The 5 Most Common Pharmacy Claim Rejections and How to Fix Them

Transaction Data Systems About The Author

Oct 13, 2016 8:06:02 AM

Rejected.png

Claim rejections… ugh! They are such a headache, and in the pharmacy industry you deal with them every day. Since these are a part of your daily life, you’re aware that for every rejection you receive you also get a code, indicating why that claim was rejected.

This starts the process of fixing that claim. You have to identify the claim based on its code, fix the issue that caused the initial rejection, and resubmit the claim. If you’re lucky, it can be fixed without a time-consuming call the insurance company.

To help expedite part of this process, we’ve collected five of the most common pharmacy claim rejections and solutions for fixing them.

Code 04: M/I Processor Control Number (PCN)

Meaning: There is either no PCN on the claim, the PCN is Invalid, or the PCN submitted is not the number the PBM is looking for.

Solutions: First, look to see if the rejection came with an additional message. If the PCN is not the number that the PBM is looking for, the message that comes with the rejection may give you the number needed. If the number is missing, you will need to get the code from the patient’s insurance card or insurance company and edit the claim information before resubmitting. If you check the claim information and the PCN is correct based off the information you’ve been given, you will need to call the insurance company to sort out the problem.

Code 06: M/I Group Number

Meaning: There is either no group number on the claim, or the group number submitted is not the number the PBM is looking for.

Solution: You can determine if the number is missing or invalid by looking at the claim information in the Prescription Edit screen. If there is no information populated for the group number the number is missing, and you will need to retrieve this number from the patient or their insurance card, input the number, and resend the claim. If there is a number there, verify that it is correct. If the number is correct, you will have to call the insurance company for assistance.

Code 40: Pharmacy Not Contracted With Plan on Date of Service

Meaning: There is either no NPI on the claim, or the NPI submitted is not recognized as a pharmacy that is contracted with the plan.

Solution: First, determine if the NPI number is missing or invalid. You can do this by looking in the settings of your pharmacy software and determining whether there is a number in that field or not. If there is no NPI number in your settings, you will need to input your store’s NPI. You can then go into the rejected claim and resend it. If there is a number in the NPI field, this number is most likely incorrect. Double check this number with the correct NPI and adjust accordingly. Once the number is correct in your software settings you can edit the claim rejection by removing the incorrect NPI number and resubmitting the claim with that field blank. If the NPI is not missing or invalid, this indicates the plan does not have a contract on file for your pharmacy.  To fix this you would have to contact the plan’s contracting department.

Code 52: Non-Matched Cardholder ID Number

Meaning: There is either no Cardholder ID Number on the claim, or the number submitted is not the number the PBM is looking for.

Solution: To determine whether the number is missing or invalid, pull up the cardholder information for the patient on the prescription. You may be able to pull this up from the prescription edit screen. Otherwise, you will need to look up the patient. If the field is blank, enter the cardholder id in the correct field. If there is a number, you should verify that it is correct. If you continue to get a rejection with the correct number, you will need to call the insurance company.

Code 76: Plan Limitations Exceeded

Meaning: The claim submitted needs prior approval before coverage because of the medication expense, the medication has already been filled in the last 30 days, or the quantity dispensed is over the allowed amount for the day supply.

Solution: First determine the reason for the rejection by looking at the price, last filled date, day supply on the prescription. If the medication has been filled in the last 30 days and still needs to be filled (due to a dosage change or a similar circumstance), you will need to obtain an override from the insurance company for the claim to be processed. If the prescription is for a high-dollar medication, you will need to obtain approval on the cost from the insurance before the claim can be processed. If the day supply is more than 30 days the insurance generally won’t approve it. You may try submitting for a smaller quantity or contact the insurance company for prior authorization.

 

This is just a handful of the rejections you can receive any given day at your pharmacy. For a more complete source of information, your pharmacy software partner should have resources available to help you easily identify and remedy claim rejections or a knowledgeable support team ready to help you.

If you interested in learning what other services your pharmacy software partner should be offering, click below.

Request a live demonstration