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Sub-Field: 52.25

Package: Outpatient Pharmacy

PRESCRIPTION(#52)-->52.25

Sub-Field: 52.25


Information

Parent File Name Number Package
PRESCRIPTION(#52) REJECT INFO 52.25 Outpatient Pharmacy

Details

Field # Name Loc Type Details
.01 NCPDP REJECT CODE 0;1 FREE TEXT
************************REQUIRED FIELD************************

  • INPUT TRANSFORM:  K:$L(X)>4!($L(X)<1) X S DIC(0)="QM",DIC="^BPSF(9002313.93," D ^DIC S X=$P(Y,U,2) K:Y<0 X
  • LAST EDITED:  JUN 29, 2005
  • HELP-PROMPT:  Answer must be 1-4 characters in length.
  • DESCRIPTION:  
    NCPDP Reject Code that indicates the reason for the claim rejection for this prescription.
  • TECHNICAL DESCR:  
    Although this fields does not point to the BPS NCPDP REJECT CODES file (#9002313.93), the value should have a corresponding entry in that file.
  • NOTES:  XXXX--CAN'T BE ALTERED EXCEPT BY PROGRAMMER
  • CROSS-REFERENCE:  52.25^B
    1)= S ^PSRX(DA(1),"REJ","B",$E(X,1,30),DA)=""
    2)= K ^PSRX(DA(1),"REJ","B",$E(X,1,30),DA)
1 DATE/TIME DETECTED 0;2 DATE

  • INPUT TRANSFORM:  S %DT="ESTX" D ^%DT S X=Y K:X<1 X
  • LAST EDITED:  DEC 13, 2005
  • HELP-PROMPT:  Date/time when the reject was detected by Outpatient Pharmacy or CMOP.
  • DESCRIPTION:  
    Date/Time when the reject was detected by Outpatient Pharmacy.
  • FIELD INDEX:  REJDAT (#254) REGULAR IR LOOKUP & SORTING WHOLE FILE (#52)
    Short Descr:  Cross-reference to sort REJECTs by the DATE/TIME DETECTED field.
    Set Logic:  S ^PSRX("REJDAT",X,DA(1),DA)=""
    Kill Logic:  K ^PSRX("REJDAT",X,DA(1),DA)
    Whole Kill:  K ^PSRX("REJDAT")
    X(1):  DATE/TIME DETECTED  (52.25,1)  (Subscr 1)  (forwards)
2 PAYER MESSAGE 1;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>140!($L(X)<1) X
  • LAST EDITED:  JUN 16, 2005
  • HELP-PROMPT:  Answer must be 1-140 characters in length
  • DESCRIPTION:  
    Message from the 3r party payer regarding the rejection of the claim.
3 REASON 1;2 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>100!($L(X)<1) X
  • LAST EDITED:  APR 19, 2005
  • HELP-PROMPT:  Answer must be 1-100 characters in length
  • DESCRIPTION:  
    Reason why the claim is being rejected by the 3rd party payer.
4 PHARMACIST 0;3 POINTER TO NEW PERSON FILE (#200) NEW PERSON(#200)

  • LAST EDITED:  APR 19, 2005
  • HELP-PROMPT:  Pharmacist using the Outpatient Pharmacy appliction when the REJECT was detected.
  • DESCRIPTION:  
    Pharmacist using the application when the reject was detected.
5 FILL NUMBER 0;4 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>12)!(X<0)!(X?.E1"."1.N) X
  • LAST EDITED:  APR 19, 2005
  • HELP-PROMPT:  Type a number between 0 and 12, 0 Decimal Digits
  • DESCRIPTION:  
    This field is used to indicate which fill the reject is related to.
6 GROUP NAME 2;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>30!($L(X)<1) X
  • LAST EDITED:  JUN 16, 2005
  • HELP-PROMPT:  Answer must be 1-30 characters in length
  • DESCRIPTION:  
    This is the patient's insurance group name.
7 PLAN CONTACT 2;2 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>30!($L(X)<1) X
  • LAST EDITED:  JUN 16, 2005
  • HELP-PROMPT:  Answer must be 1-30 characters in length
  • DESCRIPTION:  
    This is the patient's insurance company contact information.
8 PLAN PREVIOUS FILL DATE 2;3 DATE

