GENERAL OPHTHALMIC SERVICES. ELECTRONIC SUBMISSION OF CLAIMS (egos) - OPERATIONAL PROTOCOL

Transcription

1 GENERAL OPHTHALMIC SERVICES ELECTRONIC SUBMISSION OF CLAIMS (egos) - OPERATIONAL PROTOCOL Background In June 2006 the Strategic Planning Group project initiated the developement of a facility for the electronic submission of GOS claims from ophthalmic contractors (The contractor) to the centralised ophthalmic payments system. The development was led by Health & Social Care Information Centre (HSCIC). The project successfully demonstrated the feasibility of electronic submission and the Project Board recommended roll out of the facility beyond the initial seven payment agencies which took part in the pilot. Current GOS regulations require signed GOS claim forms to continue to be submitted to the responsible NHS organisation for payment. It is anticipated the Department of Health will at some point amend the regulations and remove the requirement for paper forms to be submitted in parrallel with the electronic record. Key Responsibilities 1. Health & Social Care Information Centre To specify the datafile format, provide testing facilities and approve accredition for the supplier/contractor. To provide an electronic mailbox to which datafiles are submitted by the contractor. To monitor the electronic mailbox for receipt of datafiles submitted by the contractor between the hours of 08:00am and 1:00am, Monday to Saturday, excluding public holidays. These being the hours of operation. To validate the datafiles submitted to the mailbox by the contractor for the correct format and compliance with GOS regulations twice an hour. Acknowledge receipt of a submitted datafile within 3 hours of submission. To return datafiles of claims which fail format or compliance vaildation to the contractor within 30 minutes of their submission. To provide an activation document to each accredited supplier as part of the activation process. To provide hardware and software updates outside of agreed service hours (i.e.; 01:00 weekdays and Saturday); however there may be a requirement for planned downtime. Page 1 of 29

2 2. NHS Organisations Ensure that the Practitioner s Uniform List Number is correctly defined within the central ophthalmic payments system and contains the correct GOC number, GMC number or Corporate Optician number for this practitioner record. Provide a list of names and telephone numbers of key staff to the contractors. Provide contractors with a list of local cut off dates, payment dates and hours of operation. Accept for payment egos claims received from Health & Social Care Information Centre s central ophthalmic payments system and which have therefore passed the format and compliance validation checks. Examine the supporting paper claims submitted by contractors and to notify them of any discrepancies within 2 working days of receiving them, subject to normal hours of operation. Paper claims to be returned to Contractors within 5 working days for appropriate action. Working days are usually Monday to Thursday 8.30am pm and Friday 8.30am pm. 3. Contractors Submit all claims electronically from a date to be agreed with their responsible NHS organisation, manual claims to only be submitted with the prior agreement of the their responsible NHS organisation. Agree a submission schedule with their responsible NHS organisation. Submit the supporting paper claims to their responsible NHS organisation within 48 hours of receiving notification from Health & Social Care Information Centre of acceptance of the electronic claim. Check that all paper claims are appropriately signed and dated prior to submission. Check that electronic and paper claims are identical. Rejected claims cannot be viewed by their responsible NHS organisation, therefore Contractors will need to contact their supplier for assistance. Please send link claims in separate envelope clearly marked Electronic Link Claims on the envelope, along with the submission batch reference number, if available. Page 2 of 29

3 To action any paper claims returned by their responsible NHS organisations promptly and return as soon as possible. Provide a list of names and telephone numbers of key staff to their responsible NHS organisation. 4. Suppliers of store system software Provide a point of contact to stores for the resolution of problems with the electronic submission of ophthalmic claims. To aid the movement of GOS paper work When a submission has no rejection messages and therefore contains legitimate GOS claims, it would be beneficial if the associated GOS paperwork is sent as soon as possible to the practice s responsible NHS organisation for processing. Automatically Approved GOS claims The responsible NHS organisation or payment agency will choose when to set the central ophthalmic payments system to automatically approve legitimate GOS claims submitted electronically from a specific practitioner or practice. A GOS claim automatically approved for payment will usually generate a response file showing the claim status as approved. However, there may be a small delay in receiving this response during the final stages of the monthly payment process, as their responsible NHS organisation or payment agency has yet to create the next month s payment cycle in to which these claims will be allocated. General NHS organisations and contractors to meet prior to commencement of the link to undertake joint training and establish excellent local communications, using the Agreement to Link check sheet to confirm dates and details. NHS organisations and contractors to monitor and review progress and where necessary agree recommendations for change. Contractors to avoid submitting all claims for the month close to the last date available for submission, as there will be limited time for rejected claims to be corrected and resubmitted. Local Practitioner Code / Local Contractor Code This local practitioner code, as issued by the NHS organisation responsible for payment, is used to identify the store or practice for GOS payments. It MUST exist Page 3 of 29

