Chart 1 – Recipient with Coverage Codes H, K, M, O or ALL on file

Field 308-C8 Value	Field 431-DV Value	NCPDP Format Version	Field 104-A4 Value	Claim Status
0, 1, 2, 3, 4, 5, 6, 7, 8	431-DV is Not sent	51	Non-ECCA (Processor Control Number not sent) or ECCA (Processor Control Number sent)	If all other edits are passed, the transaction will be accepted for issuing service authorizations and/or DVS prior authorizations. (“C - capture” (field 112-AN) and “NO CLAIM TO FA” (field 503-F3) will be returned).
0, 1, 4 or 7	Zeros or greater	51	ECCA or Non-ECCA	The transaction will be rejected. NCPDP Reject Code: 13 “M/I Other Coverage Code” and Response Code: 717 “Client Has Other Insurance” will be returned online.
2 or 8	Zeros	51	ECCA or Non-ECCA	The transaction will be rejected. NCPDP Reject Code 13 “M/I Other Coverage Code” and Response Code 715 ‘Other Payor Amount Must Be Greater Than 0’ will be returned.
2 or 8	Greater than Zero	51	ECCA	If all other edits are passed, the claim will be approved for payment. (“C - capture” (field 112-AN) and an invoice number (field 503-F3) will be returned). Other payor amount will be subtracted from the claim’s payment amount.
2 or 8	Greater than Zero	51	Non-ECCA	If all other edits are passed, the transaction will be accepted for issuing service authorizations and/or DVS prior authorizations. (“C - capture” (field 112-AN) and “NO CLAIM TO FA” (field 503-F3) will be returned).
3, 5 or 6	Zeros, blank or not sent	51	ECCA	If all other edits are passed, the claim will be approved for payment. (“C - capture” (field 112-AN) and an invoice number (field 503-F3) will be returned).
3, 5 or 6	Zeros	51	Non-ECCA	If all other edits are passed, the transaction will be accepted for issuing service authorizations and/or DVS prior authorizations. (“C - capture” (field 112-AN) and “NO CLAIM TO FA” (field 503-F3) will be returned).
3, 5 or 6	Greater than Zero	51	ECCA or Non-ECCA	The transaction will be rejected. NCPDP Reject Code “13 M/I Other Coverage Code” and Response Code “716 ‘ Other Payor Amount Must Be Equal to 0” will be returned.

Chart 2 – Recipient without Coverage Codes on file

Field 308-C8 Value	Field 431-DV Value	NCPDP Format Version	Field 104-A4 Value	Claim Status
0, 1, 2, 3, 5, 6, 7 or 8	Not sent	51	Non-ECCA	If all other edits are passed, the transaction will be accepted for issuing service authorizations and/or DVS prior authorizations. (“C - capture” (field 112-AN) and “NO CLAIM TO FA” (field 503-F3) will be returned).
0, 1 or 7	Not sent	51	ECCA	If all other edits are passed, the claim will be approved for payment. (“C - capture” (field 112-AN) and an invoice number (field 503-F3) will be returned).
0, 1, 3, 5, 6 or 7	Zeros	51	Non-ECCA	If all other edits are passed, the transaction will be accepted for issuing service authorizations and/or DVS prior authorizations. (“C - capture” (field 112-AN) and “NO CLAIM TO FA” (field 503-F3) will be returned).
0, 1, 7	Zeros	51	ECCA	If all other edits are passed, the claim will be approved for payment. (“C - capture” (field 112-AN) and an invoice number (field 503-F3) will be returned).
3, 5 or 6	Zeros, blank or not sent	51	ECCA	If all other edits are passed, the claim will be approved for payment. (“C - capture” (field 112-AN) and an invoice number (field 503-F3) will be returned).
0, 1, 3, 4, 5, 6 or 7	Greater than Zero	51	Non-ECCA or ECCA	The transaction will be rejected. NCPDP Reject Code “DV - M/I Other Payor Amount Paid” and Response Code “320 – Other Insurance Information Inconsistent” will be returned.
2, 3, 5, 6, or 8	Not sent	51	Non-ECCA or ECCA	If all other edits are passed, the transaction will be accepted for issuing service authorizations and/or DVS prior authorizations. (“C - capture” (field 112-AN) and “NO CLAIM TO FA” (field 503-F3) will be returned).
4	Not sent or zeros	51	Non-ECCA or ECCA	If all other edits are passed, the transaction will be accepted for issuing service authorizations and/or DVS prior authorizations. (“C - capture” (field 112-AN) and “NO CLAIM TO FA” (field 503-F3) will be returned).
2 or 8	Greater than Zero	51	Non-ECCA	If all other edits are passed, the transaction will be accepted for issuing service authorizations and/or DVS prior authorizations. (“C - capture” (field 112-AN) and “NO CLAIM TO FA” (field 503-F3) will be returned).
2 or 8	Greater than Zero	51	ECCA	If all other edits are passed, the transaction will be accepted for payment. (“C - capture” (field 112-AN) and an invoice number (field 503-F3) will be returned).
2 or 8	Zeros	51	Non-ECCA or ECCA	The claim will reject. NCPDP Reject Code “13 M/I Other Coverage Code” and Response Code “715 Other Payor Amount Must Be Greater Than 0” will be returned.

3.1 DUR Response Fields (Rev. 11/03)

The following information is returned in the response from the Pro-DUR system for each identified DUR conflict:

Drug Conflict Code (439-E4)

Clinical Significance (528-FS)

Other Pharmacy Indicator (529-FT)

Previous Date of Fill (530-FU)

Quantity of Previous Fill (531-FV)

Database Indicator (532-FW)

Other Prescriber Indicator (533-FX)

Free Text (544-FY)

Reason For Service (Conflict Code)

The Drug Conflict Code identifies the type of DUR conflict found when a new prescription is compared against the recipient's drug history file and demographics. Following are the values that may be returned as Drug Conflict Codes:

TD = Therapeutic Duplication

DD = Drug-Drug Interactions

DC = Inferred Drug Disease Precaution

PG = Drug Pregnancy Alert

PA = Drug Age Precaution

LD = Low Dose Alert

HD = High Dose Alert

Clinical Significance

The Clinical Significance is a code that identifies the severity level and how critical the conflict. The following chart lists each drug conflict code and the clinical significance codes which may be returned for that code as well as whether they are DUR rejects or warnings.

Conflict Code	Reject/ Warning	Clinical Significance	Description of Clinical Significance
TD Therapeutic Duplication	R	1	An Original Prescription that duplicates a therapy the recipient is already taking.
	W	2	Prescription is a Refill and is being filled prior to 75% of the prior script's days supply.
DD Drug-Drug	R	1	Most significant. Documentation substantiates interaction is at least likely to occur in some patients, even though more clinical data may be needed. Action to reduce risk of adverse interaction usually required.
	W	2	Significant. Documentation substantiates interaction is at least likely to occur in some patients, even though more clinical data may be needed. Assess risk to patient and take action as needed.
	W	3	Possibly significant. Little clinical data exists. Conservative measures are recommended because the potential for severe adverse consequences is great.
DC Drug Disease	W	1	Absolute Contraindication. Drug Therapy for the recipient should be changed.
	W	2	Precaution. The risk/benefit of therapy should be considered and the recipient's response closely monitored.
PG Pregnancy	W	D	PREGNANCY There is positive evidence of human fetal risk based on adverse reaction data from investigation or marketing experience or studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.
	W	X	PREGNANCY Studies in animals or humans have demonstrated fetal abnormalities and/or there is positive evidence of human fetal risk based on adverse reaction data from investigation or marketing experience, and the risks involved in use of the drug in pregnant women clearly outweigh potential benefits.
	W	1	PREGNANCY No FDA rating but is contraindicated or not recommended; may have animal and/or human studies or pre- or post-marketing information.
	W	1	LACTATION Absolute Contraindication. The Drug should not be dispensed.
	W	2	LACTATION Precaution. Use of the Drug should be evaluated carefully.
PA Drug Age	W	1	Absolute Contraindication. Drug Therapy should be changed.
LD Low Dose	W	1	Prescribed dose is less than the minimum appropriate for the drug.
HD High Dose	W	1	Prescribed dose is greater than the maximum appropriate for the drug.

Other Pharmacy Indicator (529-FT)

The following values may be returned in the Other Pharmacy Indicator:

0 = Not Specified

1 = Your Pharmacy

3 = Other Pharmacy

Previous Date of Fill (530-FU)

The Previous Date of Fill provides the date the conflicting drug was dispensed.

Quantity of Previous Fill (531-FV)

The Quantity of Previous Fill provides the quantity of the conflicting drug.

Database Indicator (532-FW)

The Database Indicator will always be returned with a value of 1 to indicate that First DataBank is the DUR database provider.

Other Prescriber Indicator (533-FX)

The Other Prescriber Indicator compares the Prescriber of the current prescription to the Prescriber of the conflicting drug from the recipient's active drug profile, and returns one of the following codes:

0 = Not Specified

1 = Same Prescriber

2 = Other Prescriber

Conflict Code Free Text Descriptions

A Free Text message is returned for each conflict to provide additional information about the DUR condition. Following is a description of the Free Text:

Note: Bold Text in the examples below represents Free Text.

CODE	FREE TEXT DESCRIPTION
TD	For Clinical Significance 1, the name, strength, dose form and day’s supply of the conflicting drug from the Drug Profile.
	*Example*
	TD	1	1	20020926			0000030000			1		1		PROPRANOLOL							10MG	TABLET 030

	For Clinical Significance 2 the words WARNING - EARLY REFILL MMDDYY

	*Example*
	TD	2	1		20020929			0000030000		1			1		WARNING – EARLY REFILL 10/22/02

	Note: MMDDYY is the earliest date that the refill should be filled.
DD	Will contain the Clinical Effect Code followed by the Drug Name from the Drug Profile of the drug interacting with the new prescription being filled. The latter drug will be the new prescription drug and the former drug will be the drug from the Drug Profile. The Clinical Effect Code will consist of one of the following values: Examples of each Clinical Effect code is included.
	INF Increased effect of former drug

	*Example*
	DD	2	1		20021011			0000030000		1			1		INF DIGITALIS/KALURETICS

	DEF Decreased effect of former drug

	*Example*
	DD	2	1	20021012		0000030000			1		1		DEF					CORTICOSTEROIDS/BARBITURAT

	INL Increased effect of latter drug

	*Example*
	DD	3	1		20021003			0000030000		1			1	INL					VERAPAMIL/DIGOXIN

	DEL Decreased effect of latter drug

	*Example*
	DD	2	1		20020920			0000060000		1			1	DEL					NSAID/LOOP DIURETICS

	ARF Adverse reaction of former drug

	*Example*
	DD	2	1		20021018			0000090000		1			1	ARF					THEOPHYLLINES/TICLOPIDINE

	ARL Adverse reaction of latter drug

	*Example*
	DD	1	1		20021014			0000050000		1			1	ARL					NSAID/TRIAMTERENE

	MAR Adverse reaction of both drugs

	*Example*
	DD	2	1		20020920			0000090000		1			1	MAR					ACE INHIBITORS/POTASS.SPAR

	MXF Mixed effects of former drug

	*Example*
	DD	2	1		20021018			0000015000		1			1	MXF					ANTICOAGULANTS,ORAL/ANTITH

	MXL Mixed effects of latter drug

	*Example*
	DD	2	1		20020919			0000060000		1			1	MXL					HYDANTOINS/DISOPYRAMIDE

DC	The description of the drug/disease contraindication.

	*Example*
	DC	1	1		20020914			0000090000		1			1			HYPERTENSION

PG	For pregnancy precautions the words PREGNANCY PRECAUTION

	*Example*
	PG	1	0		00000000			0000000000		1			0				PREGNANCY PRECAUTION

	For lactation precautions the words LACTATION PRECAUTION

	*Example*
	PG	2	0		00000000			0000000000		1			0				LACTATION PRECAUTION

PA	For pediatric precautions the word PEDIATRIC

	*Example*
	PA	1	0		00000000			0000000000		1			0				PEDIATRIC

	For geriatric precautions the word GERIATRIC

	*Example*
	PA	1	0		00000000			0000000000		1			0				GERIATRIC

LD	For low dose precautions the recommended minimum and maximum dosage will be shown.

	*Example*
	LD	1	0		00000000			0000000000					1						0	3.000			12.000

HD	For high dose precautions the recommended minimum and maximum dosage will be shown.

	*Example*
	HD	1	0		00000000			0000000000					1						0	1.000			8.00

5.0 Pro-DUR/ECCA Input Information (Rev. 11/03)

This section describes the input fields required by the New York State Pro-DUR/ECCA system. The way you see this information as you provide input is largely a factor of your computer's software. In fact, some of these field values may be entered on your behalf by your software.

5.1 Header Information Fields

The required header information shown in this section is needed for each transaction request that is sent to the MEVS Pro-DUR/ECCA system.

The NCPDP field numbers are shown in parenthesis at the end of the description for each field.

Following is a description of the fields that must be submitted to the Pro-DUR/ECCA system for each transaction.

