July 21, 2006
PRIMARY PAYER REJECT CODES / BIN
Effective Thursday, August 3, 2006, PACE will accept only valid reject codes from the primary payer in Field 472-6E.
PACE defines VALID codes as a reject reason that can not be corrected by the provider and resubmitted to the primary payer.
The following are some, but not all, examples of Valid reject codes:
NCPDP Error Code “3Y”-- Prior Authorization Denied
NCPDP Error Code “65”-- Patient is Not Covered
NCPDP Error Code “69” Filled After Coverage Terminated
NCPDP Error Code “70” Product/Service Not Covered
Only primary reject codes that are non-correctable by the provider will be accepted for claims submitted with an Other Coverage Code (OCC) of 3, 5, 6 or 7.
PACE defines INVALID codes as a reject reason that can be corrected by the provider and resubmitted to the primary payer. These errors should be corrected and the claim resubmitted to the primary payer. Claims submitted to PACE/PACENET with an invalid or correctable code, will be rejected with PACE Error 005; NCPDP Error 6E --- Missing / Invalid Other Payer Reject Code.
The following are some, but not all, examples of Invalid reject codes:
NCPDP Error Code “19” Missing/Invalid Days Supply
NCPDP Error Code “52” Non-Matched Cardholder ID
NCPDP Error Code “6E” Missing /Invalid Other Payer Reject Code
NCPDP Error Code “25” Missing/Invalid Prescriber ID
In conjunction with this edit enhancement, effective August 3, 2006, PACE is also requiring that Field 340-7C, the OTHER PAYER’S ID or BIN, contain 6 numeric values. BIN’s containing names, i.e., “PCS” or cardholders ID’s, i.e., “123456789” will reject with PACE Error 007; NCPDP Error 7C --- Missing/ Invalid Other Payer ID. In the near future PACE will edit the BIN received on the submitted claim with the BIN contained on the Program’s file to insure accuracy.
REMINDER: The First Health Medicare Discount Card Plan ended on May 15, 2006. Only claims filled on or before May 15, 2006 should contain the First Health Medicare Discount Plan BIN of 011487.
Questions may be directed to Provider Services at 1-800-835-4080.