4 as an active entry on the Practitioner List / Contractor List found within the central ophthalmic payments system. Once a store has been activated, the local practitioner code should NOT be changed within the central ophthalmic payments system or made an inactive member of the Practitioner List. If the NHS organisation resonsible for payment wishes to change the local practitioner code, they should contact the Health & Social Care Information Centre s National Help Desk ( ) and raise a 3 rd line ophthalmic payments support log. The log should have an initial description of Request for a change of practitioner code for an electronically activated practice. Activation Process Check for an accredited supplier at the practice; these details can be found at national availabilty. If the supplier is not listed then the practice is unable to use egos to link to the NHS. Please pass on the web address for the Health & Social Care Information Centre s Ophthalmic Payments egos website ( and ask the practice to forward it to their system supplier. If the supplier is accredited, then begin the activation process with the practice. Please follow the steps below to activate the practice: 1. Contact the store and confirm an activation date; 2. Ensure the practice has a copy of the electronic egos operational protocol and the contents should be discussed if necassary; 3. Ensure the practice have signed the agreement to link form, as well as a member of the ophthalmic team from their responsible NHS organisation; 4. Collect the necassary information required by Health & Social Care Information Centre to process an activation request for this practice, as listed below: a. The store name and address. b. The store contact name and telephone number. c. The local code and uniform list number, as recognised within the central ophthalmic payments system, for the store. d. The NHS organisation code and name in which the store is located. e. Agreed 'go-live' date (allow 5 working days from contact date). f. Name of accredited system supplier. g. The address to be registered for egos from the practice. (Required for Ocuco / Opticabase / Optisoft / Optinet) 5. Contact the Health & Social Care Information Centre s National Help Desk ( ) and raise a 3rd line ophthalmic payments service request log. The log should have an initial description of Request for Activation of Ophthalmic Payments Electronic Links and should contain all the information specified above. Any missing information will cause a delay in processing the activation request. Please allow a minimum of 5 working days to process the activation request(s) Page 4 of 29

5 Many stores in England and Wales are now equipped with the electronic claims software, including all Specsavers stores, and require an activation key to commence submission of electronic claims. Please follow the activation process above to enable egos at a practice. The registered egos address for a linked practice should not be changed once live submissions have been received by the NHS. Page 5 of 29

6 Rejection Codes General Rejection Codes Rejection Description Condition Code 1 Record Status is The record status field has not been set as REQUESTED 2 Version is missing or is The version field is missing or is an value 3 Currency is missing or is The currency field is missing or is an value 4 Record type is missing or is The record type field is missing or is an value 5 Date of file creation is missing or is The date of file creation field is missing or is an date or is in the future 6 Time of file creation is missing The time of file creation field is or is 7 Responsible organisation is missing or is unknown 8 Batch reference or record reference number are too big missing or is an time The responsible organisation code field is missing or is unknown to the central ophthalmic payments system The submitting organisation batch reference or record reference number are too big 9 Invalid Title The patient s title field is an value 10 Surname is missing The patient s surname field is missing or is an value 11 Forenames is missing The patient s forenames field is missing or is an value 12 Address line is missing The patient s address detail is missing or is an value 13 Postcode is missing The patient s postcode field is missing or is an value 14 Patient s date of birth is missing, is or is in the future 15 Date of last sight test, prescription is an value or before patient s date of birth 16 NHS reason is missing or is The patient s date of birth field is missing, is an date or is a date in the future The date of the last sight test or prescription field is an value The patient s NHS reason field is missing or contains an value 17 Evidence not seen is missing The evidence not seen field is missing 18 Who signed is missing or is The who signed field is missing or is an value 19 Payment account code is The payment account code is Page 6 of 29

7 missing or is 20 Local practitioner code is missing or is 21 Practitioner s uniform list number is missing, is unknown to the central ophthalmic payments system or is an format 22 Date of claim is missing, is or is in the future 23 Record end is missing or is 24 Practitioner is no longer active on the responsible NHS organisations practitioner list and the date of the GOS service is after their date off list 25 Practitioner is yet to be activated onto the responsible NHS organisations practitioner list and the date of the GOS service is before their date on list 26 Patient reason is Over 60 and the patient was not 60 or over when the GOS service was performed 27 Patient reason is Under 16 and the patient was not under 16 when the GOS service was performed 28 Patient reason is HC2 and the certificate number has not been supplied when the evidence not seen field is set to No 29 Patient reason is HC3 and the certificate number has not been supplied when the evidence not seen field is set to No 30 Patient reason is Student and the patient was not aged between 16 and 18 when the missing or is an value The local practitioner code field is missing or is an unknown value to the central ophthalmic payments system The practitioner s uniform list number field is missing, is not registered on the practitioner list within the specified responsible organisation or is an format The date of claim field is missing, is, is a date before the service date or is a date in the future The record end field is missing or not set to REND The practitioner identified by the practitioner list number is no longer active on the responsible NHS organisation practitioner list and the date of the GOS service is after their date off list The practitioner identified by the practitioner list number is yet to be activated on the responsible NHS organisation practitioner list and the date of the GOS service is before their date on list The NHS patient reason field has been set to Over 60 and the patient was not 60 or over when the GOS service was performed by the practitioner The NHS patient reason field has been set to Under 16 and the patient was not under 16 when the GOS service was performed by the practitioner The NHS patient reason field has been set to HC2 and the certificate number field has not been supplied when the evidence not seen field has been set to No The NHS patient reason field has been set to HC3 and the certificate number field has not been supplied when the evidence not seen field has been set to No The NHS patient reason field has been set to Student and the patient was not aged 16, 17 or 18 when the Page 7 of 29