FIELD	DESCRIPTION
Bin Number	All requests must send 004740, which identifies the New York MEVS Pro-DUR/ECCA system. In most cases, this information is automatically provided by your computer software. (101-A1)
Cardholder ID Number	The Cardholder ID Number is the eight position alpha numeric Medicaid Client Number (CIN) or the thirteen digit Access Number without the six digit ISO # prefix. Both of these values are provided on the recipient's benefit card. (302-C2)
Date of Birth	The Date of Birth is the date the recipient was born, including the century, which is provided on the recipient's benefit card. Format = CCYYMMDD (304-C4)
Date of Service	The Date Filled is the date the prescription was dispensed. The current date must be used for DVS transactions. (401-D1)
ETIN	The 3 character Electronic Transmitter Identification Number entered in the Processor Control Number is assigned to the provider by the EMedNY contractor. (104-A4)
Patient Gender Code	The patient gender code indicates the recipient's gender as follows: 1 = Male 2 = Female (305-C5)
Person Code	The Person Code is the Sequence Number found on the recipient's benefit card in the last 2 positions of the access number. (303-C3)
Pharmacist's Initials	The Pharmacist's Initials entered in the Processor Control Number provides the first and last initial of the person submitting the claim. (104-A4)
Pharmacy Number	The Pharmacy Number is an eight digit Medicaid Provider Identification Number assigned to the pharmacy by the Department of Health. (201-B1)
PIN	The four digit PIN entered in the Processor Control Number is the Personal Identification Number previously selected by the provider and submitted to the Department of Health. (104-A4)
Pregnancy Indicator	This code will specify whether the patient is pregnant. Valid values are: Blank = Not Specified 1 = Not pregnant 2 = Pregnant (335-2C)
Processor Control Number	Information entered in the Processor Control Number is used to indicate that you are requesting Electronic Claim Capture and Adjudication. The following fields are required by Pro-DUR/ECCA if you are requesting your claim(s) to be captured for adjudication by the eMedNY contractor. Read Certification Statement Indicator Pharmacist's Initials PIN ETIN (104-A4)
Read Certification	A (Y) entered in the Read Certification Indicator contained in the Processor Control Number indicates that you have read and attest to the agreements in the Certification Statement (refer to Form Section on page 19.0.1). An "N" indicates that you have not read the Certification Statement or that you do not agree. (104-A4)
Service Provider Id	This field must contain the NYS Medicaid Provider number assigned by NYSDOH (201-B1)
Service Provider Id Qualifier	This code will qualify the entry in the Service Provider Id field (201-B1) as an MMIS Provider ID number. Acceptable entry is: 05 = Medicaid (Must be submitted in conjunction with provider number assigned by NYSDOH) (202-B2)
Software Vendor/Certification ID	Mandatory field used to identify the software source by switches and/or processors. If not available or not used between trading partners, then submit 10 spaces. (110-AK)
Transaction Code	This field identifies the type of transaction request being submitted. Acceptable codes are: E1 = Eligibility Verification with no claim submitted B1 = Rx Billing P1 = P.A. Request and Billing P4 = Prior Authorization Request Only B2 = Rx Reversal B2 is used to cancel a previous transaction. Please refer to section on Reversals on page 7.0.1. B3 = Rx Rebill Note: B3 is used to adjust a previously paid claim(s). N1 = Rx DUR only N2 = Rx DUR Reversal N3 = Rx DUR Rebill N1 is used to supply DUR information only for purposes of updating a recipient's drug history file when no claim submission or reimbursement is allowed or expected. (103-A3)
Transaction Count	This field identifies the number of prescriptions being submitted for a specific transaction. A number from 1 to a maximum of 4 is allowed dependent on the type of transaction. E1 = Eligibility (1 only) B1 = Billing submit from 1 to 4 B2 = Reversal submit 1 per transaction for NYS. If reversing a four (4) line transaction submit each line on a separate B2 transaction. B3 = Rebill submit from 1 to 4. P1 = Billing with P.A. Request submit only 1 P2 = P.A. Reversal submit only 1. P4 = P.A. Request Only submit only 1. N1 = DUR Info Report submit from 1 to 4. N2 = DUR Reversal submit 1 per transaction. N3 = DUR Rebill submit from 1 to 4. (109-A9)
Version/Release Number	This identifies the NCPDP version used for your transaction and is commonly provided by your computer software. 51 = Telecommunication Format (102-A2)

5.2 Claim Information (Rev. 02/04)

Following is a list of information that may be required to process a claim.

FIELD	DESCRIPTION
Compound Code	The Compound Code identifies the type of prescription as follows: 0 = Not specified. Use for DVS transactions. 1 = Not a compound - use when dispensing a prescription drug with an 11 digit NDC code. 2 = Compound - use when dispensing a compound drug. Please Note: 0 or 1 may be used for valid sickroom supplies if you are using the NCPDP 5.1 format. Refer to sections 4.2 and 4.3 in the MMIS Pharmacy Provider Manual. The 837 Professional ASC X12N MUST be used for sickroom supplies that are only billable under Category of Service 0442. (406-D6)
Date Prescription Written	The Date the Prescription was written is entered in this field. The Date Prescription Written must be no more than 60 days prior to the Date Filled for original scripts. For Refills, the Date Prescription Written cannot be over 180 days old from the Date Filled. (414-DE)
Days Supply	The Days Supply is the estimated number of days that the prescription should last. New York State does not accept a days supply greater than 366. When the prescription's directions state "take as directed" (PRN), it is strongly advised that 180 be entered as the days supply. (405-D5)
Dispense As Written (DAW)/Product Selection Code	Acceptable values for the Dispense As Written (DAW) code are as follows: 0 = No product selection 1 = Substitution not allowed by prescriber 4 = Substitution allowed - Generic Drug not in stock 5 = Substitution allowed - Brand Drug dispensed as a Generic 7 = Substitution not allowed - Brand Drug mandated by Law 8 = Substitution allowed - Generic Drug not available in the Marketplace (408-D8)
Eligibility Clarification Code	The Eligibility Clarification Code is used to indicate: · An eligibility override for Excess Income/Spenddown recipients when the spenddown has been met but eligibility has not been updated on file. · To resubmit a previously denied claim when a Client is a Resident of an In-State Skilled Nursing Facility or Health Related Facility which includes coverage for pharmacy services. When the Client has been discharged and the records still reflect residency within the Facility, the claim may be incorrectly denied. An override may be submitted which will result in a pend status, giving the local district time to update the Client’s file. Recognized value is: 2 = Override (309-C9)
Fill Number	The New/Refill Code values are as follows: 00 = New Prescription 01 = First Refill 02 = Second Refill 03 = Third Refill 04 = Fourth Refill 05 = Fifth Refill The maximum number of refills allowed is 5. This value cannot be greater than the Number of Refills Authorized. (403-D3)
Number of Refills Authorized	The Number of Refills Authorized is entered in this field. New York State only allows a maximum of 5 refills. (415-DF)
Other Coverage Code	This field is used by the pharmacy to indicate whether or not the patient has other insurance coverage. (308-C8) Valid entries NYSDOH are: 0 = Not Specified – Use for Medicare 1 = No Other Coverage Identified 2 = Other Coverage Exists, Payment Collected 3 = Other Coverage Exists, This Claim Not Covered. 4 = Other Coverage Exists, Payment Not Collected The following codes if submitted will be cross-indexed as follows: 5 = Managed Care Plan – Denial is equated to 3 6 = Other Coverage Denied – Not Participating Provider is equated to 3 7 = Other Coverage – Not in Effect at Time of Service is equated to 1 8 = Claim is Billing for Co-pay is equated to 2 (308-C8)
Other Payor Amount Paid	For TPL: Enter the dollar amount of payments made by the other insurance. A maximum of 9 amounts can be submitted. This field is used by the pharmacy to enter the dollar amount received from a recipient’s other third party insurance company. Note: If other third party coverage exists but the claim being submitted is not covered, enter zeros or blanks in this field. You may also choose not to send this field if the primary carrier has denied the claim. Refer to the chart in Section 2.5 on page 2.5.1 for information on the proper completion of this field. (431-DV) For MEDICARE: Enter a series of dollar amounts with the appropriate qualifiers to identify the type of Medicare amount submitted. Refer to the Other Payer Amount Paid Qualifier (342-HC) below
Other Payer Amount Paid Qualifier	This code will qualify the other payer amount. Valid value for TPL reporting is: 07 = Drug Benefit (342-HC) This code will qualify the other payer amount. Valid values for Medicare COB (Coordination of Benefits) reporting are: 07 = Drug Benefit (used for Medicare Approved Amount) 08 = Sum All Reimbursements (used for Medicare Paid Amount) 99 = Other (1^st99 = Deductible Amount) 99 = Other (2^nd99 = Coinsurance Amount) 99 = Other (3^rd99 = Co-Payment Amount) (342-HC)
Other Payer ID	ID assigned to the payer when submitting electronically. For TPL use: 99 = Other ID assigned to the payer when submitting Medicare COB claims. For Medicare use: 13 = Medicare Part B. (340-7C)
Other Payer Date	Payment of denial Date of the claim being submitted for coordination of benefits. (443-E8)
Other Payer Amount Paid Count	Other payer amount paid count which is the count of other payer amount occurrences. (341-HB)
Other Payer ID Qualifier	Code qualifying the ‘Other Payer ID’. (340-7C) NYSDOH will process “99” in conjunction with the Other Payer ID. 99 = Other (339-6C)
Other Payer Coverage Type	Code identifying the Other Payer ID. (340-7C) 01 = Primary 02 = Secondary 03 = Tertiary. (338-5C)
Other Payer Reject Count	Code identifying the number of third party denial codes. (471-5E)
Other Payer Reject Code	Enter the rejection code that was received from the primary payer. (472-6E)
Patient Paid Amount Submitted	This field is used by the pharmacy to enter the dollar amount collected as a spenddown from an excess income recipient. Note: If the spenddown was previously met but the eligibility file has not yet been updated, enter zeroes in this field. Refer to Section 2.13 on page 2.13.1 for additional information on this field. (433-DX)
Primary Care Provider ID	The Primary Prescriber is used to enter the 8 digit MMIS Provider ID Number of the primary provider to which the recipient is restricted. This field must be completed for a restricted recipient unless you are the primary provider or the primary provider is indicated as the prescriber in field 411-DB. (421-DL)
Primary Care Provider ID Qualifier	This code will qualify the entry in field (421-DL). Primary Care Provider Id field has a 8 digit Medicaid Provider Id number. Valid values are: 05 = Medicaid (468-2E)
Prior Authorization Number Submitted	The Prior Authorization Number Submitted is used to enter a prior approval number. The format for this field is: an 8 digit prior approval number and then three zeroes. Refer to Section 2.11 on page 2.11.1 for additional information on this field. (462-EV)
Prior Authorization Type Code	This code will specify co-pay exemption or clarify a Prior Authorization request or submission. Valid values are: 0 = Not specified 1 = Prior Authorization 4 = Exemption from co-pay (461-EU)
Prescriber ID	The Prescriber ID is the Ordering Provider who wrote the prescription. Either the ordering provider's MMIS Provider ID number or license type and license number must be entered. Refer to MEVS Denial code 056 in Table 2 on page 10.0.1 for further clarification. (411-DB)
Prescriber Id Qualifier	The code entered will qualify the entry in the Prescriber Id (411-DB) field as either a MMIS Provider Id or a State License number. Valid values are: 05 = Medicaid 08 = State License (466-EZ)
Prescription/Service Reference Number	The Prescription Number is assigned by the pharmacy. Reference number assigned by the provider for the dispensed drug / product and/or service provided. (402-D2)
Prescription/Service Reference Number Qualifier	Indicates the type of billing submitted. Valid Values are: 1 = Rx Billing NYSDOH only supports prescription billing. (455-EM)
Product/Service Id Number	The NDC Number is the 11 digit National Drug Code identifying the dispensed drug. When using compounds use code 99999999999. (407-D7)
Product/Service Id Qualifier	The Product/Service Id Qualifier is used to identify the Product Type dispensed. This field must contain a HCPCS "09" when the item dispensed is a product supply item (sections 4.2 and 4.3 in the MMIS Pharmacy Provider Manual), or for item codes requiring a DVS number which were published in a list. 09 = HCPCS 03 = NDC (436-E1)
Reason for Service Code	The DUR Conflict Code is used to indicate an override for a DUR reject of a previously entered claim. Acceptable values are: TD = Therapeutic Duplication DD = Drug to Drug Interaction (439-E4)
Result of Service Code	The DUR Outcome Code is used to indicate the action taken by the pharmacist, and is required for a DUR override. Acceptable values are: 1A = Filled as is, false positive 1B = Filled, Prescription as is 1C = Filled with Different Dose 1D = Filled with Different Directions 1E = Filled with Different Drug 1F = Filled with Different Quantity 1G = Filled with Prescriber Approval (441-E6)
Submission Clarification Code	The Submission Clarification Code is used to indicate a Utilization Threshold override and replaces the use of the SA Exception Code. Following are the recognized values: 00 = Not Specified 01 = No Override 02 = Other Override - use to replace SA Exception Code P (pending an override) 07 = Medically Necessary - use to replace SA Exception Code J (Immediate Urgent Care) & L (Emergency). Note: These are the only values used for UT Override by NYSDOH when using the NCPDP format. Any other value entered in this field will be ignored. (420-DK)
Quantity Dispensed	The Quantity Dispensed is the total number of Metric Units dispensed for the prescription. (442-E7)
Usual and Customary Charge	The Usual and Customary Charge is used to enter the amount charged for the prescription. (426-DQ)

FIELD

DESCRIPTION

Compound Code

The Compound Code identifies the type of prescription as follows:

0 = Not specified. Use for DVS transactions.

