Common Insurance Rejections

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The following is a brief list of commonly encountered insurance rejects and errors that are encountered when adjudicating prescriptions electronically. This list is subject to change and update as new errors are encountered.

Click here for the full list of fields and data that are included in an electronic prescription transmission using the D.0 standard.

Switching Rejections

The switching program acts as a go-between for your pharmacy and the insurance company. Common pharmacy switches include RxLink, NDC SecureTrans, ERx, and RSI. If the switch is having transmission difficulties, you might receive these transmission errors:

No answer via Internet

This rejection indicates that there is no communication locally. Check the following:

  • Your claims switching program (RxLink, NDC SecureTrans, ect) might be off or having software problems. Check and see if it is active on the desktop.
  • Your local (within the pharmacy) network might be having problems. Consider restarting your router and contact your hardware support.
  • Your internet connection might be down. Contact your Internet Service Provider.

Host Processing Error

This is a universal reject that indicates communication problems between the switch and the insurance company. In instances where the switch is having communication issues, you may need to wait awhile and reprocess the claim again. Take note of any additional information that accompanies this reject.

Syntax Error

There are multiple things that can cause this rejection. Typically it indicates that the transmission is wrong on a programming level (as opposed to having missing or incorrect information). Most common causes for this rejection include:

  • Claim is sending a Prior Authorization code that is unnecessary or is in a bad format. This can be triggered accidentally, as QuickSCRIP is set to look for '/PA' in the SIGS lines and treat this as a Prior Auth code. Having SIGs with phrases like "As needed for cramping/pain" will trigger this.
  • Claim is sending the patient's address, but the state is missing. Check the Patient File Maintenance screen, and make sure the address is entered correctly.

Pricing and Drug Quantity issues

Certain switches offer PPE (Pre and Post Editing) Services. PPE allows the switch to make adjustments to your electronic claim before it is sent to the insurance company, and can optimize insurance reimbursement. Additionally, switches with PPE services will block claims if they feel a drug has not been setup properly. Both of these can prevent a claim from being filled if PPE is bumping a drug's price up too high for an insurance to pay, or if PPE is blocking a drug that the insurance would normally accept. These can be tricky to diagnose, but a common rule of thumb is that if the insurance company cannot see the claim, then it is likely being blocked by the switch.

If you think your switch is preventing a claim from being processed, you can try using a /PA9999 in the SIG lines of the claim. This is a universal override that disables PPE.

Primary Claims

These are common rejections that are encountered when transmitting to a primary insurance.

DOC Segment Bad Format

This reject refers to the Doctor segment of the electronic transmission. As of the conversion to the D.0 transmission format, most insurance companies use the doctor's NPI (National Provider Identifier) when processing claims. This reject is typically triggered when the doctor's NPI number is missing from the vendor file.

Prior Authoization Type

In addition so sending a Prior Authorization Code, some insurance overrides require a Prior Authorization Type. The insurance reject can indicate what PA Type an insurance requires, otherwise it may be necessary to call them. A PA Type code is entered into the SIG lines as /PCxxxx (where xxxx is the type), and can be entered alongside a PA Code /PAxxxx.

DUR Rejection

Many claims will reject with insurance companies for unusual dose sizes, duplicate therapies in other drugs, or drug-disease interactions. These rejections will note that they are a DUR rejection, and will often include the specific reason why they rejected. This is especially common on compound claims.

Click here to see the full list of DUR causes, and how to enter DUR codes into the SIG lines.

Pharmacy Service Type and Patient Residence Code

These two rejects are commonly bundled together. Some insurances require that we transmit the Pharmacy Service Type (Field U7-147, the kind of service that has been provided by the pharmacy) and the Patient Residence Code (4X-384). These can be set in the SIG Lines or the Third Party Notes as /PSTxx and /PRSxx. Additionally, QuickSCRIP can set this to always be sent on an insurance company. Pull up the insurance company in the Vendor File Maintenance, type 'O3' to go to screen three, and add /PST amd /PRS to line 22.