8 GOS service was performed 31 GOS service date is before 1 st April 1995, no known payment fee 32 Supplementary Name is missing 33 Supplementary Town is missing 34 Date of GOS service is before patent s date of birth 35 Beneficiary s date of birth is or is in the future GOS service was performed by the practitioner No GOS fees are available within the central ophthalmic payments system for any GOS claims where the service date is before 1 st April 1995 The supplementary name field should contain a value when the NHS reason has been set to student, diabetic, glaucoma, glaucoma risk, blind or prisoner on leave. A minimum of 4 characters is required The supplementary town field should contain a value when the NHS reason has been set to student, diabetic, glaucoma or glaucoma risk. A minimum of 4 characters is required The GOS service date is before the patient s date of birth The beneficiary s date of birth is an date or is in the future 36 Possible Duplicate claim This is a possible duplicate claim. See below for GOS Sight Test Intervals and Early Re-test Codes 37 NHS Number too large The patient s NHS Number is too large 38 NI Number too large The patient s NI Number is too large 39 Beneficiary NHS Number too large 40 Beneficiary NI Number too large The beneficiary s NHS Number is too large The beneficiary s NI Number is too large 41 NHS Sight Test fee too large Sight Test fee is too large or is a negative number 42 National Code too large National Code is too large 43 NHS Domiciliary fee too large Domiciliary fee is too large or is a negative number 44 Total GOS Claim value too large Total claim value is too large or is a negative number 45 Beneficiary name too large The beneficiary s name is too large 46 Patient reason is Income Support and patient not aged between 16 and the National Retirement age when the GOS service was performed The NHS patient reason field has been set to Income Support and the patient was not aged between 16 and National Retirement age when the GOS service was performed by the practitioner Page 8 of 29

9 47 Patient reason is Pension Credit and patient not reached the State Pension age when the GOS service was performed 48 Patient reason is Tax Credit and patient not aged 16 or over when the GOS service was performed 49 Patient reason is Job Seekers Allowance and patient is not aged between 16 and the National Retirement age when the GOS service was performed 50 Patient reason is 40+ & glaucoma relative and patient age was not over 40 when the GOS service was performed 51 A previously accepted GOS claim record has now been manually rejected The NHS patient reason field has been set to Pension Credit and the patient had not reached the State Pension age when the GOS service was performed by the practitioner The NHS patient reason field has been set to Tax Credit and the patient was not 16 or over when the GOS service was performed by the practitioner The NHS patient reason field has been set to JSA and the patient was not aged between 16 and the National Retirement age when the GOS service was performed by the practitioner The NHS patient reason field has been set to 40+ & glaucoma relative and the patient was not aged over 40 when the GOS service was performed by the practitioner An accepted claim has been deleted from the central ophthalmic payments system by the responsible paying organisation and will not be paid. No rejection text will be available under this rejection code, but the reason is usually concerning an incomplete paper GOS form 52 Any other reason for rejection There is some other reason why this claim has been rejected 53 Patient reason is Prisoner on Leave from Prison and patient not aged 16 or over when the GOS service was performed The NHS patient reason field has been set to Prisoner on Leave from Prison and the patient was not aged 16 or over when the GOS service 54 Patient reason is Employment and Support Allowance (ESA) and patient not aged between 16 and the National Retirement age when the GOS service was performed 55 Duplicate claim(s) have been found within the same submission 56 Patient reason is Universal Credit (UC) and patient not aged between 16 and the National Retirement age when was performed by the practitioner The NHS patient reason field has been set to Employment and Support Allowance (ESA) and the patient was not aged between 16 and National Retirement age when the GOS service was performed by the practitioner. Duplicate claim(s) have been found within the same submission The NHS patient reason field has been set to Universal Credit (UC) and the patient was not aged between 16 and National Retirement Page 9 of 29

10 the GOS service was performed age when the GOS service was performed by the practitioner. Page 10 of 29

11 GOS 1 Rejection Codes Rejection Description Code 1000 Incorrect number of elements found within the GOS 1 claim record 1001 Date of sight test is missing, is or is in the future Condition The number of elements found within the GOS 1 claim record does not match the expected number for the specified version The date of sight test field is missing, is an date, is more than 6 months ago or is in the future 1002 Referred to GP is The referred to GP field is not set to Yes or No 1003 No prescription is The no prescription field is not set to Yes or No 1004 Unchanged prescription is The unchanged prescription field is not set to Yes or No 1005 No change is The no change field is not set to Yes or No 1006 New prescription issued is The new prescription issued field is not set to Yes or No 1007 No prescription and new prescription issued are both set to Yes The no prescription and new prescription issues have both been set to Yes 1008 Voucher Issued is The voucher issued field is not set to Yes or No 1009 Voucher code 1 is The voucher code 1 field has been set to an voucher code. Valid voucher codes for the patient s first pair of glasses are: A, B, C, D, E, F, G, H, CC or CF If no voucher code is required, for the patient s first pair of glasses, this field can be set to blank 1010 Voucher code 2 is The voucher code 2 field has been set to an voucher code. Valid voucher codes for the patient s second pair of glasses are: A, B, C, D, or CC If no voucher code is required, for the patient s second pair of glasses, this field can be set to blank 1011 Voucher issued has been set to yes and voucher code 1 has no voucher code The voucher issued field has been set to yes and the voucher code 1 field has no voucher code 1012 Supplementary type 1 is The supplementary type 1 field has been set to an supplementary code. Page 11 of 29