1 = Not a compound - use when dispensing a prescription drug with an 11 digit NDC code.

2 = Compound - use when dispensing a compound drug.

Please Note: 0 or 1 may be used for valid sickroom supplies if you are using the NCPDP 5.1 format. Refer to sections 4.2 and 4.3 in the MMIS Pharmacy Provider Manual. The 837 Professional ASC X12N MUST be used for sickroom supplies that are only billable under Category of Service 0442.

(406-D6)

Date Prescription Written

The Date the Prescription was written is entered in this field. The Date Prescription Written must be no more than 60 days prior to the Date Filled for original scripts. For Refills, the Date Prescription Written cannot be over 180 days old from the Date Filled.

(414-DE)

Days Supply

The Days Supply is the estimated number of days that the prescription should last. New York State does not accept a days supply greater than 366. When the prescription's directions state "take as directed" (PRN), it is strongly advised that 180 be entered as the days supply.

(405-D5)

Dispense As Written

(DAW)/Product Selection

Code

Acceptable values for the Dispense As Written (DAW) code are as follows:

0 = No product selection

1 = Substitution not allowed by prescriber

4 = Substitution allowed - Generic Drug not in stock

5 = Substitution allowed - Brand Drug dispensed as a Generic

7 = Substitution not allowed - Brand Drug mandated by Law

8 = Substitution allowed - Generic Drug not available in the Marketplace

(408-D8)

Eligibility Clarification Code

The Eligibility Clarification Code is used to indicate:

· An eligibility override for Excess Income/Spenddown recipients when the spenddown has been met but eligibility has not been updated on file.

· To resubmit a previously denied claim when a Client is a Resident of an In-State Skilled Nursing Facility or Health Related Facility which includes coverage for pharmacy services. When the Client has been discharged and the records still reflect residency within the Facility, the claim may be incorrectly denied. An override may be submitted which will result in a pend status, giving the local district time to update the Client’s file. Recognized value is:

2 = Override

(309-C9)

Fill Number

The New/Refill Code values are as follows:

00 = New Prescription

01 = First Refill

02 = Second Refill

03 = Third Refill

04 = Fourth Refill

05 = Fifth Refill

The maximum number of refills allowed is 5. This value cannot be greater than the Number of Refills Authorized.

(403-D3)

Number of Refills

Authorized

The Number of Refills Authorized is entered in this field. New York State only allows a maximum of 5 refills.

(415-DF)

Other Coverage Code

This field is used by the pharmacy to indicate whether or not the patient has other insurance coverage. (308-C8) Valid entries NYSDOH are:

0 = Not Specified – Use for Medicare

1 = No Other Coverage Identified

2 = Other Coverage Exists, Payment Collected

3 = Other Coverage Exists, This Claim Not Covered.

4 = Other Coverage Exists, Payment Not Collected

The following codes if submitted will be cross-indexed as follows:

5 = Managed Care Plan – Denial is equated to 3

6 = Other Coverage Denied – Not Participating Provider is equated to 3

7 = Other Coverage – Not in Effect at Time of Service is equated to 1

8 = Claim is Billing for Co-pay is equated to 2

(308-C8)

Other Payor Amount Paid

For TPL:

Enter the dollar amount of payments made by the other insurance. A maximum of 9 amounts can be submitted.

This field is used by the pharmacy to enter the dollar amount received from a recipient’s other third party insurance company.

Note: If other third party coverage exists but the claim being submitted is not covered, enter zeros or blanks in this field. You may also choose not to send this field if the primary carrier has denied the claim. Refer to the chart in Section 2.5 on page 2.5.1 for information on the proper completion of this field.

(431-DV)

For MEDICARE:

Enter a series of dollar amounts with the appropriate qualifiers to identify the type of Medicare amount submitted.

Refer to the Other Payer Amount Paid Qualifier (342-HC) below

Other Payer Amount Paid Qualifier

This code will qualify the other payer amount. Valid value for TPL reporting is:

07 = Drug Benefit

(342-HC)

This code will qualify the other payer amount. Valid values for Medicare COB (Coordination of Benefits) reporting are:

07 = Drug Benefit (used for Medicare Approved Amount)

08 = Sum All Reimbursements (used for Medicare Paid Amount)

99 = Other (1^st99 = Deductible Amount)

99 = Other (2^nd99 = Coinsurance Amount)

99 = Other (3^rd99 = Co-Payment Amount)

(342-HC)

Other Payer ID

ID assigned to the payer when submitting electronically.

For TPL use:

99 = Other

ID assigned to the payer when submitting Medicare COB claims.

For Medicare use:

13 = Medicare Part B.

(340-7C)

Other Payer Date

Payment of denial Date of the claim being submitted for coordination of benefits.

(443-E8)

Other Payer Amount Paid Count

Other payer amount paid count which is the count of other payer amount occurrences.

(341-HB)

Other Payer ID Qualifier

Code qualifying the ‘Other Payer ID’. (340-7C)

NYSDOH will process “99” in conjunction with the Other Payer ID.

99 = Other

(339-6C)

Other Payer Coverage Type

Code identifying the Other Payer ID. (340-7C)

01 = Primary

02 = Secondary

03 = Tertiary.

(338-5C)

Other Payer Reject Count

Code identifying the number of third party denial codes.

(471-5E)

Other Payer Reject Code

Enter the rejection code that was received from the primary payer.

(472-6E)

Patient Paid Amount Submitted

This field is used by the pharmacy to enter the dollar amount collected as a spenddown from an excess income recipient.

Note: If the spenddown was previously met but the eligibility file has not yet been updated, enter zeroes in this field. Refer to Section 2.13 on page 2.13.1 for additional information on this field.

(433-DX)

Primary Care Provider ID

The Primary Prescriber is used to enter the 8 digit MMIS Provider ID Number of the primary provider to which the recipient is restricted. This field must be completed for a restricted recipient unless you are the primary provider or the primary provider is indicated as the prescriber in field 411-DB.

(421-DL)

Primary Care Provider ID Qualifier

This code will qualify the entry in field (421-DL). Primary Care Provider Id field has a 8 digit Medicaid Provider Id number. Valid values are:

05 = Medicaid

(468-2E)

Prior Authorization Number Submitted

The Prior Authorization Number Submitted is used to enter a prior approval number. The format for this field is: an 8 digit prior approval number and then three zeroes. Refer to Section 2.11 on page 2.11.1 for additional information on this field.

(462-EV)

Prior Authorization Type Code

This code will specify co-pay exemption or clarify a Prior Authorization request or submission. Valid values are:

0 = Not specified

1 = Prior Authorization

4 = Exemption from co-pay

(461-EU)

Prescriber ID

The Prescriber ID is the Ordering Provider who wrote the prescription. Either the ordering provider's MMIS Provider ID number or license type and license number must be entered. Refer to MEVS Denial code 056 in Table 2 on page 10.0.1 for further clarification.

(411-DB)

Prescriber Id Qualifier

The code entered will qualify the entry in the Prescriber Id (411-DB) field as either a MMIS Provider Id or a State License number. Valid values are:

05 = Medicaid

08 = State License

(466-EZ)

Prescription/Service Reference Number

The Prescription Number is assigned by the pharmacy.

Reference number assigned by the provider for the dispensed drug / product and/or service provided.

(402-D2)

Prescription/Service Reference Number Qualifier

Indicates the type of billing submitted.

Valid Values are:

1 = Rx Billing

NYSDOH only supports prescription billing.

(455-EM)

Product/Service Id Number

The NDC Number is the 11 digit National Drug Code identifying the dispensed drug. When using compounds use code 99999999999.

(407-D7)

Product/Service Id Qualifier

The Product/Service Id Qualifier is used to identify the Product Type dispensed. This field must contain a HCPCS "09" when the item dispensed is a product supply item (sections 4.2 and 4.3 in the MMIS Pharmacy Provider Manual), or for item codes requiring a DVS number which were published in a list.

09 = HCPCS

03 = NDC

(436-E1)

Reason for Service Code

The DUR Conflict Code is used to indicate an override for a DUR reject of a previously entered claim. Acceptable values are:

TD = Therapeutic Duplication

DD = Drug to Drug Interaction

(439-E4)

Result of Service Code

The DUR Outcome Code is used to indicate the action taken by the pharmacist, and is required for a DUR override. Acceptable values are:

1A = Filled as is, false positive

1B = Filled, Prescription as is

1C = Filled with Different Dose

1D = Filled with Different Directions

1E = Filled with Different Drug

1F = Filled with Different Quantity

1G = Filled with Prescriber Approval

(441-E6)

Submission Clarification Code

The Submission Clarification Code is used to indicate a Utilization Threshold override and replaces the use of the SA Exception Code. Following are the recognized values:

00 = Not Specified

01 = No Override

02 = Other Override - use to replace SA Exception Code P (pending an override)

07 = Medically Necessary - use to replace SA Exception Code J (Immediate Urgent Care) & L (Emergency).

Note: These are the only values used for UT Override by NYSDOH when using the NCPDP format. Any other value entered in this field will be ignored. (420-DK)

Quantity Dispensed

The Quantity Dispensed is the total number of Metric Units dispensed for the prescription.

(442-E7)

Usual and Customary

Charge

The Usual and Customary Charge is used to enter the amount charged for the prescription.

(426-DQ)

FIELD	DESCRIPTION
Header Response Status	An A (Accepted) will be returned if the information in the transmission is valid. An R (Rejected) will be returned if the information in the transmission is invalid. Further clarification of the reject will be indicated by NCPDP Reject codes and in the Message Area. Note: When an R is returned in the Header Response Status, all of the claims submitted on this request transaction will be rejected. (501-F1)

Following is a description of the information that will be returned from Pro-DUR/ECCA for each claim sent.

Note: The following field descriptions are in alphabetical order and not necessarily the order in which they appear in the response.

