Claims Processing – Edits and Messaging

• Eligibility
  • 65 – Patient is covered
  • 68 – Filled after coverage terminated

• DOB
  • 09 – M/I Birth date (if no match on DOB submitted vs. eligibility)
  • 10 – M/I Patient gender code (if no match on submitted vs. eligibility)
  • CA – M/I Patient first name (if no match on submitted vs. eligibility)
  • 11 – M/I Patient relationship code (if no match on submitted vs. eligibility – member, spouse, dependent, etc.)

• Benefit
  • Formulary

• QUEST
  • TEMP FILL OF 7 D/S ALLOW WITH PA/MC=11111; Closed Form ‘Form=drugname’

• Commercial/Med D
  • Non-form Rx; Form=drugname (claim is processed)

• PA required
  • Commercial:
    • PRIOR AUTHORIZATION REQUIRED (no phone number)

• QUEST
  • TEMP FILL OF 7 D/S ALLOW WITH PA/MC=11111; PRIOR AUTHORIZATION REQUIRED (no phone number)

• Med D
  • PRIOR AUTHORIZATION REQUIRED; CALL 1-800-753-2851

• 79 = Refill too soon
  • Next RFL 110409;DAYS TO RFL 2;LASTG FILL 101309 AT YOUR PHARM;REFILL TOO SOON

Revision History