12 Valid supplementary code are: C, P, T or any combination, like CPT If no supplements are required on the patients first pair of glasses, then this field can be set to blank 1013 Supplementary type 2 is The supplementary type 2 field has been set to an supplementary code. Valid supplementary code are: C, P, T or any combination, like CPT If no supplements are required on the patients second pair of glasses, then this field can be set to blank 1014 Supplement type 1 or supplement type 2 has been set to C and the NHS patient reason has not been set to Complex or visa versa 1015 Reason for earlier sight test is 1016 Pre-reg performed the sight test is 1017 Supplementary uniform list number is unknown to the central ophthalmic payments system or is an format 1018 Assistant uniform list number is unknown to the central ophthalmic payments system or is an format 1019 Supplementary uniform list number and assistant uniform list number both supplied If the patient requires a complex supplement for their prescription, the NHS reason must be set to complex and supplement type 1 or supplement type 2 must have a C present The reason for earlier sight test field has been set to an re-test code. See below for Early Re-test Codes The pre-reg performed this sight test field has not been set to Yes or No The supplementary uniform list number does not currently exist within the central ophthalmic payment system or is an format The assistant uniform list number does not currently exist within the central ophthalmic payment system or is an format Only one optician is able to perform this sight test, so both of these can not be known Page 12 of 29

13 GOS 3 Rejection Codes Rejection Description Code 3000 Incorrect number of elements found within the GOS 3 claim record 3001 Voucher code 1 is missing or is 3002 Voucher code 2 is missing or is Condition The number of elements found within the GOS 3 claim record does not match the expected number for the specified version The voucher code 1 field is missing or has been set to an voucher code. Valid voucher codes for the patient s first pair of glasses are: A, B, C, D, E, F, G, H, CC or CF The voucher code 2 field has been set to an voucher code. Valid voucher codes for the patient s second pair of glasses are: A, B, C, D, or CC If no voucher code is required, for the patient s second pair of glasses, this field can be set to blank 3003 Supplementary type 1 is The supplementary type 1 field has been set to an supplementary code. Valid supplementary code are: C, P, T or S or any combination, like CPTS If no supplements are required on the patients first pair of glasses, then this field can be set to blank 3004 Supplementary type 2 is The supplementary type 2 field has been set to an supplementary code. Valid supplementary code are: C, P, T or S or any combination, like CPTS If no supplements are required on the patients second pair of glasses, then this field can be set to blank 3005 Supplement type 1 or supplement type 2 has been set to C and the NHS patient reason has not been set to Complex or visa versa If the patient requires a complex supplement for their prescription, the NHS reason must be set to complex and supplement type 1 or supplement type 2 must have a C present 3006 Right prescription values are Some or all of the values supplied for the right prescription are not numerical values 3007 Left prescription values are Some or all of the values supplied Page 13 of 29

14 3008 Prescription values and issued voucher code(s) are incorrect 3009 Code of the NHS Organisation receiving relevant sight test is missing or 3010 The practitioner s uniform list number, who performed the sight test, is missing or is 3011 The date of sight test is missing, is or is in the future 3012 Patient s contribution value is 3013 The date ordered is missing, is or is in the future 3014 Glasses or contacts supplied is missing or is 3015 New or changed prescription is 3016 Unchanged prescription but wear and tear is 3017 New or changed prescription and unchanged prescription but wear and tear are both set to Yes for the left prescription are not numerical values The patient s prescription values are not associated to the voucher code(s) dispensed Code of the NHS Organisation receiving relevant sight test is an value The practitioner s uniform list number, who performed the sight test, is missing or is an value The date of sight test is missing, is an date or is a date in the future The patient s contribution value is not a numerical value, is a negative number, is larger than or is missing when the patient reason is HC3 The date ordered is missing, is, is more than 2 years ago or is in the future Glasses or contact lenses dispensed by the supplier is missing or is an value The new or changed prescription field is not set to Yes or No The unchanged prescription but wear and tear is not set to Yes or No The new or changed prescription and unchanged prescription but wear and tear fields are both set to Yes 3018 Retail price for 1 st pair is The retail price value for the 1 st pair is not a numerical value or is a negative number 3019 Retail price for 2 nd pair is The retail price value for the 2 nd pair is not a numerical value or is a negative number 3020 Voucher value for the 1 st pair is 3021 Voucher value for the 2 nd pair is 3022 Complex value for 1 st pair is The voucher value for the 1 st pair is not a numerical value or is a negative number The voucher value for the 2 nd pair is not a numerical value or is a negative number The complex value for the 1 st pair is not a numerical value or is a negative number Page 14 of 29