FIELD	DESCRIPTION
Additional Message Info	The Additional message area, in the NCPDP format, is used to return additional MEVS information about your request transaction. Your system may separate this information to clearly identify the contents of this additional message. However, some systems may display this message as it is returned in the NCPDP format. The following information is returned in the Additional Message: MEVS Accepted or Pending Code Utilization Threshold/Post & Clear Code Maximum Per Unit Price Co-Payment Code Co-Pay Met Date DVS Reason Code Medicare Coverage HIC Number Insurance Carrier Codes Insurance Coverage Codes Indication of Additional Coverage Restriction Information - Exception Codes Dispensing Validation System Number (526-FQ) Please refer to Chart B on page 8.0.3 for an example of the Additional Message. The following information is returned in the Message field for rejected claims (when Claim Response = R): MEVS Accepted, or Denial Code Rx Denial Code Utilization Threshold/Post & Clear Code DVS Reason Code Please refer to Chart C for an example of the Message. (526-FQ)
Amount of Copay/ Coinsurance	The amount of co-pay due for the entered NDC or HCPCS (NY Product Supply Code) will be returned in the Amount of Copay/Coinsurance if the recipient has not met their co-pay or is exempt. (518-FI)
Anniversary Month	The Anniversary Month found in the Message Text is the beginning month of the benefit year under the Utilization Threshold program. (504-F4)
Authorization Number	The authorization number is the 9 digit invoice number returned if ECCA was requested and all edits were passed. This is the invoice number that will appear on your remittance statement from the eMedNY contractor. Please Note: NO CLAIM TO FA will be returned if the claim is captured but cannot be processed for adjudication. Below are a few examples of when this will occur: • Original claims over 90 days old. • Processor Control Number blank or missing. If a claim is captured but cannot be processed for adjudication, it must be billed via paper, on magnetic media or Electronic Batch Dial-Up. (503-F3)
Category of Assistance	Category of Assistance Code returned within the Message Text: S = SSI * = No valid category of assistance is available (504-F4)
Transaction Response Status	This is the status for each claim that was submitted. A "C" indicates that the claim is accepted and/or pending, and an "R" indicates that it is rejected. A separate Claim Response Status will be received for each claim submitted on your request (1 - 4). Refer to the Reject Codes, the MEVS Denial Code, the Rx Denial Code, the Utilization Threshold/Post & Clear Code, and the Dispensing Validation Reason Code to determine why an "R" is returned in the Claim Response Status. If a "C" is returned, the Authorization Number field must be checked to determine if the claim has been electronically captured for adjudication. The MEVS Pend Response Code Table should also be checked to see if the claim is pending. (112-AN)
Clinical Significance	Clinical Significance returned within the DUR Response area indicates how critical the conflict is. This value reflects the severity level assigned to a contraindication. Refer to DUR Processing Section for a list of clinical significance codes and their meanings. (528-FS)
Co-Payment Code	The Co-Payment Code returned within the Additional Message area provides the status of co-payment for this claim. (526-FQ)
Co-Payment Met Date	The Co-Payment Met Date returned within the Additional Message area identifies the date the recipient has met this year's co-payment requirement. (526-FQ)
County Code	The two-digit code for the county of fiscal responsibility for the recipient is provided within the Message Text. Refer to the list of county codes in the Codes section of the MEVS Manual. (504-F4)
Database Indicator	The Database Indicator returned within the DUR Response area is always 1 to indicate that First DataBank is the source of the DUR database. (532-FW)
Dispensing Validation System Number	The eight digit DVS Number (prior approval) will be returned in the Additional Message area if the DVS transaction is accepted. The number will be automatically entered on your ECCA claim for adjudication processing. If you did not submit the claim for ECCA and are billing manually, this number must be put on your claim form. (526-FQ)
Dispensing Validation System Reason Code	The three-digit code indicating either the accepted or rejected status of the DVS request is returned within the Additional Message area. Refer to Table 9 for the codes and descriptions. (526-FQ)
Reason for Service Code	The Reason for Service Code returned within the DUR Response area will be generated and sent back to the pharmacy when a DUR conflict is detected. Refer to DUR Processing section for further clarification. The following values may be returned. TD = Therapeutic Duplication DD = Drug-Drug Interactions DC = Inferred Drug Disease Precaution PG = Drug Pregnancy Alert PA = Drug Age Precaution LD = Low Dose Alert HD = High Dose Alert (439-E4)
Exception Codes	Up to four Exception Codes may be returned within the Additional Message area. These codes indicate special eligibility circumstances and can be found in the Codes section of the MEVS Provider Manual. (526-FQ)
Free Text	The Free Text returned within the DUR Response area contains information to assist the pharmacist in further identifying the DUR conflict. Please refer to the DUR Processing section. (544-FY)
HIC Number	The HIC Number returned within the Additional Message area is the Health Insurance Claim number for Medicare. (526-FQ)
Indication of Additional Coverage	A ZZ in the Indication of Additional Coverage, returned within Additional Message area, indicates that the recipient has more than two insurance carriers. You must call the Provider Services Department at 1-800-343-9000 to obtain complete information. (526-FQ)
Insurance Carrier Codes	Up to two Insurance Carrier Codes are returned within the Additional Message area to provide the codes for insurance carriers. (Also, see Insurance Coverage Codes). (526-FQ)
Insurance Coverage Codes	Up to two sets of Insurance Coverage Codes are returned within the Additional Message area. These correspond one for one to the Insurance Carrier Codes and indicate the scope of benefits. Refer to the Codes section of the MEVS Provider Manual for a description of the Insurance Coverage Codes. (526-FQ)
Maximum Per Unit Price	The Maximum Per Unit Price returned within the Additional Message Area is the per unit amount on New York State’s Drug File. The price is the maximum reimbursable unit price amount. The dollar amount returned to you in your response does not indicate the amount of payment you will receive. (526-FQ)
Medicaid Number	The Client's Identification Number (CIN) is provided within the Message Text. (504-F4)
Medicare Coverage	The Medicare Coverage code is returned within the Additional Message area and indicates the type of Medicare coverage. A = Recipient has only Part A Medicare coverage (inpatient hospital). B = Recipient has only Part B Medicare coverage (outpatient). AB = Recipient has both Part A and Part B Medicare coverage. ABQMB = Recipient has Part A and Part B Medicare coverage and is a Qualified Medicare Beneficiary (QMB). If a recipient’s eligibility code is 09 (Medicare Coinsurance/Deductible), Medicaid will only reimburse for the Medicare coinsurance/deductible if Medicare approves the drug or item being dispensed. Since the majority of drugs are not covered by Medicare, Medicaid would not be making payment in most cases. Therefore, the DUR system has been programmed to reject this type of claim (Table 2 code 105). In the rare case that Medicare does approve the drug, the claim can be manually submitted to the eMedNY contractor for payment. If the recipient has full Medicaid coverage (coverage code 01) and is QMB, the claim will not be rejected but will be captured and if ECCA was opted, processed for adjudication. (526-FQ)
MEVS Accepted Code	The MEVS Accepted Code returned within the Additional Message area indicates the type of Medicaid eligibility the recipient has. Refer to Table 1 on page 9.0.1 for a list of values and meanings. (526-FQ)
MEVS Denial Code	The MEVS Denial Code returned within the Additional Message area indicates the type of MEVS error for rejected transactions. Refer to Table 2 on page 10.0.1 for a list of values and meanings. (526-FQ)
Message field	A Message Text area returned in the NCPDP format is used to provide MEVS information about your requested transaction. Your system may separate this information to clearly identify the contents of this message. However, some systems may display this message as it is returned in the NCPDP format. The following information is returned in the Message field for accepted claims (when Claim Response = C): Medicaid Number County Code Anniversary Month Patient Gender Code Year of Birth Category of Assistance Re-certification Month Office Number Service Date Please refer to Chart A on page 8.0.2 for an example of the Message. (504-F4)
Office Number	The Office Number returned within the Message Text represents the New York City office code. Refer to the Codes section of the MEVS Provider Manual for a list of valid office codes. (504-F4)
Other Pharmacy Indicator	The Other Pharmacy Indicator returned within the DUR Response area indicates the source of the previous prescription that forms the basis for the conflict with the present prescription. The following values may be returned. 0 = Not Specified 1 = Your Pharmacy 3 = Other Pharmacy (529-FT)
Other Prescriber Indicator	The Other Prescriber Indicator returned within the DUR Response area compares the Prescriber of the current prescription to the Prescriber of the previously filled conflicting prescription. The following values may be returned: 0 = Not Specified 1 = Same Prescriber 2 = Other Prescriber (533-FX)
Pend Reason Code	The Pend Reason Code returned within the Additional Message Area indicates that the claim has passed all other online adjudication edits but has been pended for one of the reasons listed in Table 10 (page 15.0.1). Refer to Section 15.0 on page 15.0.1 for values and descriptions. The Table 10 (page 15.0.1) reason code will be returned in the same field positions that a Table 1 (page 9.0.1) Accepted Code is normally returned (526-FQ) field. Consequently, when the return of a Table 10 (page 15.0.1) Pend Code is warranted, a Table 1 (page 9.0.1) Accepted Code will not be returned. (526-FQ)
Previous Date of Fill	The Previous Date of Fill returned within the DUR Response area is the date that the previous prescription was filled. (530-FU)
Quantity of Previous Fill	The Quantity of Previous Fill returned within the DUR Response area is the quantity of the previously filled prescription. (531-FV)
Recertification Month	The Recertification Month returned within the Message Text is the month the recipient is due for recertification. (504-F4)
Reject Codes	A maximum of 20 Reject Codes could be returned if the Claim Response Status is "R" (Reject). Refer to NCPDP Reject Code list on page 16.0.1 for values. (511-FB)
Rx Denial Code	The Rx Denial Code returned within the Additional Message area provides prescription related reject reasons. Refer to Table 7 on page 12.0.1 for possible values. (526-FQ)
Service Date	The Service Date returned within the Message Text is the same as the Date Filled (or dispensed), entered on your transaction. (504-F4)
Patient Gender Code	Valid patient gender Codes returned within the Message Text are: F = Female M = Male U = Unborn (504-F4)
Utilization Threshold/ Post and Clear	The Utilization Threshold/Post & Clear codes indicate the status of the UT/P&C service authorization requests. Refer to Table 8 on page 13.0.1 for further clarification. (526-FQ)
Year of Birth	The Year of Birth returned within the Message Text shows the century and year of the recipient's birth. Example: 1980 will appear as 980. (504-F4)

10.0 MEVS DENIAL CODES - TABLE 2 (Rev. 02/04)

All of the following codes are MEVS Denial Codes. Their presence in your response area means the entire transaction has been rejected. If a MEVS Denial Code has a comparable NCPDP Reject Code, both codes will be returned. If there is no comparable code, then NCPDP code 85, "Claim Not Processed" is returned along with the MEVS Code. In those cases, the MEVS Denial Code will further qualify the reason for the claim being rejected. The following chart indicates the relationship between the MEVS Denial Code and any comparable NCPDP Reject Code, if one applies.

Code 999 will be returned if any invalid data is entered in the NCPDP required header fields. For example, an entry of 05 in the Transaction Code field will result in an MEVS Denial Code 999 being returned since it exceeds the number of claims authorized to be sent in a transaction. Also included is a description and relevant comments about the code.

MEVS CODE	DESCRIPTION	NCPDP CODE	DESCRIPTION
001	Not MA Eligible	65	Patient is Not Covered
030	Expired Card	07	M/I Cardholder ID Number
031	Invalid Card Status	07	M/I Cardholder ID Number
033	Non-Current Card	07	M/I Cardholder ID Number
045	No Authorization Found	87	Reversal Not Processed
050 *	Alternate Access Not Allowed	**
051	Invalid Provider Number	05	M/I Pharmacy Number
052	Provider Not on File	50	Non-Matched Pharmacy Number
053	SSN Access Not Allowed	07	M/I Cardholder ID Number
054	Provider Cannot Access by Account Type	**
055	Provider Not Eligible	**
056 *	Re-enter Ordering Provider Number	25	M/I Prescriber ID
059 *	Invalid License Type	25	M/I Prescriber ID
061 *	Invalid Access Number	07	M/I Cardholder ID Number
062 *	Invalid Medicaid Number	07	M/I Cardholder ID Number
063 *	Invalid Sequence Number	08	M/I Person Code
065	Recipient Not on File	52	Non Matched Cardholder ID
066	Disqualified Ordering Provider	25	M/I Prescriber ID
067	Deceased Ordering Provider	25	M/I Prescriber ID
068	Invalid Ordering Provider	25	M/I Prescriber ID
071	Invalid Date	15	M/I Date of Service
092	Invalid Specialty Code	05	M/I Pharmacy Number
100 *	Invalid Referring Provider Number	35	M/I Primary Care Provider Id
101 *	Restricted Recipient No Auth	35	M/I Primary Care Provider Id
103	No Coverage: Pending Family Health Plus	65	Patient Not Covered
104	No Coverage: Excess Income	65	Patient Not Covered
105	QMB Requires Medicare Approval	65	Patient Not Covered
118 *	MCCP Recipient No Auth	35	M/I Primary Care Provider Id
300	Service Date Prior to Birthdate	09	M/I Birthdate
302	Provider Ineligible Service on Date Performed	**
303	Prior Approval Indicated Denied/Rejected by NYS	EV	M/I Prior Authorization Number Submitted
304	Recipient ID Unequal to Prior Approval File	EV	M/I Prior Authorization Number Submitted
305	Child Care Recipient – Bill Agency	**
307	Prior Approval Units or Payment Amount Exceeded	**
308	Service Date Not Within Prior Approval Range	**
309	Claim Type Unequal to Prior Approval Record Class	**
312	Pregnancy Indicated – Invalid for Recipient Sex or Age	**
313	Provider Reimbursed for Medicare Only	**
314	Recipient Not QMB, Services Not Reimbursable	**
315	Recipient Not Medicare, Services Not Reimbursable	**
316	Claim Previously Paid Using Another Provider Number	**
318	Prescribing Provider License Not in Active Status	25	M/I Prescriber ID
320	Other Insurance Information Inconsistent	DV
321	Pharmacy Service Included In Out-of-State Facility Rate	**
322	Online Adjustments/Rebills Not Allowed For DVS Items/Drugs	**
323	Processor Control Number Needed for Rebill/Reversal of Paid Claim	**
324	The system or file necessary to process the transaction is currently unavailable.	92	System Unavailable
325	Pharmacy Service Included in In-State Facility Rate	**
700 *	Year of Birth Not Equal to File	09	M/I Birthdate
701	Sex Not Equal to File	10	M/I Patient Gender Code
702*	ECCA Not Allowed	81 04	Claim too Old M/I Processor Control Number
703 *	Invalid PIN	04	M/I Processor Control Number
704 *	Invalid ETIN	04	M/I Processor Control Number
999	Header Field Error	***

* For further explanation and examples of error conditions refer to Table 2 Error Chart

** NCPDP equivalent reject code does not exist. Code 85 "Claim Not Processed" will be returned.

*** Several Different NCPDP Reject Codes could be returned with MEVS Code 999. These Reject Codes will indicate which header field is in error.