Secondary Claims

Secondary claims can be more complicated than primary claims, as there are many different ways to send COB and Copay coverage information. The following are some common rules for sending secondary claims, along with some common rejects. If you are having difficulty processing a secondary claim, feel free to contact us.

Insurances vs Coupon and Copay Reduction Cards

In general, full-fledged insurance companies that are functioning as a secondary coverage prefer an other coverage code of 2. Coupons and Copay reduction cards prefer an other coverage code of 8.

Click here for more information on other coverage codes and their meaning.

6C or 7C Other Payer ID Rejections

Some secondaries want to know the BIN number of the primary insurance. By default, this is not transmitted. 6C and 7C are the names of the fields that this information is sent. To transmit the Other Payer ID, pull up the secondary insurance company in the Vendor File Maintenance, type 'O3' to go to screen three, and add /O# (letter O, pound symbol) to line 16.

MI OP Copay Amount (DX) or NQ Missing Invalid Patient Responsibility

The DX field is an optional field that specifies the patient's copay amount that was left over from the primary claim. To transmit the Copay Amount, pull up the secondary insurance company in the Vendor File Maintenance, and on line 20, add /CS on RXC Line. If you are still getting this reject, we may be transmitting the wrong copay value, or we may be transmitting the correct copay value, and the insurance simply won't cover it.

Some insurance companies do not want to receive the DX field. For these insurances, pull up the secondary insurance company in the Vendor File Maintenance, got to screen 3, and on line 16, add /NY on the RXOL51 Line

H8 Other Amount Claimed Type

This is commonly encountered with copay cards and coupons. We are sending the H8 field, and the insurance does not want it. Send the claim with an other coverage code of 8, and with a Y instead of an O.

Missing/Invalid Copay amount Qualifier

This reject is common on claims where the primary didn't pay. To correct it, pull up the secondary insurance company in the Vendor File Maintenance, type 'O3' to go to screen three, and add /OPQ to line 16.

NR - Copay Amount sent / Count

Similar to the copay amount qualifier rejection above. This rejection is caused by the Other Payer Reject field. To correct it, pull up the secondary insurance company in the Vendor File Maintenance, type 'O3' to go to screen three, and add /OPR to line 16.


/OPR can also sometimes fix DV and HB rejects.

COB Segment Bad Format - AM

There are multiple Causes for this reject, all of which are caused by the Other Payer Amount fields (fields which indicate how much of the drug was covered by the primary. A common fix is to blank-out fields HB-341, HC-342, and DV-431. To correct it, pull up the secondary insurance company in the Vendor File Maintenance, type 'O3' to go to screen three, and add /OPA to line 16.

DX Missing Invalid OPAP

As mentioned in the DX and NR rejections above, the DX field indicates the patient's copay amount left over from the primary claim. There are two things that can cause the above reject:

  • The primary DIDN'T pay anything and the secondary won't cover
  • QuickSCRIP is calculating the copay amount incorrectly. Reverse the claim from the primary and reprocess from cash, or contact us.

M/I Benefit Stage Qualifier - MV

Insurance does not want us to send the benefit stage (MV) field. /XM on the Ins Vendor file for the Secondary, Screen 3, Line 16 should get this.

Reversals

Occasionally, an electronic claim will be accepted by the insurance, but will reject when you try to reverse it. Some reversals may require that you contact the insurance company and get them to reverse it manually.

Insurance / Group Segment Bad Format

Some insurance companies want the cardholder information transmitted on the reversal. To transmit this, pull up the secondary insurance company in the Vendor File Maintenance, type 'O3' to go to screen three, and add /IDR (for Ins segment) and /GPR (for group number) to line 16.

Missing/Invalid COB Segment

In rare instances, an insurance will want the Coordination of Benefits information included in the rejection (typically Other coverage code and copay info). To transmit this, pull up the secondary insurance company in the Vendor File Maintenance, type 'O3' to go to screen three, and add /CBR to line 16.