15 3023 Complex value for 2 nd pair is 3024 Supplementary values for the 1 st pair are 3025 Supplementary values for the 2 nd pair are 3026 Prism supplement code for 1 st pair is 3027 Prism value for the 1 st pair is 3028 Prism supplement code for 2 nd pair is 3029 Prism value for the 2 nd pair is 3030 Tint supplement code for 1 st pair is 3031 Tint value for the 1 st pair is 3032 Tint supplement code for 2 nd pair is 3033 Tint value for the 2 nd pair is 3034 Small glasses supplement code for 1 st pair is 3035 Small glasses supplement value for the 1 st pair is The complex value for the 2 nd pair is not a numerical value or is a negative number Some or all of the values supplied for the 1 st pair supplementary costs are not numerical values or are negative numbers Some or all of the values supplied for the 2 nd pair supplementary costs are not numerical values or are negative numbers The prism supplement code for the 1 st pair is due to the 1 st pair voucher code or is missing when the prism supplement for 1 st pair is set to Yes The prism value for the 1 st pair is not a numerical value or is a negative number The prism supplement code for the 2 nd pair is due to the 2 nd pair voucher code or is missing when the prism supplement for 2 nd pair is set to Yes The prism value for the 2 nd pair is not a numerical value or is a negative number The tint supplement code for the 1 st pair is due to the 1 st pair voucher code or is missing when the tint supplement for 1 st pair is set to Yes The tint value for the 1 st pair is not a numerical value or is a negative number The tint supplement code for the 2 nd pair is due to the 2 nd pair voucher code or is missing when the tint supplement for 2 nd pair is set to Yes The tint value for the 2 nd pair is not a numerical value or is a negative number The small glasses supplement code for the 1 st pair is due to the 1 st pair voucher code or is missing when the small glasses supplement for 1 st pair is set to Yes or the patient is over 7 years old The small glasses value for the 1 st pair is not a numerical value or is a Page 15 of 29

16 st pair boxed centre distance is 3037 Small glasses supplement code for 2 nd pair is 3038 Small glasses supplement value for the 2 nd pair is nd pair boxed centre distance is 3040 Photo chromic supplement code for 1 st pair is 3041 Photo chromic supplement value for the 1 st pair is 3042 Photo chromic supplement code for 2 nd pair is 3043 Photo chromic supplement value for the 2 nd pair is 3044 Facial supplement for 1 st pair is 3045 Facial supplement value for the 1 st pair is 3046 Facial supplement for 2 nd pair is 3047 Facial supplement value for the 2 nd pair is negative number The 1 st pair boxed centre distance field is larger than the 55 millimetres, is not a numerical field or is a negative number when patient supplied with a small glasses supplement The small glasses supplement code for the 2 nd pair is due to the 2 nd pair voucher code or is missing when the small glasses supplement for 2 nd pair is set to Yes or the patient is over 7 years old The small glasses value for the 2 nd pair is not a numerical value or is a negative number The 2 nd pair boxed centre distance field is larger than the 55 millimetres, is not a numerical field or is a negative number when patient supplied with a small glasses supplement The photo chromic supplement code for the 1 st pair is due to the 1 st pair voucher code or is missing when the photo chromic supplement for 1 st pair is set to Yes. This is only valid on an HES claim The photo chromic value for the 1 st pair is not a numerical value or is a negative number The photo chromic supplement code for the 2 nd pair is due to the 2 nd pair voucher code or is missing when the photo chromic supplement for 2 nd pair is set to Yes. This is only valid on an HES claim The photo chromic value for the 2 nd pair is not a numerical value or is a negative number The facial supplement field for the 1 st pair is not set to Yes or No. This is only valid on an HES claim The facial value for the 1 st pair is not a numerical value or is a negative number The facial supplement field for the 2 nd pair is not set to Yes or No. This is only valid on an HES claim The facial value for the 2 nd pair is not a numerical value or is a negative Page 16 of 29

17 3048 Voucher and supplements value for 1 st pair is 3049 Voucher and supplements value for 2 nd pair is number The voucher and supplements value for the 1 st pair is not a numerical value or is a negative number The voucher and supplements value for the 2 nd pair is not a numerical value or is a negative number 3050 Maximum amount is The maximum amount field is not a numerical value or is a negative number 3051 Total amount payable is The total amount payable field is not a numerical value or is a negative number 3052 Supply date for 1 st pair is 3053 Supply date for 2 nd pair is 3054 Number of glasses or contact lenses supplied is The supply date field for the 1 st pair is missing, is an date, is before date ordered or is a date in the future The supply date field for the 2 nd pair is an date, is before date ordered or is a date in the future The number of glasses or contact lenses supplied is missing or not set as 0, 1 to 365. Use 0 if Uncollected = Yes Use 1 or 2 when glasses dispensed Use 1 up to 365 when contact lenses dispensed 3055 Date collected is The date collected is missing, is an date, is more than 2 years ago, is more than 2 years after the date ordered or is a date in the future when Uncollected is No 3056 Uncollected Glasses The uncollected glasses field is an value 3057 Who signed 2 is The who signed 2 field is missing or is an value 3058 Patient declaration date is The patient declaration date is an date or is a date in the future when Uncollected is No Page 17 of 29