TABLE 2 ERROR CHART

Key: b = Blanks/Spaces

Left Justify = Begin in First Position on Left

MEVS CODE	NCPDP CODE	EXAMPLES OF CORRECT ENTRY	COMMON ERRORS BEING MADE / COMMENTS
050 Alternate Access not allowed	None	None - No entry made	1. In order to access the DUR/ECCA online system you must choose an alternate access method. 2. Code 050 will be returned if your provider number has not been updated with your selected access method on the eMedNY contractor’s production file. 3. In order to be updated on the production file, you must have: A) Notified the eMedNY contractor of your alternate access method. B) Signed the contract and sent it to the eMedNY contractor. C) Signed the contract and submitted your check to your switch company if you chose to transmit through a switch. The switch must then send an approval to the eMedNY contractor before your number will be updated on production.
053 SSN Access Not Allowed	None	None – 9 digit entry not allowed	Card holder ID (302-C2) field has only two acceptable formats: 1. Eight position alpha/numeric Medicaid Client Number (CIN) OR 2. Thirteen-digit Access Number without the six-digit ISO # prefix
054 Provider Cannot Access by Account Type	None	None – No entry made	If you submit a transaction via an access method other than the method assigned to your provider number on the production file, code 054 will be returned. For example, if your provider number is on the file as going through a switch company and a transaction is sent using a second switch company that is not on your file, your transaction will be rejected.
056 or 059 Reenter Ordering Provider Number or Invalid License Type	25 M/I Prescriber ID	0100567892 (NYS Physician) 290F654938 (Nurse Practitioner) 00240588 (8 digit MMIS Provider ID for enrolled prescriber) 11NJ456193 (Out of State Physician from New Jersey). 250U452749 (Optometrist)	1. The Prescriber ID field length is 10. The Prescriber's License type must be in the first two positions, followed by either two zeroes or two alpha (out of state) followed by the 6 digit license number. The Prescriber ID Qualifier must be equal to 08 when submitting a license number. An 8 digit provider number must be left justified, space filled. The Prescriber ID Qualifier must be equal to 05. Note: When entering a license number, the last six positions of the entry should be the actual numeric license number. If the license number does not contain six numbers, zero fill the appropriate positions preceding the actual license number. For example, an entry for an Optometrist whose license number is U867 would be 250U000867. 2. Some incorrect entries being received are: A) 567892: License number only B) 00567892: License number without License Type. C) 0156892: License Type, License Number without zeroes or 2 alpha in between. D) bb00240588: Eight digit MMIS Provider Number NOT left justified. E) DEA Number: Some software packages are sending the physician's DEA numbers instead of the license number. 3. Nurse Practitioners: A nurse practitioner may have several different license numbers because the State Education Department issues them a license for each specialty for which they are certified. Not All Nurse Practitioners are licensed to prescribe drugs. A nurse practitioner who is licensed to prescribe will have the letter "F" preceding the 6 digit license number. This is the license number that must be used when submitting your transaction. The license type 29 followed by 0F and the 6 digit number is the only correct entry for nurse practitioners’ license numbers. 4. Optometrists: An optometrist who is licensed to prescribe will have the letter ‘U’ or ‘V’ preceding the six -digit license number. The license type 25 followed by ‘OU’ or ‘OV’ and the six- digit number are the only correct entries for optometrists’ license numbers.
061 Invalid Access Number 062 Invalid Medicaid Number.	07 M/I Cardholder ID Number	2631578424139 (13 digit access number found on recipient's Medicaid card) LZ00083W (CIN Number)	1. The entry in the Cardholder ID field must contain either the recipient's 13 digit access number or their 8 character alpha numeric CIN number. Both must be left justified, space filled. 2. The most common error being received that causes code 061 to be returned is an entry of 8 numeric digits in the Cardholder ID field. Check your software to make sure the alpha characters in the CIN number are not being converted to numeric values. 3. Rejections also occur when either number is not left justified. 4. Code 062 is returned when the number entered cannot be found on the file.
063 Invalid Sequence Number	08 M/I Person Code	03 (2 digit sequence number) 12 (2 digit sequence number)	1. The recipient's 2 digit sequence number is required on each transaction. The sequence number can be found on the recipient's Medicaid card. 2. Our format requires the 2 digit sequence number to be placed in the 3 digit Person Code field. The number must be left justified and space filled. We have learned that some software packages have the number placed in a different field, which is fine as long as it is sent to the eMedNY contractor in the Person Code field. 3. Some incorrect entries being received are: A) Person Code field is blank B) Sequence number is not left justified. C) Sequence number transmitted does not match the most current number on the eMedNY contractor’s file. A new sequence number is issued each time a recipient receives a new card.
100 Invalid Referring Provider Number 101 Restricted Recipient No Auth 118 MCCP Recipient No Auth	35 M/I Primary Care Provider Id	00240588 (8 digit MMIS identification number of the provider to which a recipient is restricted).	1. If a recipient is restricted, the Primary Care Provider field must contain the 8 digit MMIS Number that the recipient is restricted to. The provider number is the only valid entry. An entry in this field is in addition to an entry in the Prescriber ID field. The entry must be left justified and space filled. The Primary Care Provider ID Qualifier must have a value of 05 when this field is entered. 2. Some incorrect entries being received are: A) bb00240588: Eight digit MMIS Provider number NOT left justified. B) 00240588bA: Eight digit MMIS Provider number left justified but followed by a space and an alpha character. C) Field is blank and recipient is restricted. D) Field contains the same provider number that is being sent in the Prescriber ID field and recipient is not restricted to that provider. E) Field contains a license number.
700 Year of Birth not equal to file.	09 M/I Birthdate	19490228 (Century, Year, Month, Day)	The Date of Birth field requires an 8 digit entry, which includes the Century of the recipient's birth. The majority of your software packages only require you to enter the birth year and the software is automatically sending 19 as the Century. This has caused some rejections when the recipient was born in the 18th Century. When this occurs, you need to contact your software company.
702 ECCA Not Allowed	81 Claim Too Old	20010601 (Century, Year, Month, Day)	1. The date filled requires an eight-digit entry, which includes the century of the date filled. The eMedNY contractor will only accept fill dates up to two years old via NCPDP for rebills and reversals. This reject will be returned for any rebill or reversal with a fill date over two years old.
	04 M/I Processor Control Number	Y (Yes)	2. The first position of the Processor Control Number must equal ‘Y’ to indicate the provider has read and attests to the data in the Certification Statement on page 19.0.3.
703 Invalid PIN 704 Invalid ETIN	04 M/I Processor Control Number	YTG1234QBK (Certification, Initials, PIN, ETIN)	1. If you wish your transaction to be electronically captured, the Processor Control Number field must be completed. Correct completion of this field alerts the online system to capture an accepted claim transaction for adjudication. 2. The reject denial code 703 will be returned if: A.) You have not submitted the PIN selection form to the Department of Health. B.) The PIN number has not been added to your provider file record at the eMedNY contractor. C.) The PIN number transmitted does not match the number selected, which was added to your provider file record. 3. The reject denial code 704 will be returned if: A.) You have not applied for and/or submitted your ETIN number on a notarized certification statement to the eMedNY contractor. B.) The ETIN transmitted does not match the ETIN submitted on the certification statement, which was added to the ETIN file. 4. Some software has hard coded the ETIN of the billing service into this field. If that ETIN was not on the certification statement, the transaction will reject.
705 NDC/APC Not Covered	70 Product/Service Not Covered 77 Discontinued Product/Service Id Number	00074738601 (11 digit NDC Code)	1. The Product/Service Id field entry must contain an 11 digit numeric NDC code. 2. Some common errors being received are: A) NDC field is blank - software is not pulling code off of your drug file. B) NDC field is incomplete. Entry does not contain a full 11 numbers, but is a combination of blanks and numbers. C) We have learned that some software packages are converting your 11 digit NDC code entry to a five digit alpha/numeric code for some over the counter items that used to be billed using the alpha/numeric code but have now been assigned an 11 digit NDC code. D) Conversely, other software packages are converting your 5 digit alpha/numeric HCPCS code entry to an 11 digit NDC code. These items used to be billed using an NDC code but have been changed to a five digit alpha/numeric code. Note: If you receive a rejection code for your NDC entry, you should check with your software vendor to see what code is being transmitted. E) The Compound Code field must contain a value of 1 for each NDC entry. An entry of any other code in the compound code field when submitting an 11 digit NDC code will cause a rejected claim. F) The Product/Service Id Qualifier (436-E1) field does not contain a value of 03.
710 Maximum Quantity Exceeded	76 Plan Limitations Exceeded	0000100000 (100 Tablets) 0000001000 (1 package of gauze pads) 0000075000 (75 Caloric Units)	1. The Quantity Dispensed is a 10 digit numeric field, which contains 3 decimal positions. 2. The quantity that you enter in this field is checked against the maximum quantity on the Drug Plan File for each drug or supply item. If the amount entered exceeds the amount on the Drug Plan File, the claim will deny. 3. If you have received prior approval to dispense a quantity that exceeds the established maximum, you must enter the prior approval number on your transaction. This will allow your claim to override the edit. 4. Some incorrect entries being received are: A) 00500 - The number of items in a box or package are being submitted rather than the number of boxes or packages. If there are 500 gauze pads in 1 box, the quantity should be submitted as 0000001000.
712 Override Denied UT Not at Limit	34 M/I Prescription Denial Override	00 (No Override required) 01 (No Override Required) 02 (UT Service Authorization Exception Code P - Override Pending) 07 (UT Service Authorization Exception Code J or L - Immediate Urgent Care or Emergency)	1. An entry must be placed in the Submission Clarification Code field. 2. If the recipient is not at their UT limit, 00 or 01 should be entered. 3. If the recipient is at their limit, value 02 or 07 should be entered to override the limit. 4. Code 712 is returned if a value of 02 or 07 is entered and the recipient has not reached their limit.

MEVS CODE

NCPDP CODE

EXAMPLES OF

CORRECT ENTRY

COMMON ERRORS BEING

MADE / COMMENTS

050

Alternate Access not allowed

None

None - No entry made

1. In order to access the DUR/ECCA online system you must choose an alternate access method.

2. Code 050 will be returned if your provider number has not been updated with your selected access method on the eMedNY contractor’s production file.

3. In order to be updated on the production file, you must have:

A) Notified the eMedNY contractor of your alternate access method.

B) Signed the contract and sent it to the eMedNY contractor.

C) Signed the contract and submitted your check to your switch company if you chose to transmit through a switch. The switch must then send an approval to the eMedNY contractor before your number will be updated on production.

053

SSN Access Not Allowed

None

None – 9 digit entry not allowed

Card holder ID (302-C2) field has only two acceptable formats:

1. Eight position alpha/numeric Medicaid Client Number (CIN)

2. Thirteen-digit Access Number without the six-digit ISO # prefix

054

Provider Cannot Access by Account Type

None

None – No entry made

If you submit a transaction via an access method other than the method assigned to your provider number on the production file, code 054 will be returned. For example, if your provider number is on the file as going through a switch company and a transaction is sent using a second switch company that is not on your file, your transaction will be rejected.

056 or 059

Reenter Ordering

Provider Number

or Invalid License Type

M/I Prescriber ID

0100567892

(NYS Physician)

290F654938

(Nurse Practitioner)

00240588

(8 digit MMIS Provider ID for enrolled prescriber)

11NJ456193

(Out of State Physician from New Jersey).

250U452749

(Optometrist)

1. The Prescriber ID field length is 10. The Prescriber's License type must be in the first two positions, followed by either two zeroes or two alpha (out of state) followed by the 6 digit license number. The Prescriber ID Qualifier must be equal to 08 when submitting a license number. An 8 digit provider number must be left justified, space filled. The Prescriber ID Qualifier must be equal to 05.

Note: When entering a license number, the last six positions of the entry should be the actual numeric license number. If the license number does not contain six numbers, zero fill the appropriate positions preceding the actual license number. For example, an entry for an Optometrist whose license number is U867 would be 250U000867.

2. Some incorrect entries being received are:

A) 567892: License number only

B) 00567892: License number without License Type.

C) 0156892: License Type, License Number without zeroes or 2 alpha in between.

D) bb00240588: Eight digit MMIS Provider Number NOT left justified.

E) DEA Number: Some software packages are sending the physician's DEA numbers instead of the license number.

3. Nurse Practitioners:

A nurse practitioner may have several different license numbers because the State Education Department issues them a license for each specialty for which they are certified. Not All Nurse Practitioners are licensed to prescribe drugs. A nurse practitioner who is licensed to prescribe will have the letter "F" preceding the 6 digit license number. This is the license number that must be used when submitting your transaction. The license type 29 followed by 0F and the 6 digit number is the only correct entry for nurse practitioners’ license numbers.

4. Optometrists:

An optometrist who is licensed to prescribe will have the letter ‘U’ or ‘V’ preceding the six -digit license number. The license type 25 followed by ‘OU’ or ‘OV’ and the six- digit number are the only correct entries for optometrists’ license numbers.

061

Invalid Access Number

062

Invalid Medicaid Number.

M/I Cardholder ID Number

2631578424139

(13 digit access number found on recipient's Medicaid card)

LZ00083W

(CIN Number)

1. The entry in the Cardholder ID field must contain either the recipient's 13 digit access number or their 8 character alpha numeric CIN number. Both must be left justified, space filled.

2. The most common error being received that causes code 061 to be returned is an entry of 8 numeric digits in the Cardholder ID field. Check your software to make sure the alpha characters in the CIN number are not being converted to numeric values.

3. Rejections also occur when either number is not left justified.

4. Code 062 is returned when the number entered cannot be found on the file.

063

Invalid Sequence Number

M/I Person Code

(2 digit sequence number)

1. The recipient's 2 digit sequence number is required on each transaction. The sequence number can be found on the recipient's Medicaid card.

2. Our format requires the 2 digit sequence number to be placed in the 3 digit Person Code field. The number must be left justified and space filled. We have learned that some software packages have the number placed in a different field, which is fine as long as it is sent to the eMedNY contractor in the Person Code field.

3. Some incorrect entries being received are:

A) Person Code field is blank

B) Sequence number is not left justified.

C) Sequence number transmitted does not match the most current number on the eMedNY contractor’s file. A new sequence number is issued each time a recipient receives a new card.

