Top 20 D.0 Rejection Reasons
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1 Top 20 D.0 Rejection Reasons
2 Copyright Definitive Homecare Solutions All Rights Reserved. This document is the copyrighted proprietary property of Definitive Homecare Solutions. The unauthorized copying without proper software license or altering of this document, whether in hard copy or digital format, is strictly prohibited. While every effort has been made to ensure the accuracy of this publication, Definitive Homecare Solutions assumes no liability for error or omission from use of the information. For a complete list of CPR+ documentation, please refer to the software s F1 Help or the Training Resource Center (training.cprplus.com). Definitive Homecare Solutions 707 Park Meadow Road Westerville, OH Document History Writer(s) SMEs / Editors Release Date Version Edition / Changes Laura Modisette Desirae DeBellis 11/24/ New Document Top 20 D.0 Rejection Reasons Rev: 8/8/2014
3 Table of Contents Overview... 1 Stop Being Rejected!... 1 R8: Syntax Error... 1 NX: M/I Submission Clarification Code... 1 DK: Submission Clarification Code Not Supported... 1 AK: M/I Software Vendor / Certification ID X: M/I Patient Residence... 3 E2: M/I Route of Administration E: M/I DUR / PPS Level of Effort... 4 SG: Submission Clarification Code Count Does Not Match Number of Repetitions M: Sum of Compound Ingredient Costs Does Not Equal Ingredient Cost... 5 C8: Discrepancy Between Other Coverage Code And Other Payor Amt... 6 NQ: M/I Other Payor-Patient Responsibility... 7 NP: M/I Other Payor Patient Responsibility... 8 MW: M/I Other Benefit Stage Amount... 8 MX: Benefit Stage Amount does not match number or repetitions HB: Other Payor Amount Paid Count Exceeds Number of Supported Groupings NR: M / I Other Payer Patient Responsibility C: M / I Coordination of Benefits / Other Payments Count RE: Compound Product ID Qualifier Value Not Supported T: Compound Segment Requires For Adjudication E1: M/I Alternative Product Type Top 20 D.0 Rejection Reasons Rev: 8/8/2014
4 Overview In order to make the resolution of pharmacy rejections easier, we collected the 20 most common NCPDP claim rejections and created recommendations for resolving them in CPR+. This document is an invaluable resource to use when working claim rejections. Stop Being Rejected! The following pages present the top 20 rejection reasons and how to make changes so you won t be rejected again. R8: Syntax Error This error indicates there is invalid data on the claim, and it cannot be processed. When you receive this error, the payor may or may not return a rejection code to specify the field causing this error. NX: M/I Submission Clarification Code Populate the Submission Clarification Code (DK) field with a value greater than 0 (zero) to correct this rejection. DK: Submission Clarification Code Not Supported Populate the Submission Clarification Code (DK) field with a value greater than 0 (zero) to correct this rejection. 1 Top 20 D.0 Rejection Reasons Rev: 8/8/2014
5 2 Top 20 D.0 Rejection Reasons Rev: 8/8/2014
6 AK: M/I Software Vendor / Certification ID Navigate to the Insurance Companies database. Select Payor > Edit Payor > Electronic Setup button > 1 13 sub-tab > #9 Software Certification ID. Select the appropriate value using the drop-down. 4X: M/I Patient Residence Populate or correct the (4X) Place of Residence (D.0) field on the Prescription Data tab of the claim. 3 Top 20 D.0 Rejection Reasons Rev: 8/8/2014
7 E2: M/I Route of Administration Populate the (E2) Route of Administration field on the Prescriber / Cmpd /Auth tab of the claim. 8E: M/I DUR / PPS Level of Effort Populate the (8E) DUR / PPS Level of Effort field by editing the line item(s) of the claim. 4 Top 20 D.0 Rejection Reasons Rev: 8/8/2014
8 SG: Submission Clarification Code Count Does Not Match Number of Repetitions Populate the (DK) Submission Clarification Code field on the Prescriber / Cmpd /Auth tab of the claim with a value greater than 0 (zero). 8M: Sum of Compound Ingredient Costs Does Not Equal Ingredient Cost Review and correct, if applicable, both the (D9) Ingredient Cost field for each line item on the compound claim and the Payor s Electronic Setup option #10, Calculate Gross Amt Based On field. 5 Top 20 D.0 Rejection Reasons Rev: 8/8/2014
9 C8: Discrepancy Between Other Coverage Code And Other Payor Amt Ensure that the correct (C8) Other Coverage Code is populated. 6 Top 20 D.0 Rejection Reasons Rev: 8/8/2014
10 NQ: M/I Other Payor-Patient Responsibility To avoid this rejection, select the Prescription Data tab > COB / Other Payor > Edit Payor > Patient Resp.> Add. Populate the (NP) PR Qualifier and (NQ) PR Amount fields. 7 Top 20 D.0 Rejection Reasons Rev: 8/8/2014
11 NP: M/I Other Payor Patient Responsibility To avoid this rejection, select the Prescription Data tab > COB / Other Payor > Edit Payor > Patient Resp. Enter or edit the corresponding Patient Responsibility. MW: M/I Other Benefit Stage Amount Select the Prescription Data tab > COB / Other Payor > Edit Payor > Benefit Stage > Add. Enter the (MV) Benefit Qualifier and (MW) Benefit Amount fields 8 Top 20 D.0 Rejection Reasons Rev: 8/8/2014
12 9 Top 20 D.0 Rejection Reasons Rev: 8/8/2014
13 MX: Benefit Stage Amount does not match number or repetitions This rejection is similar to the MW rejections. See the above screenshot to make corrections. The (MV) Benefit Qualifier and (MW) Benefit Amount information can be found on the Primary Response. HB: Other Payor Amount Paid Count Exceeds Number of Supported Groupings To avoid this rejection, exclude the payment amount. This is populated on and accessed from the Prescription Data tab > COB / Other Payor > Edit Payor > Payments. 10 Top 20 D.0 Rejection Reasons Rev: 8/8/2014
14 NR: M / I Other Payer Patient Responsibility This rejection is handled by editing the Patient Resp. field. Select the Prescription Data tab > COB / Other Payor > Edit Payor > Patient Resp. 4C: M / I Coordination of Benefits / Other Payments Count This rejection is received when there is missing COB information or when a blank line appears on the COB / Other Payor Information window. RE: Compound Product ID Qualifier Value Not Supported This rejection is often found on compounded claims. To resolve this rejection, select Main Menu > Databases > Insurance Companies > desired payor > Electronic Setup > sub-tab and populate # 17 with Y. 11 Top 20 D.0 Rejection Reasons Rev: 8/8/2014
15 6T: Compound Segment Requires For Adjudication To resolve this rejection, select Main Menu > Databases > Insurance Companies > desired payor > Electronic Setup > sub-tab and populate #20 with N. 12 Top 20 D.0 Rejection Reasons Rev: 8/8/2014
16 E1: M/I Alternative Product Type This rejection is often found on compound claims. To resolve this rejection is a two step process. You need to edit the payor settings and the claim. To edit the payor settings, select Main Menu > Databases > Insurance Companies >desired payor > Electronic Setup > sub-tab and populate #17 = Y; #18 = 00; #20 = N. To correct the claim once the payor settings are applied, change the Product / Service ID Qualifier to 00 on the Prescriber / Cmpd / Auth tab. Enter 2 in the Compound Code field and Related in all other compound-related fields. Subsequent claims will be correct. 13 Top 20 D.0 Rejection Reasons Rev: 8/8/2014
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