18 GOS 4 Rejection Codes Rejection Description Code 4000 Incorrect number of elements found within the GOS 4 claim record 4001 Patient s contribution value is 4002 Loss or damage indicator is 4003 Loss or damage reason is Condition The number of elements found within the GOS 4 claim record does not match the expected number for the specified version The patient s contribution value is not a numerical value, is a negative number, is larger than or is missing when the patient reason is HC3 The loss or damage indicator is missing or is an value when the NHS Reason is not set as under 16 The loss or damage reason is too large or is not a valid code when the NHS Reason is not set as under Date ordered is The date ordered field is missing, is an date, is more than 2 years ago or is a date in the future 4005 Patient repaired or replaced is The patient repaired or replaced is missing or is an value 4006 Who signed 2 is The who signed 2 fields is missing or is an value 4007 Date collected is The date collected is missing, is an date, is more than 2 years ago, is more than 2 years after the date ordered or is a date in the future when Uncollected is No 4008 Uncollected Glasses The uncollected glasses field is an value 4009 Repaired glasses The repaired glasses field is missing or is an value 4010 Replaced glasses/contact lenses 4011 Repaired glasses and replaced glasses/contact lenses are both set to Yes or No 4012 Right prescription values are 4013 Left prescription values are The replaced glasses /contact lenses field is missing or is an value The repaired glasses and replaced glasses/contact lenses fields are both set to Yes or No Some or all of the values supplied for the right prescription are not numerical values when replacing a voucher or repairing lenses Some or all of the values supplied for the left prescription are not numerical values when replacing a voucher or repairing lenses Page 18 of 29

19 4014 Prescription values and issued voucher code(s) are incorrect 4015 Voucher code is missing or is The patient s prescription values are not associated to the voucher code(s) dispensed. The voucher code field has been set to an voucher code. If replaced glasses/contact lenses = Yes Valid voucher codes for the patient s first pair of glasses are: A, B, C, D, E, F, G, H, CC or CF 4016 Supplementary type is The supplementary type field has been set to an supplementary code. Valid supplementary code are: C, P, T or S or any combination, like CPTS If no supplements are required on the patients first pair of glasses, then this field can be set to blank 4017 Voucher Value is The voucher value field is not a numerical value or is a negative number. If replaced glasses/contact lenses = Yes 4018 Right lens repaired is The right lens repaired field is not set to Yes or No. If repaired glasses = Yes 4019 Left lens repaired is The left lens repaired field is not set to Yes or No. If repaired glasses = Yes 4020 Both lenses repaired is The both lenses repaired field is not set to Yes or No. If repaired glasses = Yes 4021 Repaired lens code is The repaired lens code is incorrect or is an value. If repaired glasses = Yes 4022 Repair lens value is The repair lens value field is not a numerical value or is a negative number. If repaired glasses = Yes 4023 Front frame repaired is The front frame repaired field is not set to Yes or No. If repaired glasses = Yes 4024 Side frame repaired is The side frame repaired field is not set to Yes or No. If repaired glasses = Yes 4025 Whole frame repaired is The whole frame repaired field is not set to Yes or No. If repaired glasses = Yes 4026 Repair frame code is The repair frame repaired code is incorrect or is an value. If repaired glasses = Yes 4027 Repair frame value is The repair frame value field is not a Page 19 of 29

20 4028 Supplement type 1 or supplement type 2 has been set to C and the NHS patient reason has not been set to Complex or visa versa numerical value or is a negative number. If repaired glasses = Yes If the patient requires a complex supplement for their prescription, the NHS reason must be set to complex and supplement type 1 or supplement type 2 must have a C present 4029 Complex value is The complex value field is not a numerical value or is a negative number 4030 Prism supplement code is The prism supplement code is incorrect or is an value 4031 Prism value is The prism value field is not a numerical value or is a negative number 4032 Tint supplement code is The tint supplement code is incorrect or is an value 4033 Tint value is The tint value field is not a numerical value or is a negative number 4034 Repair small glasses supplement code is 4035 Repair small glasses value is 4036 Replacement small glasses supplement code is 4037 Replacement small glasses value is 4038 Voucher and supplements total value is 4039 Parts and supplements total value is 4040 Voucher and supplements total value and parts and supplements total value are The repair small glasses supplement code is incorrect or is an value. If repaired glasses = Yes The repair small glasses value field is not a numerical value or is a negative number. If repaired glasses = Yes The replacement small glasses supplement code is incorrect or is an value. If replaced/glasses contact lenses = Yes The replacement small glasses value field is not a numerical value or is a negative number. If replaced/glasses contact lenses = Yes The voucher and supplements total value field is not a numerical value or is a negative number The parts and supplements total value field is not a numerical value or is a negative number The voucher and supplements total value and parts and supplements total value fields have both been set to a value. A GOS4 claim can only be a repair or a replacement 4041 The GOS 4 claim is The voucher code and lens code or frame code have both been set to a value. A GOS4 claim can only be a repair or a replacement Page 20 of 29

21 4042 Retail price is The retail price field is not a numerical value or is a negative number 4043 Total claim is The total claim field is not a numerical value or is a negative number 4044 Patient repaired or replaced and practitioner repaired glasses or replaced glasses/contact lenses are 4045 The fields right lens repaired, left lens repaired and both lenses repaired are 4046 The fields Frame front repaired, frame side repaired and frame whole repaired are The patient declaration of service does not match the practitioner s declaration of service These fields fail the GOS regulations. Only one should be set to Yes as appropriate for the lens repair These fields fail the GOS regulations. Only one should be set to Yes as appropriate for the frame repair Page 21 of 29