100

Invalid Referring Provider Number

101

Restricted Recipient No Auth

118

MCCP Recipient No Auth

M/I Primary Care Provider Id

00240588

(8 digit MMIS identification number of the provider to which a recipient is restricted).

1. If a recipient is restricted, the Primary Care Provider field must contain the 8 digit MMIS Number that the recipient is restricted to. The provider number is the only valid entry. An entry in this field is in addition to an entry in the Prescriber ID field. The entry must be left justified and space filled. The Primary Care Provider ID Qualifier must have a value of 05 when this field is entered.

2. Some incorrect entries being received are:

A) bb00240588: Eight digit MMIS Provider number NOT left justified.

B) 00240588bA: Eight digit MMIS Provider number left justified but followed by a space and an alpha character.

C) Field is blank and recipient is restricted.

D) Field contains the same provider number that is being sent in the Prescriber ID field and recipient is not restricted to that provider.

E) Field contains a license number.

700

Year of Birth not equal to file.

M/I Birthdate

19490228

(Century, Year, Month, Day)

The Date of Birth field requires an 8 digit entry, which includes the Century of the recipient's birth. The majority of your software packages only require you to enter the birth year and the software is automatically sending 19 as the Century. This has caused some rejections when the recipient was born in the 18th Century. When this occurs, you need to contact your software company.

702

ECCA Not Allowed

Claim Too Old

20010601

(Century, Year, Month, Day)

1. The date filled requires an eight-digit entry, which includes the century of the date filled. The eMedNY contractor will only accept fill dates up to two years old via NCPDP for rebills and reversals. This reject will be returned for any rebill or reversal with a fill date over two years old.

M/I Processor Control Number

(Yes)

2. The first position of the Processor Control Number must equal ‘Y’ to indicate the provider has read and attests to the data in the Certification Statement on page 19.0.3.

703

Invalid PIN

704

Invalid ETIN

M/I Processor Control Number

YTG1234QBK

(Certification, Initials, PIN, ETIN)

1. If you wish your transaction to be electronically captured, the Processor Control Number field must be completed. Correct completion of this field alerts the online system to capture an accepted claim transaction for adjudication.

2. The reject denial code 703 will be returned if:

A.) You have not submitted the PIN selection form to the Department of Health.

B.) The PIN number has not been added to your provider file record at the eMedNY contractor.

C.) The PIN number transmitted does not match the number selected, which was added to your provider file record.

3. The reject denial code 704 will be returned if:

A.) You have not applied for and/or submitted your ETIN number on a notarized certification statement to the eMedNY contractor.

B.) The ETIN transmitted does not match the ETIN submitted on the certification statement, which was added to the ETIN file.

4. Some software has hard coded the ETIN of the billing service into this field. If that ETIN was not on the certification statement, the transaction will reject.

705

NDC/APC Not Covered

Product/Service Not Covered

Discontinued Product/Service Id Number

00074738601

(11 digit NDC Code)

1. The Product/Service Id field entry must contain an 11 digit numeric NDC code.

2. Some common errors being received are:

A) NDC field is blank - software is not pulling code off of your drug file.

B) NDC field is incomplete. Entry does not contain a full 11 numbers, but is a combination of blanks and numbers.

C) We have learned that some software packages are converting your 11 digit NDC code entry to a five digit alpha/numeric code for some over the counter items that used to be billed using the alpha/numeric code but have now been assigned an 11 digit NDC code.

D) Conversely, other software packages are converting your 5 digit alpha/numeric HCPCS code entry to an 11 digit NDC code. These items used to be billed using an NDC code but have been changed to a five digit alpha/numeric code. Note: If you receive a rejection code for your NDC entry, you should check with your software vendor to see what code is being transmitted.

E) The Compound Code field must contain a value of 1 for each NDC entry. An entry of any other code in the compound code field when submitting an 11 digit NDC code will cause a rejected claim.

F) The Product/Service Id Qualifier (436-E1) field does not contain a value of 03.

710

Maximum Quantity Exceeded

Plan Limitations Exceeded

0000100000

(100 Tablets)

0000001000

(1 package of gauze pads)

0000075000

(75 Caloric Units)

1. The Quantity Dispensed is a 10 digit numeric field, which contains 3 decimal positions.

2. The quantity that you enter in this field is checked against the maximum quantity on the Drug Plan File for each drug or supply item. If the amount entered exceeds the amount on the Drug Plan File, the claim will deny.

3. If you have received prior approval to dispense a quantity that exceeds the established maximum, you must enter the prior approval number on your transaction. This will allow your claim to override the edit.

4. Some incorrect entries being received are:

A) 00500 - The number of items in a box or package are being submitted rather than the number of boxes or packages. If there are 500 gauze pads in 1 box, the quantity should be submitted as 0000001000.

712

Override Denied UT Not at Limit

M/I Prescription Denial Override

(No Override required)

(No Override Required)

(UT Service Authorization Exception Code P - Override Pending)

(UT Service Authorization Exception Code J or L - Immediate Urgent Care or Emergency)

1. An entry must be placed in the Submission Clarification Code field.

2. If the recipient is not at their UT limit, 00 or 01 should be entered.

3. If the recipient is at their limit, value 02 or 07 should be entered to override the limit.

4. Code 712 is returned if a value of 02 or 07 is entered and the recipient has not reached their limit.

320

Other Insurance Information Inconsistent

COB Segment:

Field 342-HC “99” (First Occurrence)

Field 431-DV = $100.00

1. Your claim will deny if the Medicare Deductible reported on your claim is either greater than $100.00 or non-numeric. Refer to the amount entered in field 431-DV, after the first occurrence of qualifier “99” in field 342-HC on your claim in the COB segment. The amount entered cannot be more than $100.00 or non-numeric.

COB Segment:

Field 342-HC “07”

Field 431-DV = $50.00 or (Blank if no Medicare Involvement)

2. If a claim is being denied for the Medicare approved amount non-numeric, this would be caused by the dollar amount entered in field 431-DV following qualifier “07” in field 342-HC, (Medicare approved Amount) on your claim. The Medicare approved Amount must be either blank, (if Medicare is not involved), or numeric (if Medicare is involved).

COB Segment:

Field 342-HC “08”

Field 431-DV = $25.00 or (Blank if no Medicare Involvement)

3. Your claim will deny when the Medicare Paid amount is non-numeric. The Medicare Paid amount must be blank (if Medicare is not involved), or numeric (if Medicare is involved).

320

COB Segment:

Field 342-HC “07”

Field 431-DV = $100.00

Field 342-HC “08”

Field 431-DV = $80.00

Field 342-HC “99”

Field 431-DV = $10.00 (Deductible Amount)

Field 342-HC “99”

Field 431-DV = $10.00 (Coinsurance Amount)

Field 342-HC “99”

Field 431-DV = $00.00 (Copay Amount)

4. If the Medicare Data reported on the claim is inconsistent, your claim will be denied. This denial will result when the Medicare Approved Amount is completed and the Medicare paid amount is blank, or the Medicare paid amount is completed and the Medicare Approved amount is blank. Denial can also occur if the sum of the Deductible, Coinsurance and Copay amount reported on the claim is greater than the difference between the Medicare Approved amount and Paid Amounts.

320

Pricing Segment:

Field 426-DQ = $100.00 (Total Amount Charged)

COB Segment:

Field 342-HC “07”

Field 431-DV = $80.00 (Medicare Approved Amount)

5. When the Amount Charged that is reported on your claim in field 426-DQ in the Pricing Segment, is less than the Medicare Approved Amount reported on your claim, it will deny.

306

COB Segment:

Field 342-HC “07”

Field 431-DV = $100.00

Field 342-HC “08”

Field 431-DV = $80.00

1. When the Medicare Paid Amount Reported on the claim is less than reasonable, your claim will pend. The system is programmed for a $100.00 deductible and a maximum of 20% Coinsurance payment. If the amounts entered on the claim do not conform to the logic, your claim will pend.

12.0 Rx DENIAL CODES - TABLE 7 (Rev. 11/03)

All of the Table 7 codes are denial codes. Their presence in your response means that the claim has been rejected. If none of the Table 7 codes apply to your claim, you will see 000 in your response instead.

MEVS CODE	DESCRIPTION	NCPDP CODE	DESCRIPTION
132	M/I Item / NDC Code	21	M/I Product/Service Id
133	Product/Service Not Covered for Patient Gender	61	Drug Not Covered for Patient Gender
134	Patient Age Exceeds Maximum Age	66	Patient Age Exceeds Maximum Age
135	Patient Age Precedes Minimum Age	85	Claim Not Processed
136	Requested Item Exceeds Frequency Limitation	85	Claim Not Processed
137	Missing/Invalid Quantity Dispensed	E7	M/I Quantity Dispensed
140	Category of service not valid for item / NDC code	05	M/I Pharmacy Number
142	Missing / Invalid category of service	05	M/I Pharmacy Number
705	NDC/APC Not Covered	70, 77	Product/Service Not Covered, Discontinued Product/Service Id Number
706	Refill Code Exceeds Number of Refills Authorized	17	M/I Fill Number
707	Previously Filled Refill	17	M/I Fill Number
708	Exceeds NY Allowed Refill Maximum	29	M/I Number Refills Authorized
709	Maximum Day’s Supply Exceeded	19	M/I Days Supply
710	Maximum Quantity Exceeded	76	Plan Limitations Exceeded
711	Date Filled Prior to Date Rx Written	28	M/I Date Prescription Written
712	Override Denied - UT not at limit	34	M/I Submission Clarification Code
713	Refill over 180 days from Date Rx Written	28	M/I Date Prescription Written
714	Date Filled More than 60 days from Date Rx Written	28	M/I Date Prescription Written
715	Other Insurance Amount must be greater than zero	13	M/I Other Coverage Code
716	Other Insurance Amount must be equal to zero	13	M/I Other Coverage Code
717	Recipient has Other Insurance	13	M/I Other Coverage Code
718	HR Recipient - No Rebate Agreement	77	Discontinued Product/Service Id Number
719	MA Only Covers Family Planning	65	Patient Is Not Covered
720	Days Supply is Less than the Minimum Required	19	M/I Days Supply
722	Family Health Plus Denial	65	Patient is Not Covered

The chart starting on the following page lists the most frequently returned reject denial codes from Table 7 and describes the entry errors being received.

CODE	DESCRIPTION
301	Pending for Manual Pricing. (The NDC being billed requires manual review and pricing by DOH).
306	Item Requires Manual Review. (The NDC being billed requires manual review by DOH prior to payment).
310	Pharmacy Service Included in In-state Facility Rate
311	PCP Plan Code Not on Contract File. (Recipient is enrolled in a managed care plan but the plan code has not yet been added to DOH’s Managed Care Contract file). Call Provider Services 1-800-343-9000
317	Claim Pending: Excess Income/Spenddown. (Recipient has income in excess of the allowable Medicaid levels and will be considered eligible for Medicaid reimbursable services only at the point his/her excess income is reduced to the appropriate level. This response will be issued if you override the excess income denial [code 104] and the LDSS has not yet updated eligibility on the Client database).
319	Prior Approval Not on or Removed From File. (PA is not found on or no longer active on the eMedNY contractor’s PA file).

16.0 NCPDP REJECT CODES (Rev. 11/03)

CODE	DESCRIPTION - M/I = Missing/Invalid	MEVS CODE
01	M/I BIN
04	M/I Processor Control Number	702,703, 704
05	M/I Pharmacy Number	051, 092, 140, 142
07	M/I Cardholder ID Number	030, 031, 033, 061, 062
08	M/I Person Code	063
09	M/I Birthdate	300, 700
10	M/I Patient Gender Code	701
13	M/I Other Coverage Code	715, 716, 717
14	M/I Eligibility Clarification Code
15	M/I Date of Service	071
16	M/I Prescription/Service Reference Number
17	M/I Fill Number Code	706, 707
19	M/I Days Supply	709, 720
20	M/I Compound Code
21	M/I Product/Service Id	132
22	M/I Dispense as Written Code (DAW) Product Selection Code
25	M/I Prescriber ID	056, 059, 066, 067, 068, 318
28	M/I Date Prescription Written	711, 713, 714
29	M/I Number Refills Authorized	708
34	M/I Submission Clarification Code	712
35	M/I Primary Care Provider Id	100, 101, 118
50	Non-Matched Pharmacy Number	052
52	Non-Matched Cardholder ID	065
61	Product/Service Not Covered For Patient Gender	133
65	Patient is Not Covered	001, 103, 104, 719, 722
66	Patient Age Exceeds Maximum Age	134
70	Product/Service Not Covered	705
75	Prior Authorization Required
76	Plan Limitations Exceeded	710
77	Discontinued Product/Service Id Number	705, 718
81	Claim Too Old	702
82	Claim is Post Dated
83	Duplicate Paid/Captured Claim
84	Claim Has Not Been Paid/Captured
85	Claim Not Processed
87	Reversal Not Processed	045
88	DUR Reject Error
92	System Unavailable	324
DQ	M/I Usual and Customary
DV	M/I Other Payor Amount Paid	320
DX	M/I Patient Paid Amount Submitted
EV	M/I Prior Authorization Number Submitted	303, 304, 319
E1	M/I Product/Service Id Qualifier
E4	M/I Reason for Service Code
E6	M/I Result for Service Code
E7	M/I Quantity Dispensed	137
MZ	Error Overflow

Up to twenty (20) NCPDP reject codes can appear in the rejected response. If a code has a comparable MEVS reject code that code will also be returned in the response. Most of the NCPDP reject codes are self-explanatory or have been further explained in other sections. Those needing further clarification are described below.