  • INPUT TRANSFORM:  S %DT="ESTX" D ^%DT S X=Y K:X<1 X
  • LAST EDITED:  MAY 02, 2005
  • HELP-PROMPT:  (No range limit on date)
  • DESCRIPTION:  
    In case of a REFILL TOO SOON reject (#79) and the payer returns the last date the prescription was filled, it will be stored on this field.
9 STATUS 0;5 SET
  • '0' FOR OPEN/UNRESOLVED;
  • '1' FOR CLOSED/RESOLVED;

  • LAST EDITED:  APR 19, 2005
  • HELP-PROMPT:  Status of the REJECT. The null value is the same as 0 (zero).
  • DESCRIPTION:  
    This field indicates whether the reject is OPEN/UNRESOLVED or CLOSED/RESOLVED.
  • FIELD INDEX:  REJSTS (#255) REGULAR IR LOOKUP & SORTING WHOLE FILE (#52)
    Short Descr:  Cross-reference for the STATUS field in the REJECT INFO (#52.25) sub-file.
    Set Logic:  S ^PSRX("REJSTS",X,DA(1),DA)=""
    Kill Logic:  K ^PSRX("REJSTS",X,DA(1),DA)
    Whole Kill:  K ^PSRX("REJSTS")
    X(1):  STATUS  (52.25,9)  (Subscr 1)  (forwards)
10 CLOSED DATE/TIME 0;6 DATE

  • INPUT TRANSFORM:  S %DT="ESTX" D ^%DT S X=Y K:X<1 X
  • LAST EDITED:  APR 19, 2005
  • HELP-PROMPT:  Date/time the Third Party Reject was closed (resolved) by the user.
  • DESCRIPTION:  
    Date/Time when the reject was marked CLOSED/RESOLVED.
11 CLOSED BY 0;7 POINTER TO NEW PERSON FILE (#200) NEW PERSON(#200)

  • LAST EDITED:  APR 19, 2005
  • HELP-PROMPT:  User responsible for closing (resolving) the Third Party Reject.
  • DESCRIPTION:  
    User responsible for marking the reject CLOSED/RESOLVED.
12 CLOSE REASON 0;8 SET
  • '1' FOR CLAIM RE-SUBMITTED;
  • '2' FOR RX ON HOLD;
  • '3' FOR RX SUSPENDED;
  • '4' FOR RX RETURNED TO STOCK;
  • '5' FOR RX DELETED;
  • '6' FOR IGNORED - NO RESUBMISSION;
  • '7' FOR RX DISCONTINUED;
  • '8' FOR RX EDITED;
  • '99' FOR OTHER;