22 GOS 5 Rejection Codes Rejection Description Code 5000 Incorrect number of elements found within the GOS 5 claim record 5001 Date of sight test is missing, is or is in the future Condition The number of elements found within the GOS 5 claim record does not match the expected number for the specified version The date of sight test field is missing, is an date, is more than 6 months ago or is in the future 5002 Referred to GP is The referred to GP field is not set to Yes or No 5003 No prescription is The no prescription field is not set to Yes or No 5004 Unchanged prescription is The unchanged prescription field is not set to Yes or No 5005 No change is The no change field is not set to Yes or No 5006 New prescription issued is The new prescription issued field is not set to Yes or No 5007 No prescription and new prescription issued are both set to Yes The no prescription and new prescription issues have both been set to Yes 5008 Voucher issued is The voucher issued field is not set to Yes or No 5009 Voucher code 1 is The voucher code 1 field has been set to an voucher code. Valid voucher codes for the patient s first pair of glasses are: A, B, C, D, E, F, G, H, CC or CF If no voucher code is required, for the patient s first pair of glasses, this field can be set to blank 5010 Voucher code 2 is The voucher code 2 field has been set to an voucher code. Valid voucher codes for the patient s second pair of glasses are: A, B, C, D, or CC If no voucher code is required, for the patient s second pair of glasses, this field can be set to blank 5011 Voucher issued has been set to yes and voucher code 1 has no voucher code The voucher issued field has been set to yes and the voucher code 1 field has no voucher code 5012 Supplementary type 1 is The supplementary type 1 field has been set to an supplementary code. Valid supplementary code are: C, P, T or any combination, like CPT Page 22 of 29

23 If no supplements are required on the patients first pair of glasses, then this field can be set to blank 5013 Supplementary type 2 is The supplementary type 2 field has been set to an supplementary code. Valid supplementary code are: C, P, T or any combination, like CPT If no supplements are required on the patients second pair of glasses, then this field can be set to blank 5014 Reason for earlier sight test is 5015 Pre-reg performed the sight test is 5016 Performer s uniform list number is unknown to the central ophthalmic payments system or is an format The reason for earlier sight test field has been set to an re-test code. See below for Early Re-test Codes The pre-reg performed this sight test field has not been set to Yes or No The performer uniform list number does not currently exist within the central ophthalmic payment system or is an format 5017 Patient s contribution value is The patient s contribution value is missing, is not a numerical value or is a negative number 5018 Domiciliary visit is The domiciliary visit field is missing 5019 Reason for domiciliary visit is st patient at address is missing or is nd patient at address is missing or is rd or subsequent patient at address is missing or is 5023 Lower of private or NHS sight test fee is 5024 Lower of private or NHS domiciliary fee is 5025 Maximum claim in respect for sight test is or is an value The reason for domiciliary visit is The 1 st patient at address field is missing or is an value The 2 nd patient at address field is missing or is an value The 3 rd or subsequent patient at address field is missing or is an value The lower of private or NHS sight test fee field is not a numerical value or is a negative number The lower of private or NHS domiciliary fee field is not a numerical value or is a negative number The maximum claim in respect of sight test fee field is not a numerical value or is a negative number 5026 Total claim value is The total claim value field is not a numerical value or is a negative number Page 23 of 29

24 GOS 6 Rejection Codes Rejection Description Code 6000 Incorrect number of elements found within the GOS 6 claim record 6001 Date of sight test is missing, is or is in the future Condition The number of elements found within the GOS 6 claim record does not match the expected number for the specified version The date of sight test field is missing, is an date, is more than 6 months ago or is in the future 6002 Referred to GP is The referred to GP field is not set to Yes or No 6003 No prescription is The no prescription field is not set to Yes or No 6004 Unchanged prescription is The unchanged prescription field is not set to Yes or No 6005 No change is The no change field is not set to Yes or No 6006 New prescription issued is The new prescription issued field is not set to Yes or No 6007 No prescription and new prescription issued are both set to Yes The no prescription and new prescription issues have both been set to Yes 6008 Voucher Issued is The voucher issued field is not set to Yes or No 6009 Voucher code 1 is The voucher code 1 field has been set to an voucher code. Valid voucher codes for the patient s first pair of glasses are: A, B, C, D, E, F, G, H, CC or CF If no voucher code is required, for the patient s first pair of glasses, this field can be set to blank 6010 Voucher code 2 is The voucher code 2 field has been set to an voucher code. Valid voucher codes for the patient s second pair of glasses are: A, B, C, D, or CC If no voucher code is required, for the patient s second pair of glasses, this field can be set to blank 6011 Voucher issued has been set to yes and voucher code 1 has no voucher code The voucher issued field has been set to yes and the voucher code 1 field has no voucher code 6012 Supplementary type 1 is The supplementary type 1 field has been set to an supplementary code. Valid supplementary code are: Page 24 of 29