Code 22 - M/I Dispense As Written Code:

An entry is required. The acceptable values are:

0 - No Product Selection Indicated.

1 - Substitution not allowed by Prescriber.

4 - Substitution allowed - Generic Drug not in stock.

5 - Substitution allowed - Brand Drug Dispensed as a Generic.

7 - Substitution not allowed - Brand Drug mandated by law.

8 - Substitution allowed - Generic Drug not available in marketplace.

Code EV - M/I Prior Authorization Number Submitted Code:

If an NDC or HCPCS requires a prior approval number, the prior approval field must contain the prior approval number assigned to you for the NDC or HCPCS. The prior approval field is 11 digits in length. The first 8 digits should contain the prior approval number followed by three zeroes. Example 56734268000. Additionally, the Prior Authorization Type Code (461-EU) field should contain a “01” if reporting a PA number with no co-pay exemption. If the patient is co-pay exemption, enter a number “04”.

Code 83 - Duplicate Paid/Captured Claim:

This code is returned when a claim is submitted and the Service Product Id Number, Cardholder ID, Date of Service, and Prior Authorization Number Submitted fields match a previously paid claim and one of the following three conditions also exist:

· Prescription/Service Reference Number, NDC/HCPCS (if not a compound), and Generic Code match, but the Fill Number Code is different.

· Prescription/Service Reference Number and Generic Code match, but NDC/HCPCS is different.

· NDC/HCPCS (if not a compound) match, but Prescription/Service Reference Number is different.

Refer to section 2.14 on page 2.14.1 for additional information.

Code 84 - Claim Has Not Been Paid/Captured:

This code is returned when a transaction is submitted (transactions codes N1 and N3) with the intent of supplying DUR information only for purposes of updating the recipient's drug history file when no claim submission or reimbursement is allowed or expected. If Code 84 is the only code returned, the drug history file has been updated.

DQ - M/I Usual and Customary:

An entry is required in the Usual and Customary Charge field. If the claim is being sent for ECCA processing, the amount in this field must be greater than zeroes. If ECCA is not being requested, the field must be zero filled.

17.0 GLOSSARY OF ABBREVIATIONS AND TERMS (Rev. 11/03)

Several abbreviations are used when referring to the Drug Utilization Program. These abbreviations are listed below with a brief description.


CPU	Central Processing Unit. This is also known as the mainframe computer.
CPU-CPU Link	A direct telecommunication connection to the eMedNY contractor’s mainframe computer using a central processing unit to access the MEVS/Pro-DUR systems.
DME	Durable Medical Equipment. These items and their codes are listed in the DME MMIS Provider Manual and are further identified by use of specialty code 307 or category of service 0442 when billing and must be submitted on a DME claim form. Some DME item codes require a DVS number. These must be submitted by using a 278 ASC X12N transaction, the Verifone Omni 3750 Terminal or ePACES.
DVS	Dispensing Validation System. This feature allows you to obtain the required prior approval number (DVS number) for pre-designated DME item codes and certain prescription drugs in the same transaction as your DUR/ECCA claim. Items, which are only reimbursable under COS 0442, cannot be submitted through the NCPDP format.
ECCA	Electronic Claims Capture and Adjudication. This is an optional feature of the Pro-DUR program, which allows you to have your DUR claim captured and adjudicated for payment by the eMedNY contractor.
ETIN	Electronic Transmitter Identification Number. A three-character code assigned by the eMedNY contractor to a provider who wishes to send their claims electronically or via magnetic media. The Electronic Transmitter Identification Number has also been referred to as a Magnetic Supplier Number. Each pharmacy must submit their ETIN with a notarized certification statement to the eMedNY contractor. The ETIN must be entered on each Pro-DUR transaction in order to have the claim electronically captured.
HCPCS	Health Care Financing Administration Common Procedure Coding System. The five digit alpha/numeric HCPCS code is assigned by CMS to over the counter sickroom supplies. These codes are found in sections 4.2 and 4.3 in the MMIS Pharmacy Provider Manual. The five digit alpha/numeric DME item codes are also entered as HCPCS codes for DVS Transactions.
MEVS	Medicaid Eligibility Verification System. The system which processes providers’ eligibility inquiries and service authorization requests for New York State Medicaid recipients.
LICENSE TYPE	Two digit code indicating the type of provider that wrote the prescription. The valid license types are: 01 NYS Physician 02 NYS Dentist 09 NYS Physician Assistant 25 NYS Optometrist 26 NYS Podiatrist 27 NYS Audiologist 29 NYS Nurse Practitioner/Midwife 11 Out-of-State Physician 12 Out-of-State Dentist 19 Out-of-State Physician Assistant 35 Out of State Optometrist 36 Out-of-State Podiatrist 37 Out-of-State Audiologist 39 Out-of-State Nurse Practitioner/Midwife
MAGNETIC MEDIA	Tape, Cartridge, or Diskette used to submit claims for processing.
NCPDP	National Council for Prescription Drug Program. A nonprofit membership organization working toward the standardization and efficiency of third party prescription drug program processing. New York State is using NCPDP's Version 5.1 Telecommunication Standard and the 1.1 Batch formats to administer the DUR program and have your DUR claim captured and adjudicated for payment by the eMedNY contractor.
NDC	National Drug Code. The eleven digit number assigned to each drug or OTC item.
NYSDOH	New York State Department of Health
OTC	Over the Counter drug or supply which does not require a prescription.
P & C	Post and Clear. The program in effect which requires certain prescribers to post their prescriptions on the MEVS system. The posted prescriptions must then be "cleared" by the dispensing provider. P&C service authorizations are required for payment to be made.
PC	Personal Computer.
PC-Host Link	A Dial-Up into the MEVS network using a personal computer to access the MEVS/Pro-DUR systems.
PIN	Personal Identification Number. A four digit number selected by each pharmacy and submitted to the New York State Department of Health for input to the pharmacy's provider file. Pharmacies must enter the number on each Pro-DUR transaction in order to have their claim electronically captured and submitted for adjudication.
Pro-DUR	Prospective Drug Utilization Review. This is a mandatory program, which alerts pharmacists to possible contraindications when dispensing drugs to a recipient.
Switch (Switching)	A company that passes the Pro-DUR/ECCA transaction from the provider to the MEVS network, via a dedicated telecommunications link, and returns the response from the MEVS network to the provider.
TSN	Transmission Supplier Number. Refer to Electronic Transmitter Identification Number (ETIN).
UT	Utilization Threshold. The mandatory program in effect, which limits Medicaid recipients to a designated number of services, prescriptions, etc. per year. Providers must receive a UT service authorization in order for payment to be made.

18.0 QUESTIONS AND ANSWERS (Rev. 02/04)

Q: How does my software work?

A: If you have any questions regarding your software, refer them to your software vendor. The New York State Department of Health and the eMedNY contractor do not have any control over software written to interface with the Pro-DUR/ECCA system.

Q: What phone number do I dial to access the production Pro-DUR/ECCA system?

A: For PC-Host going direct to the eMedNY contractor, you will receive the production phone numbers once you have completed certification and testing.

For providers going through a switch, you should contact your switch for access procedures and information.

Q: What is my PIN?

A: The Provider Services Department staff can verify if the PIN you are using is correct. They are not authorized to give out your PIN number for security reasons. If you do not know your PIN number, you must complete a new "PIN Selection Form" and return it to New York State Department of Health.

Q: What is my ETIN?

A: Contact Provider Services at 1-800-343-9000 for the ETIN that is authorized for electronic processing.

Q: Will my claim be paid?

A: If your claim is electronically captured and approved for payment, your claim will be paid. One exception to this rule is for excess income/spenddown. Once you have overridden the 104 denial response, your claim will pend waiting for an eligibility update from the WMS. If the update is not timely, your claim will release from its pending status and deny. These “captured, then denied” claims will appear on your remittance statement as being denied. Refer to the Electronic Claims Capture and Adjudication section on page 2.4.1 of the manual for additional information.

Q: Why am I getting "NO CLAIM TO FA"?

A: You receive this message any time the system has determined the claim can not be captured for adjudication. There are many reasons for this, including if the Processor Control Number is not submitted. Refer to the Electronic Claims Capture and Adjudication section on page 2.4.1 of the manual for additional information.

Q: Will this claim be paid online?

A: Your claim will be fully adjudicated. Claims approved for payment will appear as paid within the remittance statement issued for that payment cycle.

Q: What is Person Code?

A: The Person Code is the NCPDP field used to input the Recipient's Sequence Number. The sequence number can be found on the recipient's card.

Q: I received a DUR warning for high dosage and refills too early and my claim was denied? Why?

A: In the online Pro-DUR/ECCA system, the eMedNY contractor sends back warning information about certain drug interactions. These are only warnings and are NOT rejects in the online system. Some software companies will treat these warnings as REJECTS when interpreting the DUR response. You need to talk to your software provider to determine how to deal with this condition.

Q: What is the valid NDC code for a particular drug?

A: You should look at the microfiche you receive from New York Medicaid. All reimbursable drugs are listed. If you cannot find it, you can call New York State Department of Health at 1-518-486-3209.

Q: What is the proper procedure for entering sickroom supplies using Health Care Financing Administration Common Procedure Coding System (HCPCS)?

A: Refer to Section 2.8 (page 2.8.1) on HCPCS Codes in the manual for clarification.

Q: Was a UT service authorization produced by the eMedNY contractor?

A: Refer to Table 8 (page 13.0.1) on UT, P&C codes in this manual for clarification.

Q: Why am I getting M/I Prior Authorization Number Submitted? This doesn't need a PA!

A: If the item you are entering does not need Prior Approval/Authorization and you're using the version 5.1 format, the Prior Auth Number Submitted (462-EV) field should not be transmitted (your software system should take care of this).

Q: How should the Prior Auth Type Code 461-EU and Prior Auth Number Submitted 462-EV be put in the field?

A: The first field (461-EU) should contain a ‘01’ for Prior Auth Number submission or ‘04’ to identify co-pay exempt. If a P.A. No. is also required with the co-pay exempt then submit as follows: The second field (462-EV), positions 1 thru 8 = prior approval number and positions 9 thru 11 = zeroes (000) when 461-EU contains ‘01’. If 461-EU contains ‘04’ for co-pay exempt and does not require a P.A. No., do not submit 462-EV. If a P.A. No. is also required then submit 462-EV as indicated above.

Refer to Section 2.11 on page 2.11.1 for field descriptions.

Q: Why was I rejected?

A: Refer to Table 2 (page 10.0.1), Table 7 (page 12.0.1), Table 8 (page 13.0.1), Table 9 (page 14.0.1) and the NCPDP Reject Codes list for clarification.

Q: What were my DUR reject codes, I cleared my screen already?

A: You should first check with your software vendor to see if there is a method of recovering or re-displaying the response for a transaction. If there is not, you can resubmit the transaction and get the same errors.

Q: I received DUR Reject Code 85 in my response, what does it mean?

A: You should look for the accompanying error codes that are part of the response in the Additional Message field. The first is the MEVS Accepted or Denial code. This code is in the first three positions. The other code is the Rx Denial Code. It follows the MEVS code and a space. Additionally, the claim could be rejected because of UT/P&C denials or DVS denials. Refer to Table 2 (page 10.0.1), Table 7 (page 12.0.1), Table 8 (page 13.0.1), Table 9 (page 14.0.1) in this manual.

Q: Why does it say M/I Product/Service ID or Product/Service Not Covered, when the NDC is in fact covered?

A: Refer to Table 7 (page 12.0.1) error chart for further explanation.

Q: What is Maximum Quantity, or Plan Limitations exceeded?

A: The maximum quantity or plan limitations reject is when the amount in the Quantity Dispensed field is greater than the allowed or approved New York State Medicaid quantity. For assistance call Provider Services at 1-800-343-9000.

Q: I am getting a reject code of 100 or 101, what do I do?

A: Refer to Table 2 (page 10.0.1) error chart for further explanation.

Q: What is E4 Reason for Service Code or E6?

A: These are both NCPDP Reject Codes. The E4 code indicates there is a problem with the Reason for Service Code input with the claim. It could be because the data is not one of the DUR reject conflict codes, a DUR override was not required, or the field was the wrong size. The E6 code indicates there is a problem with the Result for Service Code. The common problems are a DUR override is not needed or the wrong value was input. Another common problem is only one of the fields is entered. Both fields should be reviewed and the transaction resubmitted. Refer to the Override Processing section for further clarification.

Q: How do I process an override?

A: There are four types of overrides for transactions. The first is the MEVS UT or Utilization Threshold override. It is entered in NCPDP Submission Clarification Code (420-DK) field. The UT override is needed when you receive a UT Denial or a D in the first position of the codes for UT/PC in Additional Message (526-FQ) field. The second override is for DUR. This is entered in Reason for Service Code (439-E4) field. The DUR override is required when you receive a DUR Reject, error code 88. Both can be entered in the same transaction. Beware; if the override is not required, the transaction will be rejected. Refer to the Override Processing section for further clarification. The third override is the excess income/spenddown override. This override can be entered in the Eligibility Clarification Code (309-C9) field to override response code 104. Once overridden, your claim will be captured if the processor control number field is completed properly. Once captured, your claims will pend, waiting for a WMS eligibility update to occur. If the update is not timely, your claim will appear as denied on your remittance statement.