  • LAST EDITED:  JUL 08, 2005
  • DESCRIPTION:  
    This field indicates the reason for marking the reject CLOSED/RESOLVED.
13 CLOSE COMMENTS 3;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>100!($L(X)<1) X
  • LAST EDITED:  APR 19, 2005
  • HELP-PROMPT:  Answer must be 1-100 characters in length
  • DESCRIPTION:  
    User entered comments.
14 REASON FOR SERVICE CODE 0;9 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>4!($L(X)<1) X
  • LAST EDITED:  MAY 18, 2005
  • HELP-PROMPT:  Answer must be 1-4 characters in length
  • DESCRIPTION:  
    NCPDP field indicating the resason for service code. See NCPDP REASON FOR SERVICE CODE file (#9002313.23) for possible values.
15 PROFESSIONAL SERVICE CODE 0;10 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>4!($L(X)<1) X
  • LAST EDITED:  MAY 18, 2005
  • HELP-PROMPT:  Answer must be 1-4 characters in length
  • DESCRIPTION:  
    NCPDP field indicating the professional service code. See NCPDP PROFESSIONAL SERVICE CODE file (#9002313.21) for possible values.
16 RESPONSE ID 0;11 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>9999999999)!(X<0)!(X?.E1"."1.N) X
  • LAST EDITED:  MAY 12, 2005
  • HELP-PROMPT:  Type a number between 0 and 9999999999, 0 Decimal Digits
  • DESCRIPTION:  
    This field is used to make sure the reject is recorded only once.
17 OTHER REJECTS 0;12 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>15!($L(X)<1) X
  • LAST EDITED:  APR 25, 2005
  • HELP-PROMPT:  Answer must be 1-15 characters in length
  • DESCRIPTION:  
    List of other reject codes that were returned at the same time.
18 DUR TEXT 4;1 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>100!($L(X)<1) X
  • LAST EDITED:  APR 29, 2005
  • HELP-PROMPT:  Answer must be 1-100 characters in length
  • DESCRIPTION:  
    In case of a DUR reject (#88) the 3rd party payer returns an explanation of the DUR (Drug Usability Review).
19 RESULT OF SERVICE CODE 0;13 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>4!($L(X)<1) X
  • LAST EDITED:  MAY 18, 2005
  • HELP-PROMPT:  Answer must be 1-4 characters in length
  • DESCRIPTION:  
    NCPDP field indicating the result of service code. See NCPDP RESULT OF SERVICE CODE file (#9002313.22) for possible values.
20 INSURANCE NAME 2;4 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>30!($L(X)<1) X
  • LAST EDITED:  JUN 16, 2005
  • HELP-PROMPT:  Answer must be 1-30 characters in length
  • DESCRIPTION:  
    Patient's insurance company name.
21 GROUP NUMBER 2;5 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>30!($L(X)<1) X
  • LAST EDITED:  JUN 16, 2005
  • HELP-PROMPT:  Answer must be 1-30 characters in length
  • DESCRIPTION:  
    Patient's insurance group number.
22 CARDHOLDER ID 2;6 FREE TEXT

  • INPUT TRANSFORM:  K:$L(X)>20!($L(X)<1) X
  • LAST EDITED:  JUN 16, 2005
  • HELP-PROMPT:  Answer must be 1-20 characters in length
  • DESCRIPTION:  
    ID number assigned to Cardholder/Subscriber.
23 RE-OPENED 0;14 SET
  • '1' FOR YES;

  • LAST EDITED:  NOV 14, 2005
  • DESCRIPTION:  
    This flag indicates that the user has manually re-opened another reject and this one was created.
  • TECHNICAL DESCR:  
    In order to identify the original reject, use the RESPONSED ID field. It should match with the RESPONSED ID from the re-opened reject.
24 CLARIFICATION CODE 0;15 POINTER ** TO AN UNDEFINED FILE **

  • LAST EDITED:  MAY 02, 2008
  • HELP-PROMPT:  Enter a clarification code.
  • DESCRIPTION:  
    This field contains the NCPDP Clarification Code for the reject.
  • TECHNICAL DESCR:  
    This field can contain any value from the BPS NCPDP CLARIFICATION CODES file (#9002313.25).
25 PRIOR AUTHORIZATION TYPE 0;16 SET
  • '0' FOR NOT SPECIFIED;
  • '1' FOR PRIOR AUTHORIZATION;
  • '2' FOR MEDICAL CERTIFICATION;
  • '3' FOR EPSDT;
  • '4' FOR EXEMPTION FROM COPAY;
  • '5' FOR EXEMPTION FROM RX LIMITS;
  • '6' FOR FAMILY PLANNING INDICATOR;
  • '7' FOR AFDC;
  • '8' FOR PAYER DEFINED EXEMPTION;

  • LAST EDITED:  MAR 12, 2007
  • DESCRIPTION:  
    NCPDP Prior Authorization Type.
26 PRIOR AUTHORIZATION NUMBER 0;17 NUMBER

  • INPUT TRANSFORM:  K:+X'=X!(X>999999999999)!(X<0)!(X?.E1"."1.N) X
  • LAST EDITED:  FEB 21, 2007
  • HELP-PROMPT:  Type a number between 0 and 999999999999, 0 Decimal Digits
  • DESCRIPTION:  
    NCPDP Prior Authorization Number. This field may be left blank if the claim does not require a number.
51 COMMENTS COM;0 DATE Multiple #52.2551 52.2551
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