25 C, P, T or any combination, like CPT If no supplements are required on the patients first pair of glasses, then this field can be set to blank 6013 Supplementary type 2 is The supplementary type 2 field has been set to an supplementary code. Valid supplementary code are: C, P, T or any combination, like CPT If no supplements are required on the patients second pair of glasses, then this field can be set to blank 6014 Supplement type 1 or supplement type 2 has been set to C and the NHS patient reason has not been set to Complex or visa versa 6015 Reason for earlier sight test is 6016 Pre-reg performed the sight test is 6017 Supplementary uniform list number is unknown to the central ophthalmic payments system or is an format 6018 Assistant uniform list number is unknown to the central ophthalmic payments system or is an format 6019 Supplementary uniform list number and assistant uniform list number both supplied 6020 Reason for domiciliary visit is missing 6021 Visit to one domiciliary patient is missing or is 6022 Visit to several domiciliary patients is missing or is st patient at address is missing or is nd patient at address is missing or is If the patient requires a complex supplement for their prescription, the NHS reason must be set to complex and supplement type 1 or supplement type 2 must have a C present The reason for earlier sight test field has been set to an re-test code. See below for Early Re-test Codes The pre-reg performed this sight test field has not been set to Yes or No The supplementary uniform list number does not currently exist within the central ophthalmic payment system or is an format The assistant uniform list number does not currently exist within the central ophthalmic payment system or is an format Only one optician is able to perform this sight test, so both of these can not be known The reason for the domiciliary visit field is missing The visit to one domiciliary patient field is missing or is an value The visit to several domiciliary patients field is missing or is an value The 1 st patient at address field is missing or is an value The 2 nd patient at address field is missing or is an value rd or subsequent patient at The 3 rd or subsequent patient at Page 25 of 29

26 address is missing or is address field is missing or is an value Re-test interval and clinical re-test codes As defined within the memorandum of understanding between Department of Health and Association of Optometrists and Federation of Ophthalmic and Dispensing Opticians, January Patient's Age at Time of Sight Test or Minimum Interval Between Sight Test Clinical Condition Under 16 years, in the absence of any 1 year binocular vision anomaly Under 7 years with binocular vision 6 months anomaly or corrected refractive error 7 years and over and under 16 with 6 months binocular vision anomaly or rapidly progressing myopia 16 years and over and under 70 years 2 years 70 years and over 1 year 40 years and over with family history of 1 year glaucoma or with ocular hypertension and not in monitoring scheme Diabetic patients 1 year Clinical reason codes for earlier sight test on GOS 1 and GOS 6 claims: 1. Patient is at risk of frequent changes of prescription for reasons not requiring medical referral or for reasons already known to a medical practitioner; 2. Patient has pathology likely to worsen, for example age-related macular degeneration, cataract, corneal dystrophy, or congenital anomalies; 3. Patient has presented with symptoms or concerns requiring ophthalmic investigation: 3.1. resulting in referral to a medical practitioner; 3.2. resulting in issue of a changed prescription; 3.3. resulting in either no change or no referral (the patient's record should indicate any symptoms shown to support this category of claim, if necessary). 4. Patient: 4.1. needing complex lenses; 4.2. with corrected vision of less than 6/60 in one eye. 5. Patient: 5.1. has presented for a sight test at the request of a medical practitioner; 5.2. is being managed by an optometrist under the GOC referral rules, for example suspect visual fields on one occasion which is not confirmed on repeat, or abnormal IOP with no other significant signs of glaucoma; 6. Other unusual circumstances requiring clinical investigation. Page 26 of 29

27 NB Where the early re-test code has more than one possible selection, please ensure you supply the full code including the decimal point, e.g., 3.1, 4.1, 5.1. The values of 3, 4, or 5 are not valid re-test codes and will be rejected. Page 27 of 29

28 Enhanced services (ENSV) common rejection reason codes Rejection Description Condition Code 900 Incorrect number of elements found within the ENSV claim record The number of elements found within the ENSV claim record does not match the expected number for the specified version 901 Contact ID is missing or The Contact ID is missing or is not 902 Application ID is missing or. found within the system The Application ID is missing or is not found within the system 903 Service ID is missing or The Service ID is missing or is not found within the system 904 Date of Enhanced Service is missing, is or is in the future The date of Enhanced Service field is missing, is an date, is more than 6 months ago or is in the future Enhanced services ophthalmic rejection reason codes Rejection Description Code 9001 Local Identifier is missing or is 9002 Practitioner is no longer active on the responsible NHS organisations practitioner list and the date of the enhanced service is after their date off list 9003 Practitioner is yet to be activated onto the responsible NHS organisations practitioner list and the date of the enhanced service is before their date on list 9004 Service date is before 1 st April 2004, no known payment fee 9005 Exemption Reason not entered for certain Service Types when submitted to a Welsh NHS Condition The local identifier field is missing or is an unknown value to the enhanced services system The practitioner identified by the practitioner list number is no longer active on the responsible NHS organisation practitioner list and the date of the enhanced service is after their date off list The practitioner identified by the practitioner list number is yet to be activated on the responsible NHS organisation practitioner list and the date of the enhanced service is before their date on list No Enhanced Service fees are available within the enhanced services system for any enhanced service claims where the service date is before 1 st April 2004 WECE and PEARs services (Services 11, 12, 13) require an Exemption Reason code when submitting to a Welsh NHS Page 28 of 29