The fourth override is the Nursing Home override. The Eligibility Clarification Code (309-C9) field may also be used to report a Nursing Home Override. You may use this override code when resubmitting a previously denied claim if a Client is a resident of an In-State Skilled Nursing Facility which includes coverage for pharmacy services. This will result in a pend status which will allow local districts time to update the Client’s file if the patient has been discharged from the Facility.

ETIN (1) BILLING SERVICE NAME (IF APPLICABLE (2)

MEDICAID MANAGEMENT INFORMATION SYSTEM

CERTIFICATION STATEMENT FOR PROVIDER UTILIZING ELECTRONIC BILLING

As of (date) (3) and for one year after this date all claims electronically submitted to the State's Medicaid fiscal agent, for services or supplies furnished by (provider name) (4) (provider number) (5) will be subject to the following certification.

I am (or the business entity named in this form of which I am a partner, officer or director is) a qualified provider enrolled with and authorized to participate in the New York State Medicaid Assistance Program and in the profession or specialties, if any, required in connection with this claim; the persons providing services, care and supplies have the necessary licensing, certification, training and experience to perform the claimed service; I have reviewed these claims; I (or the entity) have furnished or caused to be furnished the care, services and supplies itemized and done so in accordance with applicable federal and state laws and regulations; I have read the Medicaid Management Information Systems Provider Manual and all revisions thereto; all claims are made in full compliance with the pertinent provisions of the manual and revisions; all claims for care, services and supplies provided at the order of another professional have to the best of my knowledge been ordered by that professional in bona fide compliance with the procedures set forth in the manual and revisions. All care, services and supplies for which claim is made are medically necessary for the treatment of the named recipients, the amounts listed are due and except as noted, no part thereof has been paid by, or to the best of my knowledge is payable from any source other than the Medical Assistance Program, payment of fees made in accordance with established schedules is accepted as payment in full other than a claim rejected or denied or one for adjustment, no previous claim for the care, services and supplies itemized has been submitted or paid; ALL STATEMENTS, DATA AND INFORMATION TRANSMITTED ARE TRUE, ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE; NO MATERIAL FACT HAS BEEN OMITTED; I UNDERSTAND THAT PAYMENT AND SATISFACTION OF THIS CLAIM WILL BE FROM FEDERAL, STATE AND LOCAL PUBLIC FUNDS AND THAT I MAY BE PROSECUTED UNDER APPLICABLE FEDERAL AND STATE LAWS FOR ANY FALSE CLAIMS, STATEMENTS OR DOCUMENTS OR CONCEALMENT OF A MATERIAL FACT: taxes from which the state is exempt are excluded; all records pertaining to the care, services and supplies provided including all records which are necessary to disclose fully the extent of care, services and supplies provided to individuals under the New York State Medical Assistance Program will be kept for a period of six years from the date of payment, and such records and information regarding these claims and payments therefore shall be promptly furnished upon request to the local or State Departments of Health, the State Medicaid Fraud Control Unit or the Secretary of the Department of Health and Human Services; there has been compliance with the Federal Civil Rights Act of 1964 and with section 504 of the Federal Rehabilitation Act of 1973, as amended, which forbid discrimination on the basis of race, color, national origin, handicap, age, sex and religion: I agree (or the entity agrees) to comply with the requirements of 42 CFR Part 455 relating to disclosures by providers; the State of New York through its fiscal agent or otherwise is hereby authorized to (1) make administrative corrections to claims submitted under this agreement to enable its automated processing, subject to reversal by provider, and (2) accept the claim submitted under this agreement as original evidence of care, services and supplies furnished.

In submitting claims under this agreement I understand and agree that I (or the entity) shall be subject to and bound by all rules, regulations, policies, standards, fee codes and procedures of the New York State Department of Health as set forth in title 18 of the Official Compilation of Codes, Rules and Regulations of New York State and other publications of the Department, including Medicaid Management Information System Provider Manuals and other official bulletins of the Department. I understand and agree that I (or the entity) shall be subject to and shall accept, subject to due process of law, any determinations pursuant to said rules, regulations, policies standards, fee codes and procedures, including, but not limited to, any duly made determination affecting my (or the entity's) past, present or future status in the Medicaid program and/or imposing any duly considered sanction or penalty.

I UNDERSTAND THAT MY SIGNATURE HEREON GUARANTEES THE ABOVE CERTIFICATION WILL APPLY TO ALL ELECTRONIC CLAIMS SUBMITTED, USING MY (OR THE ENTITY'S) MEDICAID PROVIDER IDENTIFICATION NUMBER.

(Signature) (6) (Date) (7)

(Typed Name and Title) (8)

STATE OF NEW YORK

COUNTY OF NEW YORK (9)

On this day of , 19 ,before me personally came , to me known and known to me to be the individual described in and who executed the foregoing instrument, and (s)he acknowledged to me that (s)he executed the same.

(SEAL)

NOTARY PUBLIC

Electronic Billing Certification Statement Instructions

Field (1): ETIN (Magnetic Supplier Number)

Please indicate the ETIN under which the claims are being transmitted.

Field (2): BILLING SERVICE NAME

If applicable, enter the name of the billing service that the provider is enrolled with. If not using a billing service, leave this field blank.

Field (3): DATE

Enter the date the Certification Statement is signed and notarized (same date as Field 7).

Field (4): PROVIDER NAME

Enter the name of the provider whose signature is being notarized.

Field (5): PROVIDER NUMBER

Enter the 8-digit Medicaid provider ID number which was assigned by the Department of Health at the time of the provider's enrollment. This must be the individual provider number, not a group number or license number.

Field (6): SIGNATURE

Enter the signature of the individual indicated in Field 4. The signature must be original.

Field (7): DATE

Enter the date the Certification Statement is signed and notarized.

Field (8): NAME AND TITLE

Print the name and the title of the individual whose signature appears in Field 6.

Field (9): NOTARY PUBLIC

To be completed and signed by the Notary Public. Certification Statements that are not notarized cannot be accepted by the fiscal agent.

PLEASE NOTE:

Electronic Billing Certification must be renewed annually. Renewal documents will be provided prior to certification expiration.

FIELD	CONTENTS
Compound Code	Must contain a zero or one. Use zero for DVS transactions.
Product/Service Id Qualifier	Must contain a value of ’09’.
Product/Service Id	HCPCS 5 characters in length plus 2 blanks

HCPCS		QUANTITY SIZE IN MANUAL	QUANTITY DISPENSED	MAX QUANTITY
Code	Description	QUANTITY SIZE IN MANUAL	QUANTITY DISPENSED	MAX QUANTITY
Z2001	Butterfly Clamps	100's (up to 1)	0000001000 (1 box dispensed)	1 box
Z2003	Plastic Strips	50's	0000002000 (2 boxes of 50 dispensed)	5 boxes
Z2012	Adhesive Tape	2" x 5 yd	0000003000 (3 rolls dispensed)	5 rolls
A4244	Alcohol or peroxide per pint	16oz	0000001000 (1 pint bottle dispensed)	5 bottles
A4215	Needles	each (up to 200)	0000056000 (56 needles dispensed)	200 needles
A4635	Underarm pad crutch replacement	each (up to 2)	0000001000 (1 pad dispensed)	2 pads

Code	Description
002	MA Eligible
003	Eligible Only Outpatient Care
005	Eligible Capitation Guarantee Only
006	Eligible PCP
007	Emergency Services Only
008	Presumptive Eligible Long-Term/Hospice
009	Medicare Coinsurance Deductible Only
010	Eligible Except Long-Term Care
013	Presumptive Eligibility Prenatal A
014	Presumptive Eligibility Prenatal B
015	Perinatal Family
016	MA Eligible-HR-Utilization Threshold
017	Family Health Plus Services Only
018	Family Planning Services Only
021	Record Canceled – Cancels a Previously Accepted Claim

Code	Description
127	Co-payment Requirements Have Been Met
128	No Co-payment Required – Recipient Under 21 or Exempt

CODE	DESCRIPTION	APPROVAL OR DENIAL	PROCESSING RESULTS DESCRIPTION
AA	UT Approved, P&C Approved	A	UT&P&C S/A
AD	UT Approved, Services Not Ordered	D	No S/A
AN	UT Approved, P&C Not Invoked	A	UT S/A
DA	UT At Service Limits, P&C Approved	D	No S/A
DD	UT At Service Limits, Services Not Ordered	D	No S/A
DN	UT At Service Limits, P&C Not Invoked	D	No S/A
LA	UT Approved Near Limits, P&C Approved	A	UT&P&C S/A
LD	UT Approved Near Limits, Services Not Ordered	D	No S/A
LN	UT Approved Near Limits, P&C Not Invoked	A	UT S/A
NA	UT Not Invoked, P&C Approved	A	P&C S/A
ND	UT Not Invoked, Services Not Ordered	D	No S/A
NN	UT Not Invoked, P&C Not Invoked	A	Exempt - No S/A Necessary
PA	UT Override Denied, P&C Approved	D	No S/A
PD	UT Override Denied, Services Not Ordered	D	No S/A
PN	UT Override Denied, P&C Not Invoked	D	No S/A
XX	DUR Denial	D	No S/A

CODE	DESCRIPTION
129	Duplicate/Redundant DVS request
130	DVS process was not invoked
131	Item approved / DVS number issued
132	Missing / Invalid item / NDC code
133	Item not covered for patient gender
134	Patient age exceeds maximum age
135	Patient age precedes minimum age
136	Requested item exceeds frequency limitation
137	Missing / Invalid quantity dispensed
139	DVS requires current date entry
140	Category of service not valid for item / NDC code
142	Missing / Invalid category of service
705	NDC/HCPCS Not Covered
710	Maximum Order Quantity Exceeded

1.0 INTRODUCTION (Rev. 11/03)

2.0 GENERAL INFORMATION (Rev. 11/03)

2.1 Access Methods (Rev. 02/04)

2.2 Card Swipe (Rev. 11/03)

2.3 Response Formats (Rev. 11/03)

2.4 Electronic Claims Capture and Adjudication (ECCA) (Rev. 11/03)

2.5 Medicare and Third Party Claims (Rev. 02/04)

Chart 1 – Recipient with Coverage Codes H, K, M, O or ALL on file

Chart 2 – Recipient without Coverage Codes on file

2.6 Rebills/Adjustment Information (Rev. 11/03)

2.7 Refills Information (Rev. 11/03)

2.8 Health Care Financing Administration Common Procedure Coding System (HCPCS) (Rev. 11/03)

2.9 HCPCS Quantities (Rev. 11/03)

2.10 Dispensing Validation System (Rev. 11/03)

2.11 Prior Auth Type Code and Prior Auth Number Submitted (Rev. 11/03)

2.12 Temporary Medicaid Authorizations (Rev. 11/03)

2.13 Excess Income/Spenddown Claims (Rev. 01/04)

2.14 Duplicate Claim Transactions (Rev. 11/03)

3.0 Pro-DUR PROCESSING (Rev. 11/03)

3.1 DUR Response Fields (Rev. 11/03)

4.0 OVERRIDE PROCESSING (Rev. 11/03)

4.1 DUR Override (Rev. 11/03)

4.2 Utilization Threshold (UT) Override (Rev. 11/03)

5.0 Pro-DUR/ECCA Input Information (Rev. 11/03)

5.1 Header Information Fields

Service Provider Id Qualifier

5.2 Claim Information (Rev. 02/04)

DESCRIPTION

Code

Authorized

Other Payor Amount Paid

Charge

6.0 PRO-DUR/ECCA RESPONSE MESSAGES (Rev. 11/03)

DESCRIPTION

DESCRIPTION

Coinsurance

System Number

System Reason Code

Coverage

Post and Clear

7.0 PRO-DUR/ECCA REVERSAL/CANCEL TRANSACTIONS (Rev. 11/03)

8.0 MESSAGE CHARTS (Rev. 11/03)

9.0 MEVS ACCEPTED CODES - TABLE 1 (Rev. 11/03)

10.0 MEVS DENIAL CODES - TABLE 2 (Rev. 02/04)

11.0 CO-PAYMENT CODES - TABLE 6 (Rev. 11/02)

12.0 Rx DENIAL CODES - TABLE 7 (Rev. 11/03)

13.0 PHARMACY UT/P & C CODES - TABLE 8 (Rev. 11/02)

14.0 DISPENSING VALIDATION SYSTEM REASON CODES - TABLE 9 (Rev. 11/03)

15.0 PEND REASON CODES – TABLE 10 (Rev. 01/04)

16.0 NCPDP REJECT CODES (Rev. 11/03)

17.0 GLOSSARY OF ABBREVIATIONS AND TERMS (Rev. 11/03)

ECCA

ETIN

18.0 QUESTIONS AND ANSWERS (Rev. 02/04)

19.0 FORMS (Rev. 11/03)

CERTIFICATION STATEMENT FOR PROVIDER UTILIZING ELECTRONIC BILLING