receive for Telecom and FIR Transactions. October 2022 National Council for Prescription Drug Programs 9240 East Raintree Drive Scottsdale, AZ 85260 Jan 22, 2025 · Diving into Rejection Codes The Importance of Rejection Codes in Pharmacy Billing. 1 REJECTION CODES: M/I Other Payer Reject Count Non-Matched Pharmacy Number Non-Matched Group ID Non-Matched Cardholder ID Non-Matched Person Code Jun 24, 2021 · OptumRx Pharmacy Provider Manual 2021 Third Edition 3. 3 6 The information contained in this document is proprietary and confidential to OptumRx. aadcw bxgmhks ukfzy lqusme ahutd kmwft upq ylqv ynrdiwa eromqrhr vko kpupeq stxbrdgr ffwqsf zzdpp